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News release

Associated links (M17A0390)

Conflicting information and ineffective communication led to the 2017 grounding of the SBI Carioca near the Port of Belledune, New Brunswick

Dartmouth, Nova Scotia, 14 January 2019 – In its investigation report (M17A0390) released today, the Transportation Safety Board of Canada (TSB) found that conflicting information about the location of a pilot boarding station and ineffective communication between the pilot and the bridge team led to the October 2017 grounding of the bulk carrier SBI Carioca near the Port of Belledune in Chaleur Bay, New Brunswick.

On 11 October 2017, while approaching the Port of Belledune, the SBI Carioca reached a nearby boarding station to meet the pilot responsible for guiding it to its destination pier. After the boarding got delayed by a few minutes, the pilot was on the bridge at 6:55 a.m. Atlantic Daylight Time (ADT) and, following a brief exchange of information with the master, initiated a series of manoeuvres to reposition the vessel for its approach to the pier. At 7:20 a.m. ADT, the vessel ran aground within the 10-metre depth contour near the port. With no sign of damage nor pollution, and no injuries to the 23 people on board, the vessel was refloated on the next high tide with the assistance of two tugboats.

The investigation determined that the absence of clear, published information about the position of the Port of Belledune's pilot boarding station contributed to the vessel being closer to the pier than was practical for a safe approach when the pilot boarded the SBI Carioca. As this occurrence demonstrates, bringing a pilot on board without sufficient time to manoeuvre may be detrimental to a vessel's safe approach to a pier.

The investigation also found that the pilot navigated the vessel using only visual references and did not request or receive feedback from the bridge team. An ongoing exchange of information and teamwork, which are key principles of bridge resource management, are essential to help create a shared mental model necessary to safely navigate. Since January 2014, the TSB has investigated three other marine occurrences where ineffective communication on the bridge was found to be a risk factor (M16C0005, M14C0193 and M14P0014).

Moreover, if formal passage plans are not devised and shared among bridge team members, there is a risk that members will be unable to effectively monitor the vessel's track and progress. This is why the Board has long recommended that Transport Canada require that pilotage authorities publish official passage plans to enable close and continuous monitoring by ship's personnel. The Board has assessed the Atlantic Pilotage Authority's response to Recommendation M94-34 as Unsatisfactory. The recommendation is still active.

Following this occurrence and at the request of the Atlantic Port Authority, a pilot boarding station symbol was added to Canadian Hydrographic Services charts. The TSB advised the Canadian Department of Fisheries and Oceans and the United Kingdom Hydrographic Office to prompt them to update their respective sailing directions.

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
Media Relations
Telephone: 819-360-4376