Marine transportation safety investigation report M17A0004
Bunkering tanker Arca 1
Little Pond, Nova Scotia
The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. This report is not created for use in the context of legal, disciplinary or other proceedings. See Ownership and use of content.
On 08 January 2017, at 0820 Atlantic Standard Time, the bunkering tanker Arca 1 went aground while under reduced propulsion due to a failure of the port propulsion clutch. There were 6 people on board. The vessel sustained major damage to the hull and propulsion machinery. There were no injuries and there was no pollution. The vessel was refloated and towed to Sydney, Nova Scotia.
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Particulars of the vessel
|Name of vessel||Arca 1|
|Port of registry||Panama|
|Draft||Forward: 5.09 m
Aft: 5.09 m
|Built||1963, Port Weller Dry Dock Ltd.
St. Catharines, ON
|Propulsion||Two V12 diesel engines each driving a fixed-pitch propeller, producing a total of 559.5 kW|
|Registered owner||Petroil Marine, Mexico|
|Manager||MLS & Associates, Panama|
* International Maritime Organization
Description of the vessel
The Arca 1 is a bunkering tanker with a capacity of 1527 m3, designed for the transportation of oil to vessels at a maximum speed of 8 knots (Figure 1). The vessel was built in St. Catharines, Ontario, in 1963 and had operated in the ports of both Montreal and Sorel, Quebec. The vessel was restricted to minor waters voyages, Class II.Footnote 1 In 2004, a second hull was installed over the internal oil storage tanks, providing a double hull (Appendix A). The construction of the second hull provided a 750 mm space between the inner and outer hulls that incorporated 3 water ballast tanks. Two 12V92 diesel engines that power 2 Z-drives are mounted on the stern and provide thrust. The diesel engines power the Z-drives via a power take-off clutch arrangement. Each Z-drive (Figure 2) can rotate 360° and is fitted with a fixed-pitch propeller. The vessel is steered by modifying the orientation of the thrust units.
The vessel held a registry certificate as well as a Minimum Safe Manning Certificate and a Single Voyage for Delivery Authorization issued by Panama for delivery from Sorel, Quebec, Canada, to Mazatlán, Sinaloa, Mexico. The authorization specified that the vessel could carry out the voyage without statutory certificates. The vessel also held a radio station license.
Personnel certification and experience
The master held a credential document issued in the United States under the provisions of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) 1978.Footnote 2 The document entitled the master to serve in the capacity of chief engineer on vessels of not more than 3000 gross tons (GT).
This credential document also entitled the master, under the U.S. Code, Title 46 – Shipping, to serve only in the capacity of master on vessels of not more than 500 GT on U.S. domestic voyages.Footnote 3
The master had sailed in various capacities on U.S. Coast Guard vessels for 6 years in the early 1970s. In the mid-1980s, he had sailed for 2 years as master on registered yachts in southern waters. Since 2008, he had sailed in various engineering positions on commercial vessels and had also seasonally operated vessels for a small-craft towing company.
The second mate held a credential document issued in the U.S. under the provisions of the STCW Convention that entitled him to serve in the capacity of master on vessels of not more than 3000 GT. He had 40 years of experience in different capacities on various types of vessels, sailing mostly in the southern and western waters of the U.S.
The chief mate held a Watchkeeping Mate certificate of competency issued in Canada under the provisions of the STCW Convention. The document entitled him to serve in the capacity of chief mate on vessels of not more than 3000 GT. The chief mate also held a Master 3000 Gross Tonnage, Domestic certificate issued in Canada. He had 32 years of experience in different capacities on various types of vessels, sailing mostly in Canadian waters.
The motorman held an Engine Room Rating certificate issued in Canada. He had 6 years of experience sailing as an engine room rating on supply vessels, cargo ships, and seismic vessels.
Two able seamen holding the required certifications were also on board.
All crew member certificates were endorsed by the Panama Maritime Authority for a period of 3 months.
The Arca 1 was laid up at the shipyard dock in Sorel for 2 years after being decommissioned in 2014. The vessel was sold to a Mexican company in 2016. In October 2016, 3 crew members joined the vessel. The owner attempted to register the vessel as a Canadian yacht for the purpose of ferrying it to Mexico, but the registration request was denied and the 3 crew members were sent back home.
On 06 December 2016, the vessel obtained registration under the Panamanian flag. The 3 crew members were brought back on board and started to prepare the Arca 1 for its voyage to Mexico. On 08 December, having completed a condition survey of the vessel, a surveyor for the classification society Intermaritime Certification ServicesFootnote 4 issued a statement of seaworthiness for the vessel's voyage, as was required by Panama.
