2011X51 Collision in Port
Collision in Port - Canda Report No OR07
Extracts from an official report produced by the Transportation Safety Board of Canada. It makes interesting reading in respect of the comments by the Board on the psychological factors which could effect persons in control of any mode of transport. The full report can be obtained from: Place du Center, 200 Promenade du Portage, 4th Floor, Hull, Quebec K1A 1KB.
On 06 August 1994, the CATHERINE DESAGNES was alongside the Jonnick Dockin Lorain. At about 1210 she completed discharging a cargo of steel ingots.At about 1228 the vessel left the berth and, because of the limited width of the river off the dock, proceeded upstream to the lower turning basinto swing to head out to Lake Eire. While attempting to swing, the CATHERINE DESAGNES became temporarily embedded in the soft river bed; because of this and the reported moderate northerly breeze, the vessel could not be swung to head down river until about 1430, after much manoeuvring.
At about 1435, in the vicinity of the Jonnick dock, the CATHERINE DESAGNES sounded one long and one short blast to request the opening of the Norfolkand Western railway bridge. The vessel passed through the bridge at about1437 while the span was still being raised and the marine traffic signal was still at red. At about 1439, when she was about to negotiate the last bend on the approach to the Charles Berry highway bridge, the vessel sounded one long and one short blast to request the opening of that bridge. The bridge operator acknowledged the signal but, about half a minute later, sounded five short blasts to indicate that the bridge could not be opened in time.
The CATHERINE DESAGNES attempted to stop by going full astern and dropping the port anchor but she sheered to starboard out of the channel and through a marina complex before she came to a stop with the fore part of the vessela gainst the embankment which comprises of the eastern approach to the bridge. The time was approximately 1442. Floating docks and pleasure craft were damaged and sunk as the CATHERINE DESAGNES ran into the marina. Further damage was inflicted when the bridge was open and the vessel backed up and turned, preparatory to making her way through the bridge. The vessel did not follow the directions from the US Coast Guard (USCG) to remain in position in the marina but, after clearing the bridge, the CATHERINE DESAGNES was secured at a berth at the river mouth on the instructions of the USCG.
There were no injuries to persons reported and no apparent structural damage to the CATHERINE DESAGNES but 12 pleasure craft were sunk, 33 boats damaged to varying degrees and the marina dock facilities were damaged. Several hundred litres of gasoline were released by a number of the pleasurecraft sunk or damaged in the occurrence. The resulting gasoline fumes caused the bridge to be closed to road traffic for 4_ hours. Booms were deployed to facilitate the containment and recovery of the leaked gasoline.
The inquiry revealed that the Master had begun a career in the marine industry in 1939, gained a Master Mariner's Certificate in Canada in 1954,was a qualified Great Lakes Pilot and had been employed as an unrestricted Pilot in International District No.2 from 1964 to 1987 during which time he had made several calls at Lorain Harbour. He had been engaged by the owners of the CATHERINE DESAGNES as Master on a casual basis since 1988 and the vessels he commanded and which were under his conduct had been granted pilotage exemptions for all districts under the Great Lakes Pilotage Authority.He had called at Lorain three times while employed on that vessel. The Chief Officer had been going to sea since 1967 and held a Master Mariner's Certificate of Competency issued in Canada in 1987. She had been employed by the owners since 1987, during which time she had served on occasion as Master, but mainly as Chief Officer.
For the vessel's outward passage down the Black River, the Master and the Chief Officer were on the bridge, with the Quartermaster at the helm and the Second Officer together with the Bosun on the fo'c'sle. The Master had conduct of he vessel, the Chief Officer's duties were not specific but she was occupied with monitoring the Quartermaster and estimating the vessel's distance from the shore. The Chief Officer also recorded the vessel's progress by noting the times of passing certain points but did not use this information to monitor the vessel's speed.
