Watchlist issue of safety management and oversight highlighted in June 2016 close-quarters crossing in Halifax Harbour, Nova Scotia
Dartmouth, Nova Scotia, 14 September 2017 – In its investigation report (M16A0141) published today, the Transportation Safety Board of Canada (TSB) identified that misinterpretation of radar information, a lack of situational awareness, and resulting decisions made in conditions of poor visibility led to the June 2016 close-quarters crossing in Halifax Harbour, Nova Scotia.
On the morning of 29 June 2016, the passenger vessel Summer Bay departed Halifax Harbour under thick fog conditions with 39 people on board. While the Summer Bay was outbound, the cruise ship Grandeur of the Seas with about 2770 people on board was making its way into the harbour. The pilot of the Grandeur of the Seas contacted the master of the Summer Bay in order to make passage arrangements. The master informed the pilot that the Summer Bay would keep well clear by staying to the west of the cruise ship. Shortly after making this arrangement and continuing as agreed, the Summer Bay suddenly altered course and crossed the bow of the cruise ship at a distance of about 25 metres.
The investigation determined that, after making the passage arrangements, the master of the Summer Bay, with limited experience operating under conditions of poor visibility in Halifax Harbour, misinterpreted radar information. The master also had an inaccurate mental model of the situation, which included the erroneous belief that there was a shoal on his starboard side. Based on the misinterpreted radar data and his limited knowledge of Halifax Harbour, the master decided to make a last-minute course alteration with insufficient information to determine whether it could be done safely. This decision placed the Summer Bay in a close-quarters situation with the Grandeur of the Seas. If vessel operators do not have standard operating policies, practices, and procedures in place, there is a risk that vessels will not operate safely. Although not required by regulation, the Summer Bay did have a safety management system (SMS) in place but it had not been audited by an outside entity. Further, the SMS on board the Summer Bay provided no guidance for navigation in restricted visibility or guidance on operating in Halifax Harbour when vessel traffic is present.
Safety management and oversight is a Watchlist 2016 issue. An operator's SMS must be thorough in accounting for all operating conditions that pose a risk to operators, such as operating in low visibility conditions, as in this occurrence. It is also important for an SMS to be audited by an external party.
Since this occurrence, the operator of the Summer Bay has developed standard operating procedures for its vessel masters operating in reduced visibility conditions and commissioned an external audit of its safety management system.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation 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
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