On 09 December 2016, the Panama Maritime Authority issued a Minimum Safe Manning Certificate (Appendix B) as well as a Single Voyage for Delivery Authorization (Appendix C). The authorization imposed, among other things, the following requirements to mitigate risks to the vessel and its crew:
Weather forecast are to be obtained 24/48 hours prior departure and on a daily basis throughout the entire voyage planned and agreed rout [sic].
The vessel is not to depart if seas waves excedding [sic] 4 meters are expected within 24 hours. Including to all intermediate stops made during the intended voyage. […]
The vessel is not permitted to sail is [sic] seas of Beaufort 7[Footnote 5 ] and/or above. In the event thatt [sic] the vessel is at sea in said Beaufort scale, master should proceed to a port of shelter.
On 13 December 2016, Transport Canada (TC) conducted a Port State ControlFootnote 6 inspection that identified 13 deficiencies related to radio equipment, life-saving equipment, the number of crew, the certification of crew members, and voyage planning. Given the deficiencies identified in the inspection, the Port State Control inspection was suspended under section 3.6 of the Paris Memorandum of Understanding protocol and the vessel was restricted from sailing.
Following the inspection and to comply with the conditions of the Minimum Safe Manning Certificate, the capacity of the master was changed in the vessel's Articles of AgreementFootnote 7 from master to engineer, and the capacity of the second mate was changed from second mate to master. However, during the occurrence voyage, these 2 crew members carried out the same duties that were originally specified in the vessel's Articles of Agreement.
On 16 December, the crew was increased to 6 members to meet the requirements of the Minimum Safe Manning Certificate.
On 21 December, the vessel's authorized representative contacted TC Port State Control officers to ask TC to complete the inspection, clear previous findings, and remove the restricted-to-sail order. It was determined that a chief mate with the required certification was necessary to comply with the officer certification requirements of the Minimum Safe Manning Certificate. The TC inspector also asked the master to present a voyage plan that complied with the limitations of the voyage imposed by Panama's Single Voyage for Delivery Authorization (Appendix C).Footnote 8
TC was provided with a handwritten voyage plan signed by the master. The plan consisted of 2 pages that identified the 7 intermediate ports of the voyage and summarized the chart numbers for the planned route with no further details.
On 30 December, a new chief mate with the required certification arrived on board to replace the uncertificated chief mate.
History of the voyage
On 31 December 2016, the vessel departed Sorel with the master, the second mate, the new chief mate, a motorman, and 2 able seamen on board.
On 03 January 2017, the Arca 1 diverted to Îles-de-la-Madeleine, Quebec, due to a failure of a fuel injector on the starboard main engine. The repairs to the starboard main engine were completed on 06 January.
On 07 January, at approximately 1038,Footnote 9 the Arca 1 departed Îles-de-la-Madeleine. The winds were from the west at 14 knots. The forecast indicated that a gale warning was in effect with wind increasing to 40 to 45 knots, with seas building from 3 to 5 m on the morning of 08 January and to 5 to 7 m that afternoon. The vessel was underway at a speed of approximately 8 knots, on a course of 098° en route to Sydney, Nova Scotia (Appendix D).
At approximately 1710, the tachometer reading for the port main engine dropped to 0 revolutions per minute (rpm). The motorman left the bridge to check the tachometer reading on the engine. Upon arriving at the engine, the motorman noticed a burning smell. The port propulsion clutch was slipping, which had resulted in overheating of the clutch, its housing, and the engine flywheel. The master was informed of the issue and placed the propeller at 90° to the stern to provide better steerage and shut down the port engine.
At approximately 1725, the master changed course to about 111° to go around Cape North. At that time, the wind was from the northwest at 15 knots. The vessel travelled for approximately 3 hours at a reduced average speed of 6 knots. At 2005, the course was set at 173° to arrive at the entrance of Sydney Harbour.
After the last course change, the vessel travelled at approximately 6.4 knots until 0100 on 08 January, when the wind veered to the southeast and began to increase. The vessel travelled 9.1 nautical miles (nm) over the next 2 hours.
The heavy weather persisted. At approximately 0315, the Arca 1 could not make headway, and the southeasterly winds of approximately 30 to 50 knots pushed the vessel to the west, toward the shoreline.