The CATHERINE DESAGNES made "Securité" calls on VHF Ch 16 ninety minutes before departing and the railway bridge operator was advised by the vessel's agent that the ship would be leaving Jonnick Dock at about 1400. Communication with the Bridge Operators was by means of sound signals. There was no VHF communication between the vessel and the bridge operators. The speed limit in Lorain Harbour is 5.2 knots and the distance from the lower turning basin to the first highway bridge is approximately 11 cables. It was estimated that the CATHERINE DESAGNES travelled the 11 cables in about 12 minutes, giving an overall average speed of about 5.5 knots. The speed over various sections has been estimated as follows:
| Sector | Distance (cables) |
Time (minutes) |
Est. Speed (knots) |
|---|---|---|---|
| Turning Basin to Jonnick Dock | 3.7 | 5 | 4.44 |
| Jonnick Dock to railway bridge | 2.0 | 2 | 6.00 |
| Railway bridge to sounding highway bridge signal | 3.3 | 2 | 10.00 |
| Highway bridge signal to bridge embankment | 2.0 | 3 | 4.00 |
When clearing the turning basin, the vessel briefly dropped the starboard anchor while manoeuvring to clear a barge and, when approaching the railway bridge, the main engine was turning full astern and an anchor dropped again in an attempt to stop the vessel. These actions would result in a reduction in the apparent average speed in the relevant sectors. The river current at the time was negligible. The average speed was 5.5 knots. However, as the vessel did not come to an abrupt stop and, on two occasions, was running the main engine astern and/or dragging the anchor, it is apparent that she significantly exceeded the speed limit for part of the passage.
Situational awareness has been defined as "an accurate perception of the factors and conditions that affect a vessel and its crew during aspecific period of time". Persons in charge of the conduct of the vessel have to maintain situational awareness to navigate safely. To maintain situational awareness, a person scans for signals or cues which can be interpreted to reveal important information such as location, speed, and the presence of hazards. When performing routine tasks, a person expects certain cues and will use these cues to quickly confirm the assessment of the situation and take what is apparently appropriate action without referring to other information which may conflict with the evaluation. A person tends to acquire information that confirms a hypothesis and ignore conflicting data. This tendency is called "hypothesis locking or confirmation bias". Frequently, it takes the intervention of another person with contradictory information to overcome such a bias. Once a hypothesis is adopted, it is very resistant to change; the phenomenon has also been described as "reality construction". When persons are stressed, there is a tendency for their attention to become even more narrowed, so that even the cues which are present are missed, ignored, or discounted. Stress can also affect the perception of time. Understressful conditions, people overestimate the amount of time which has passed.
Different types of skills, once learned, are subject to degradation at different rates if not practised for periods of time. Continuous movement or psychomotor skills, such as steering, guiding or tracking, are relatively impervious to decay. The skills needed to satisfactorily complete complex cognitive tasks requiring information processing, problem solving, recalling bodies of information, and communication between personnel, however are subject to relatively rapid decay, within weeks if not practised. Success at psychomotor tasks can lead persons to the conclusion that their skills have not decayed when, in fact, the more difficult and important cognitive skills are degraded.
The Master had retired almost seven years before, after a full working career, and had only been casually employed in the intervening period. Insuch circumstances, complex cognitive skills are subject to decay becausethey are not practised regularly. The Master stated that, when he was preoccupiedwith the navigation of the vessel, his concentration was focused ahead, on where he was going. He did not observe several important factors, such as the railway bridge not being fully raised, the railway bridge signal still being red when the vessel passed through, and the extent of the damage the stern and the propeller were causing when backing up in the marina. The instructions of the USCG were also not perceived as such. The failureto recognise critical elements significant to the navigation of the vesseland the less controlled manner in which the vessel was navigated are considered to be consistent with the behaviour of a person exposed to stress or agitation and experiencing some degree of skill decay. The consequences became critical because the Master did not have adequate back up in the form of resource management on his bridge to provide a line of defence against inappropriate actions and reactions.