TSB # M 01/2004(Gatineau, Quebec, 22 January 2004) - The Transportation Safety Board of Canada (TSB) today re-emphasized that Transport Canada, Fisheries and Oceans Canada and Canadian pilotage authorities, among others, need to ensure that contingency plans are in place to address the serious deficiencies that came to light in the course of the Board's comprehensive investigation of the accident involving the bulk carrier Alcor four years ago. On 9 November 1999 the loaded bulk carrier Alcor was upbound for Trois-Rivières, Québec, on the St. Lawrence River, under the conduct of a pilot. At 1444 local time, while undertaking a course alteration to starboard, the vessel ran aground near the eastern end of Île d'Orléans. A refloating attempt the next evening succeeded in freeing the vessel, but only briefly, and the vessel grounded a second time near the initial grounding position. The Alcor sustained major hull damage near midships due to bending forces incurred during successive low tide cycles.The damaged hull was temporarily repaired and roughly half of the cargo was discharged onto smaller vessels. On 5 December 1999, the Alcor was refloated and conducted to the port of Québec, Quebec. It was declared a constructive total loss.In the course of the investigation, the TSB issued four Marine Safety Information Letters. Details of these and the follow up actions taken can be found in the attached backgrounder. Today, the Board has recommended that: The Department of Transport, the Department of Fisheries and Oceans, and Canadian pilotage authorities, in consultation with marine interests, develop, implement, and exercise contingency plans to ensure that risks associated with navigation-related emergencies are adequately addressed. M03-03The Board also issued a Safety Concern. While acknowledging positive steps taken by pilotage authorities by introducing a methodology for risk-based decision making to address the safety of the Canadian pilotage system and respond to the expectations of users, the Board is concerned that the methodology is limited and has yet to fully address key performance-related issues within the pilot licensing process.The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.-30-The report M99L0126 is also available on this site.BACKGROUNDERGrounding and Constructive Total Lossof the Bulk Carrier Alcor Traverse du Nord, ST. Lawrence River 9 November 1999The Transportation Safety Board, in the course of this investigation, issued four Marine Safety Information Letters (MSI 05/99, 04/01, 05/01 and 06/01) as deficiencies came to light and safety action became necessary: MSI 05/99, which was issued 8 December 1999, addressed to operators and flag states of ships similar to the Alcor (3), as well as the manufacturer of the steering helm unit, pointed out the risk this unit may present due to the unprotected nature, lack of alarm and low detent torque of the steering mode selector switch. This condition could lead to inadvertent, accidental and unknown deactivation of the helm commands from the wheel position. MSI 04/01, dated 24 May 2001 and addressed to Transport Canada, pointed out the shortcomings of working in an ad hoc fashion without the benefit of a structured approach, and stressed the advantages of a risk management model for navigation-related emergencies, including groundings in high tidal amplitude waters. MSI 05/01, sent to the Laurentian Pilotage Authority (LPA) on 18 May 2001, indicated that, in the absence of clear criteria regarding relief of pilots subsequent to an emergency, an occurrence pilot is placed in a difficult position of making a decision on whether or not to remain on board. It emphasized that, under the given circumstances, a pilot may not be the best person suited to make the decision - a decision that may have a significant impact on the safe navigation of the vessel. MSI 06/01 was issued to the LPA on 24 May 2001. This information letter expressed concern that the current training and experience requirements for C-1 pilots, and the methodology used to evaluate them, are such that pilots may not be sufficiently prepared to pilot larger vessels. Further, it highlighted that there is no effective competency-based training and evaluation program to help ensure that candidates possess the required abilities and attain a level of competency commensurate with the appropriate class and sub-class of licence.Among the actions taken following the accident are the following: The Canadian Coast Guard Marine Communication and Traffic Services (MCTS) Québec has documented information in order to develop a simulation scenario for training purposes; has increased internal quality control measures; has reviewed operational procedures in order to increase active participation of VTS officers and improve traffic management; and is instilling the importance of quality decision making in their service. Transport Canada and Fisheries and Oceans Canada signed an Memorandum Of Understanding that defines roles and responsibilities of their officials in the event of marine pollution. Sounding criteria have been established as guidance for salvors. Transport Canada identified the Alcor's three sister ships as well as bulk carriers constructed at the same shipyard over a similar 3-year period as Ships of Particular Interest (SPI) and communicated the information to Port State Control authorities. The Pilot Corporation has made available ship-handling courses to Class C pilots. The Laurentian Pilotage Authority (LPA) began the process of developing a system for assessing pilots' competence and quality of service. A risk evaluation tool was used in 2002 to evaluate; a) compulsory pilotage limits re. vessel size in the region; b) the use of docking pilots in District 2; and c) double pilotage requirements in Districts 1 and 2. The work is ongoing. The LPA regulations were amended in 2002 to require pilots to immediately report accidents or incidents. The manager of two of Alcor's sister ships required protective latches to be installed on the steering mode selector switch of both helm units. One of the two vessels was also repaired following detention by port state control officers in 2000. The Russian Maritime Registry of Shipping has implemented guidelines for surveys of vessels more than 20 years old.