At 0558, a pilot who was supposed to board the vessel at the entrance of Sydney Harbour informed Sydney Marine Communications and Traffic Services (MCTS) that the Arca 1 could not be boarded due to the strong winds and high seas.
At 0624, the Halifax Joint Rescue Coordination Centre (JRCC) contacted the vessel by cellphone and asked if they wanted to declare distress. The master confirmed, and Halifax JRCC forwarded the information to Sydney MCTS, which then broadcast the distress call and tasked several Canadian Coast Guard vessels to assist. At that time, the wind was from the east-southeast at 35 knots, and the seas were at 2 m.
At 0704, the crew dropped the vessel's only anchor in an attempt to hold the vessel's position.
At 0720, the Arca 1 was holding position with the anchor and the power of the remaining operable engine. The winds were east-northeast at 30 knots with seas of 3 m.
Shortly afterward, the anchor started to drag. The crew then raised the anchor to reset it. However, before they had a chance to do so, the vessel hit bottom, damaging the starboard Z-drive, and lost all means of propulsion. The anchor was dropped again but could not hold, and the vessel drifted closer to the shoreline until it grounded at 0811.
At 0833, the master contacted Sydney MCTS and informed them that the vessel had grounded. No search-and-rescue (SAR) vessels had arrived on scene by this time.
At approximately 1300, the crew was air lifted from the Arca 1 by a SAR helicopter sent by the Halifax JRCC. The crew was then taken to the Sydney/J. A. Douglas McCurdy Airport.
On 15 January, the vessel was refloated and towed to Sydney.
Damage to the vessel
During the occurrence, the friction plate on the port propulsion clutch arrangement slipped, which caused overheating and led to the failure of the clutch.
The starboard Z-drive separated from the mounting arrangement when the vessel contacted the bottom, causing the destruction of the starboard transmission. The outer hull was indented, and several transverse members sustained damage.
Environment and Climate Change Canada issued a marine weather statement on 07 January 2017 at 0336, indicating that gale-force northeasterly winds were expected to develop that evening with the approach of an intense low, centred to the south of Nova Scotia.
The weather forecast issued by Environment and Climate Change Canada for the Cabot Strait at 0500 on 07 January called for[w]ind increasing to east 20 [knots] overnight and to east 40 to 45 [knots] Sunday [08 January] morning.[Footnote 10 ] Wind veering to southerly 35 to 45 [knots] near noon Sunday then becoming northwest 45 [knots] Sunday afternoon.
The wave height forecast called for seas of 1 to 2 m building to 3 to 5 m in the morning of 08 January, and to 5 to 7 m that afternoon.
At the time of the grounding, the winds were from the east-northeast at 30 knots, and the seas were at 3 m.
The following life-saving and firefighting equipment was on board at the time of the occurrence, which met Canadian regulatory requirements:
- Life jackets
- Immersion suits
- Life rafts
- Line-throwing appliance
- Emergency position-indicating radio beacon
- Fire detection system
- Portable fire extinguishers
- Emergency fire pump
To ensure safe and efficient operation at all times, a vessel is required to carry certificated officers as well as certificated and non-certificated ratings of a sufficient number and grades/capacities.Footnote 11 In determining the minimum safe manning for a specific vessel, the flag state applies the International Maritime Organization's Principles of Minimum Safe Manning.Footnote 12 The minimum safe manning, as determined by the flag state, is detailed in the minimum safe manning document issued to the vessel.
The Panama Maritime Authority issued a Minimum Safe Manning Certificate to the Arca 1 for a "single voyage from Sorel, Quebec, Canada, to Mazatlan, Sinaloa, Mexico, by coastal navigation." The certificate required the vessel to carry personnel with certification meeting the STCW requirements as detailed in Table 2.
|Capacity||STCW certification required|
|Able seamen (2)||II/4 or II/5|
The vessel's Articles of Agreement indicated that the crew for the voyage consisted of a master, a chief mate, 2 able seamen, an engineer, and a motorman. The various positions undertaken by the crew are indicated in Table 3.
