MARINE TRANSPORTATION SAFETY INVESTIGATION REPORT M17P0244 BOTTOM CONTACT Tug Ocean Monarch Princess Royal Channel, British Columbia 09 July 2017 ABOUT THIS INVESTIGATION REPORT 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 the result of an investigation into a class 2 occurrence. 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Materials under the copyright of another party Some of the content in this investigation report (notably images on which a source other than the TSB is named) is subject to the copyright of another party and is protected under the Copyright Act and international agreements. For information concerning copyright ownership and restrictions, please contact the TSB. Citation Transportation Safety Board of Canada, Marine Transportation Safety Investigation Report M17P0244 (released 10 January 2019). Transportation Safety Board of Canada Place du Centre 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2019 Marine transportation safety investigation report M17P0244 Cat. No. TU3-7/17-0244E-PDF ISBN: 978-0-660-29125-3 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. TRANSPORTATION SAFETY INVESTIGATION REPORT M17P0244 | III Table of contents Summary .............................................................................................................................v 1.0 Factual information ................................................................................................. 1 1.1 Particulars of the vessels ......................................................................................................................... 1 1.2 Description of the Ocean Monarch ...................................................................................................... 1 1.3 History of the voyage ............................................................................................................................... 3 1.4 Damage to the vessel ............................................................................................................................... 4 1.5 Environmental conditions ....................................................................................................................... 5 1.6 Personnel certification and experience .............................................................................................. 5 1.7 Vessel certification and inspection ...................................................................................................... 6 1.8 Regulatory oversight ................................................................................................................................. 6 1.8.1 Tugs of greater than 15 gross tonnage ............................................................................ 7 1.8.2 Tugs of not more than 15 gross tonnage ........................................................................ 7 1.9 Gross tonnage measurement for tugs ............................................................................................... 8 1.10 Minimum safe manning ........................................................................................................................... 9 1.11 Fatigue .........................................................................................................................................................11 1.11.1 Acute sleep disruptions .........................................................................................................12 1.11.2 Chronic sleep disruptions .....................................................................................................12 1.11.3 Continuous wakefulness ........................................................................................................12 1.11.4 Circadian rhythm ......................................................................................................................12 1.11.5 Disorders, conditions, and medications ..........................................................................13 1.11.6 Task monotony .........................................................................................................................13 1.12 Regulations relating to fatigue ...........................................................................................................14 1.12.1 Hours of work and rest—Canadian waters ....................................................................14 1.12.2 Hours of work and rest—foreign waters ........................................................................15 1.13 Fatigue risk-management strategies ................................................................................................16 1.14 Company management of fatigue ....................................................................................................19 1.14.1 Hours of work and rest ..........................................................................................................19 1.15 Industry context ........................................................................................................................................21 1.16 Company operations ...............................................................................................................................21 1.17 Safety culture .............................................................................................................................................22 1.17.1 Safety management ................................................................................................................23 1.18 Coastal pilotage waivers ........................................................................................................................24 1.19 Mandatory occurrence reporting .......................................................................................................27 1.20 Previous Board safety concern ............................................................................................................28 1.21 Active TSB recommendations ..............................................................................................................28 1.22 Previous occurrences ..............................................................................................................................29 1.23 TSB Watchlist ..............................................................................................................................................30 1.24 TSB laboratory reports............................................................................................................................31 IV | TRANSPORTATION SAFETY BOARD OF CANADA 2.0 Analysis ................................................................................................................... 32 2.1 Factors leading to the bottom contact ............................................................................................32 2.2 Presence of fatigue ..................................................................................................................................32 2.2.1 Acute fatigue ..............................................................................................................................33 2.2.2 Circadian rhythm desynchronization ...............................................................................33 2.2.3 Chronic sleep disruptions .....................................................................................................33 2.2.4 Night operations ......................................................................................................................34 2.2.5 Task monotony .........................................................................................................................34 2.3 Management of fatigue .........................................................................................................................34 2.3.1 Fatigue-management plans .................................................................................................35 2.4 Management of safety ...........................................................................................................................36 2.5 Pilotage waiver compliance ..................................................................................................................37