Misinterpretation of navigational information led to the 2019 grounding of Royal Canadian Marine Search and Rescue vessel
Richmond, British Columbia, 14 January 2021 — In its investigation report (M19P0029) released today, the Transportation Safety Board of Canada (TSB) determined that a misinterpretation of navigational information led to the grounding of the Royal Canadian Marine Search and Rescue (RCMSAR) vessel Spirit of Sooke near Sooke, British Columbia.
On , at approximately 2000 PST, the Spirit of Sooke, a rigid hull inflatable jet boat departed RCMSAR Station 37 in Sooke, B.C., with a coxswain in charge, one crew member and two new crew members on board. The boat was heading to the fueling station in the Sooke Basin, using the trip as an opportunity for training the new crew members in navigation and communications procedures.
The crew started the return trip to Station 37 at approximately 2115, with the crew member at the helm and the coxswain navigating. The new crew members were assigned to maintain lookout based on their experience level. As the vessel approached Christie Point, the coxswain monitored the radar display and instructed the crew member at the helm to make a course alteration. Seconds later, the coxswain urgently shouted the same course change. Almost immediately, at approximately 2134, the Spirit of Sooke ran into shoreline rocks on Christie Point at a speed of about 27 knots. The vessel launched into the air and hit the ground stern first before sliding along the shore for approximately 25 metres and coming to rest on its starboard side, resulting in the crew members being thrown around the cabin in a violent manner and causing serious injuries.
The investigation found that on the return trip, the RCMSAR crew relaxed their adherence to operational guidance for navigation, resulting in informal helm orders and crew members not using closed-loop communication. As the vessel approached Christie Point, the coxswain’s interpretation of the radar screen showed the boat was on a good course to clear the point. However, because a plotted route and effective cross-checking of the vessel’s position were not done, the likelihood of detecting that the vessel’s course was not clear of Christie Point was reduced. Additionally, there was no experienced crew member available to actively monitor the vessel’s position and detect navigation errors. Once the impending grounding was detected, there was insufficient time to respond and avoid it, given the vessel’s high speed.
The investigation also established that if organizational guidance is not sufficiently detailed to assist crews in determining safe speed, there is a risk that the speed selected may not be appropriate for prevailing conditions. Further, if risk assessment guidance does not prompt consideration of hazards and/or the risk assessment process is not monitored to ensure consistent application, there is a risk that hazards will go unidentified and/or risks will be assessed inaccurately. As well, if external safety oversight of volunteer SAR operations is not adequate, there is a risk that safety gaps will be missed and essential guidance to maintain and improve operational safety will not be provided.
Immediately following the occurrence, operations at RCMSAR Station 37 ceased and a return-to-operations plan was initiated. Refresher training sessions for coxswains were held including an evaluation of skills, review of leadership and decision making, presentations on situational awareness and positive control, and two on-the-water training sessions with a focus on navigational communications, emergency procedures, and electronic navigation. All coxswains at Station 37 completed the refresher training and the station returned to operations.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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