|Crew member||Intended position||Position indicated on vessel's documents (on-paper role)||Actual STCW certification||Role during voyage (actual role)|
|2||2nd mate||2nd mate master*||II/2||2nd mate|
|3||chief mate||chief mate||II/2||chief mate|
* As modified in vessel documents
Subsection 14(1) of the Charts and Nautical Publications Regulations requires the master to take into account the requirements for voyage planning as detailed in the International Maritime Organization's Guidelines for Voyage Planning, which state, among other things, that the following should be included in a detailed voyage or passage plan:
- safe speed, having regard to the proximity of navigational hazards along the intended route or track, the manoeuvring characteristics of the vessel and its draught in relation to the available water depth;
- necessary speed alterations en route, e.g., where there may be limitations because of night passage, tidal restrictions, or allowance for the increase of draught due to squat and heel effect when turning;
- minimum clearance required under the keel in critical areas with restricted water depth;
- positions where a change in machinery status is required;
- course alteration points, taking into account the vessel's turning circle at the planned speed and any expected effect of tidal streams and currents;
- the method and frequency of position fixing, including primary and secondary options, and the indication of areas where accuracy of position fixing is critical and where maximum reliability must be obtained;
- use of ships' routeing and reporting systems and vessel traffic services;
- considerations relating to the protection of the marine environment; and
- contingency plans for alternative action to place the vessel in deep water or proceed to a port of refuge or safe anchorage in the event of any emergency necessitating abandonment of the plan, taking into account existing shore-based emergency response arrangements and equipment and the nature of the cargo and of the emergency itself.Footnote 13
The guidelines go on to note that the details of the voyage plan should be clearly marked and recorded,Footnote 14 the details of the voyage plan should be approved by the master,Footnote 15 the voyage plan should be available at all times on the bridge,Footnote 16 and the progress of the vessel should be closely and continuously monitored against the plan.Footnote 17 Any changes to the plan "should be made consistent with the Guidelines and clearly marked and recorded."Footnote 18 Any significant deviations from the voyage plan, such as a route diversion, should lead to the development of a new voyage plan.
The Arca 1's voyage plan consisted of a list of 7 intermediate ports as well as a list of charts covering the passage from Sorel, Quebec, to Shelburne, Nova Scotia. The original voyage plan remained unchanged after the diversion to Îles-de-la-Madeleine. There were no other detailed documented voyage plans for any leg of the voyage.
The master estimated that the passage from Îles-de-la-Madeleine to Sydney (sea buoy to sea buoy), would take approximately 12 hours at a speed of 8 knots. Based on a speed of 8 knots, this time represents a distance of 96 nm. The actual distance from berth to berth is 120 nm. This difference in distance represents an additional 3 hours in transit time, for a total of 15 hours.
Maintenance carried out before the vessel left Sorel was limited to correcting issues with the vessel's emergency fire pump, bilge-pumping arrangement, and bilge-alarm equipment, which were necessary to obtain the certificate of seaworthiness and satisfy the requirement of the Port State Control inspection.
The original equipment manufacturer's operating manual for the main propulsion clutch states the following:
New power take-offs must have clutch adjustment checked before being placed into service and after the first 10 hours of operation. This includes any power takeoffs with new friction plates. New plates have a wear-in period and the clutch may require several adjustments before the new plates are worn-in.
After wear-in, clutch adjustment should be checked regularly. Heavy duty applications (rock crushers, etc.) which have frequent engagement, numerous engagements in an operating day or relatively long periods of slip (large inertias), require more frequent readjustment than light duty applications.
Adjust the clutch BEFORE it overheats, does not pull (slips), or the operating lever jumps from the engaged position. These symptoms are indications that clutch adjustment is required.Footnote 19
Prior to departure from Sorel, the crew did not review the operating manuals for this machinery. The clutch was visually inspected, and its operation was verified at each arrival and before every departure. However, no preventative maintenance, such as lubricating, checking, or adjusting the clutch tension on the main propulsion system as per the original equipment manufacturer's recommendation, was carried out before or after the vessel's departure. Furthermore, some of the tools required to check the clutch tension were not on board.
Occurrences in Canada involving issues relating to unqualified crew members
M03M0040 – In the late evening of 03 May 2003, in clear conditions with moderate winds from the north-northwest, the Shinei Maru No. 85 was outbound from Halifax Harbour when it ran aground near Portuguese Cove. Two fuel tanks were breached, causing the loss of a considerable amount of marine diesel oil. The master of the vessel held a marine engineer certificate and was unqualified to serve as master.
Occurrences in Canada involving issues relating to maintenance that was not carried out in accordance with the original equipment manufacturer's recommendations
M14P0023 – On 11 February 2014, at approximately 0305 Pacific Standard Time, the tug Jose Narvaez, while towing the empty barge TCT 8000 down the South Arm Fraser River, British Columbia, sustained a loss of propulsion due to a main engine seizure. The investigation determined that the lubricating oil in the engine was contaminated; a complete flush and cleaning of the lubricating oil system had never been done.
