Breakdowns in situational awareness and communications were key factors leading to a striking in Vancouver Harbour
Richmond, British Columbia, 15 July 2021 — The Transportation Safety Board of Canada (TSB) today released its investigation report (M19P0057) on the 2019 striking of the anchored bulk carrier Pan Acacia by the bulk carrier Caravos Harmony in Vancouver Harbour, British Columbia.
On 17 March 2019, the bulk carrier Caravos Harmony, under the conduct of a pilot, with 22 people on board, struck the anchored bulk carrier Pan Acacia while proceeding to anchorage D in Vancouver Harbour, British Columbia. Both vessels sustained damage. No pollution or injuries were reported.
The investigation determined that as the Caravos Harmony entered First Narrows, the strong current and eddies caused the vessel to sheer to port. The pilot gave full ahead and starboard helm orders in an attempt to correct the vessel’s course, but engine orders were ineffective and the vessel continued moving to port. The pilot then ordered the starboard anchor to be released so that the vessel would swing to starboard. However, neither of the anchors had been prepared for deployment as requested by the pilot, and the starboard anchor was stuck in the stowed position and could not be released. With only the port anchor available and having a differing understanding of the situation from that of the pilot, the master ordered the port anchor to be dropped with the aim of bringing the vessel to a stop. This caused the vessel to move further to port. Shortly thereafter, the Caravos Harmony struck the Pan Acacia.
The investigation also determined that communication breakdowns impacted the team’s situational awareness and resulted in different understandings of the emerging circumstances. During the occurrence, the pilot and bridge crew did not share critical information to build a common and accurate understanding of the situation and this impeded timely and effective coordination of actions to safely manoeuvre the vessel and avoid the striking.
Additionally, it was found that, if familiarization on essential shipboard machinery and equipment is not effective and if necessary instruction manuals and vessel-specific procedures and training are not provided, the crew may not be proficient in the use of the equipment, increasing the risk of accident or injury.
Following the occurrence, the ship manager took several actions, including a review of the performance of the crew and the crewing agents. They replaced the crewing agents at the time of the occurrence with a new fully certified agency and requested that senior officers be provided additional training and familiarization before boarding. The Pacific Pilotage Authority (PPA) and British Columbia Coast Pilots Ltd. conducted a risk assessment on loaded bulk carriers entering Vancouver Harbour on a strong flood tide and implemented additional measures to mitigate the risk of a similar occurrence. Moreover, the Vancouver Fraser Port Authority amended its rules for vessels refuelling at English Bay. As of July 2020, refuelling of all vessels can occur in English Bay, thereby reducing the number of inbound laden bulk carriers transiting through the First Narrows Traffic Control Zone (TCZ-1).
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