M13W0057 – On 23 April 2013, at approximately 0818 Pacific Daylight Time, the fishing vessel American Dynasty experienced a complete loss of electrical power (blackout) while approaching the graving dock in Esquimalt, British Columbia. The vessel was under the conduct of a docking pilot and was being assisted by 2 tugs at the time. Following the blackout, the American Dynasty gained speed to an estimated 5 knots, veered to starboard, and struck the HMCS Winnipeg, which was berthed nearby at the Canadian Forces Base Esquimalt. There was extensive damage to both vessels and minor injuries were sustained by 6 shipyard workers on the HMCS Winnipeg. The investigation found that on-board maintenance of some of the safety-critical equipment on board, namely the back-up batteries and the whistle, did not follow an established schedule to ensure regular testing and servicing.
The investigation found that the port propulsion clutch on the Arca 1 failed. Due to the resulting reduced propulsion and the adverse environmental conditions, the vessel was unable to make headway, drifted to the shoreline, and went aground.
The analysis will focus on manning and crew roles, voyage planning, and the maintenance of vessel equipment.
Factors leading to the grounding
Although the master estimated that the voyage to Sydney, Nova Scotia, would take 12 hours, in reality 15 hours would have been required. This additional 3 hours of transit shortened the time available for the vessel to arrive at Sydney before the weather deteriorated.
When port propulsion was lost as a result of the failure of the port propulsion clutch, the available propulsion power was reduced by 50%, reducing the vessel's speed to approximately 6 knots. Following the reduction of speed, the increased time required to complete the passage prevented the vessel from arriving at Sydney before the weather deteriorated. In the severe weather, the vessel gradually lost headway and ultimately drifted to the west.
The anchor was deployed but could not hold and dragged. The crew raised the anchor with the intent of redeploying it later. A few minutes later, the vessel hit bottom, rendering the starboard Z-drive inoperative. The anchor was set again, but the vessel kept drifting west towards the shore until it ultimately ran aground.
Vessel manning and crew roles
To ensure safe and efficient operation at all times, a vessel is required to carry certificated officers as well as certificated and non-certificated ratings of a sufficient number and grades/capacities as laid out in the vessel's flag state's Minimum Safe Manning Certificate (Appendix C).
The Seafarer's Training, Certification and Watchkeeping Code (the STCW Code), an annex to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (the STCW Convention) sets out mandatory minimum standards for masters and engineers. A master should be qualified to carry out the tasks, duties, and responsibilities required to plan and conduct safe navigation; manoeuvre and handle the vessel in all conditions; moor and unmoor the vessel safely; and maintain a safe navigational watch. A vessel engineer should be qualified to carry out the tasks, duties, and responsibilities required to operate and monitor the vessel's main propulsion and auxiliary machinery and evaluate the performance of such machinery; manage and perform fuel and ballast operations; maintain the safety of the vessel's engine equipment, systems, and services; and maintain a safe engineering watch.
In this occurrence, the flag state required the master of the Arca 1 to be certificated according to STCW Regulation II/2, the engineering officer to be certificated according to STCW Regulation III/1, and the motorman to be certificated according to STCW Regulation III/4. Before 16 December 2016, the vessel's Articles of Agreement documented the master as master and the second mate as second mate. On 16 December, the master amended the vessel's Articles of Agreement by changing his capacity to chief engineer and the second mate's capacity to master in order to comply with the vessel's Minimum Safe Manning Certificate requirements. However, during the voyage, these crew members continued to perform the roles originally documented in the vessel's Articles of Agreement.
The investigation determined that, as a result of some crew members' performing roles for which they were not qualified, certain critical tasks were not carried out, and others were performed ineffectively.
The master, who was not qualified to serve in that role on the Arca 1, carried on assuming the role of master during the voyage and made critical decisions, such as the decision to sail on the day of the occurrence. Because he did not serve the role of chief engineer, for which he was qualified, the primary oversight of the mechanical systems during the voyage was left to the motorman, who was not a qualified chief engineer. Thus, there was no formal oversight of the vessel's mechanical systems by a qualified engineer.
During the voyage, the master was not qualified to serve in that role on the vessel, and the motorman was not qualified to act as chief engineer.
As was demonstrated in both a previous marine accident and this occurrence, if crew members are not qualified for the positions to which they are assigned, they may not carry out these duties effectively, increasing the risk of accident or injury.
The characteristics of an effective voyage plan, set out in the International Maritime Organization's resolution Guidelines for Voyage Planning, include the taking into account of all relevant information, including any vessel limitations or restrictions, and planning for contingencies, such as proceeding to a port of refuge or safe anchorage in the event of any emergency necessitating abandonment of the voyage.
A voyage plan from Sorel, Quebec, to Shelburne, Nova Scotia, was prepared during the port state control inspection process, but it listed only the intermediate ports as well as a list of charts covering the voyage and did not include details such as the limitations of the authorization or any accounting for contingencies.
Once the Arca 1 was diverted to Îles-de-la-Madeleine, the voyage plan was not revised. In the passage to Sydney no ports of refuge or safe anchorages had been identified, and none were sought after the vessel lost port propulsion. The vessel carried on with the voyage toward Sydney.
The voyage planning was carried out in a manner that was inconsistent with best practices: contingencies and limitations were not taken into account.
Decision to sail
Because the vessel was not designed for long seagoing passages, the Panama Single Voyage for Delivery Authorization prohibited departure if the current weather conditions were of Beaufort 7 or if waves of 4 m were expected within a period of 24 hours.
Although the master was aware that sea conditions in excess of the limitations imposed by the Single Voyage Delivery Authorization were forecast for the morning of 08 January 2017, he chose to sail on 07 January.
The decision to sail was not consistent with the limitations imposed on the vessel in its Single Voyage for Delivery Authorization, given that seas in excess of 4 m were forecast to develop within 24 hours.
Vessel equipment maintenance
Vessel machinery requires a certain level of maintenance to be conducted to reduce the risk of machinery failure. Maintenance procedures are usually established according to the original equipment manufacturer's recommendations. For the port main propulsion clutch, the original equipment manufacturer's operating manual stated that clutch tension should be checked and adjusted if necessary when a new clutch plate is installed and during the wearing-in process. The manual stated that, after wear-in, the clutch adjustment should be checked regularly. Clutch slippage indicates that clutch adjustment is required.
The crew was not aware of previous maintenance carried out on the vessel, and the vessel had been out of service for 2 years. The clutch had been visually inspected, and its operation was verified before departure; however, the tension on the main propulsion clutch was not checked and adjusted before or during the voyage as per the original equipment manufacturer's recommendation. Clutch slippage occurred and caused the loss of port propulsion.
If vessel maintenance is not carried out as per the original equipment manufacturer's recommendations, the equipment may fail, increasing the risk of accident or injury.
Findings as to causes and contributing factors
- The tension on the main propulsion clutch was not checked and adjusted before or during the voyage as per the original equipment manufacturer's recommendation. As a result, clutch slippage occurred and caused the loss of port propulsion.
- When the port propulsion clutch failed and port propulsion was lost, the available propulsion power was reduced by 50%.
- Following the reduction of speed, the increased time required to complete the passage prevented the vessel from arriving at Sydney, Nova Scotia, before the weather deteriorated.
- In the severe weather, the vessel gradually lost headway and ultimately drifted to the west.
- The anchor was deployed twice, but could not hold and was dragged. The vessel drifted west toward the shore until it ultimately ran aground.
- The master was not qualified to act as master of the vessel and the motorman was not qualified to act as chief engineer.
- The voyage planning was carried out in a manner that was inconsistent with best practices, as contingencies and limitations were not taken into account.
- The decision to sail was not consistent with the limitations imposed on the vessel in its Single Voyage for Delivery Authorization, given that seas in excess of 4 m were forecast to develop within 24 hours.
Findings as to risk
- If crew members are not qualified for the positions to which they are assigned, they may not carry out these duties effectively, increasing the risk of accident or injury.
- If vessel maintenance is not carried out as per the original equipment manufacturer's recommendations, the equipment may fail, increasing the risk of accident or injury.
Safety action taken
Following the occurrence, the company informed the TSB that it had taken the following measures to address safety concerns and avoid occurrences in the future:
- The owner brought the vessel to its ﬁnal destination in Mazatlán, Mexico, on board a heavy-lift transport.
- An agreement has been signed with Lloyd's Register to certify the vessel and the company's management processes under international safety management rules.
- The company has contracted Lloyd's Register to certify the vessel, limited to operations in ports and short-distance coastal navigation.
- The company has contracted Mexican (flag) maritime authorities to certify the vessel, limited to operations in ports and short-distance coastal navigation.
This report concludes the Transportation Safety Board of Canada's investigation into this occurrence. The Board authorized the release of this report on . It was officially released on .