A fuel tanker ran aground in Nunavut in 2014 after its fatigued crew made a wrong turn in Chesterfield Inlet, says a report by the Transportation Safety Board (TSB) released Monday.

The merchant vessel Nanny ran aground Oct. 14, 2014 while travelling through the inlet on its way to deliver fuel to the community of Chesterfield Inlet after doing the same for Baker Lake. It was the second time in three years the Nanny, owned by Coastal Shipping Limited of Goose Bay, had run aground in the region.

In this incident, the vessel was navigating the narrow, shallow inlet in the dark when the master ordered a helmsman to make a turn to port. The helmsman repeated the order but made a turn to starboard. When the master ordered an increase in the angle of the turn to port, the helmsman increased the angle but again in the wrong direction.

"You can think of it like being really tired in the morning and accidentally putting the jug of milk in the cupboard," said Wendy Jolliffe, the marine accident investigator with the TSB who authored the report.

​The failure in communication, coupled with the strong tide and limited sea room available, resulted in the Nanny striking bottom at Deer Island.

At the time, the Nanny had a partial cargo of diesel on board. The TSB report says "no pollution or injuries were reported, but there was damage to the ballast tanks, including a crack that allowed water ingress."

"Because the Nanny was a double bottom tanker, it was only the ballast tank that was punctured, so the risk of pollution was reduced," said Jolliffe.

The failure of communication coupled with the strong tide and limited sea room available resulted in the Nanny touching bottom at Deer Island. At the time, the Nanny had a partial cargo of diesel on board. (Transportation Safety Board)

The report finds that the helmsman incorrectly applied the helm order because of extreme fatigue and lack of sleep in the period leading up to the incident.

"When you look at the times it's a very, very limited time, the helmsman actually realized his error in under a minute and correctly applied the helm," said Jolliffe.

Causes and contributing factors

The TSB report found:

The helmsman incorrectly applied two orders, which caused the vessel to start swinging in the opposite direction of the intended course

Upon realizing that the vessel was not turning the intended way, the master continued to repeat the same command without re-evaluating the situation

At the time of the occurrence the master and helmsman were fatigued

Ineffective fatigue management on the vessel contributed to the master and helmsman being tired while on duty

The officer of the watch was not monitoring the vessel's progress to be able to detect the helmsman's error

The navigation procedure used by the bridge team were not adequate to effectively navigate the vessel

Small crew, rigorous schedule, little sleep

Despite the large size of the vessel, the Nanny had a relatively small crew with two watches. One team would work while the other was on leave to rest and sleep.

The officer of the watch was not assisting the master to navigate, and no one noticed the error in the direction applied by the helmsman. (Transportation Safety Board)

The report found that other tasks, including the needs of shore-side schedules, meant that while the crew was given approximately eight hours on the schedule to sleep, in actuality they were only able to sleep for about half of that time.

"Analysis of the master, helmsman, and OOW's [officer of the watch] self-reported hours of work and rest all indicated disruption to their sleep periods, especially the night before the occurrence," states the report.

Some issues flagged in the TSB report include the need for the development of marine regulations on fatigue management plans so that the risk of accidents is mitigated for those in safety-critical positions.

Failure to communicate

The TSB report also says the bridge crew was not communicating effectively. The officer of the watch was occupied doing other work and was not assisting the master to navigate, and no one noticed the error in the direction applied by the helmsman, nor did anyone acknowledge the helmsman's statement that he had navigated starboard instead of port as instructed by the master.

The report also finds a need for mandatory training in the principles of bridge resource management for all bridge officers.

"Bridge resource management is a fairly new concept in the marine industry," said Jolliffe.

"Everybody who is on the bridge, who is navigating the vessel, has a say and is responsible for pointing out safety issues."

The report says that since 2007, four vessels have run aground in Chesterfield Inlet, including the Nanny in 2012.

The report notes that a 2010 shipping industry request for new or modified aids such as lights and buoys to help with navigation in Chesterfield Inlet has not been resolved by the Canadian Coast Guard.

The TSB's report on the Nanny's 2012 grounding said lit range beacons would help vessels navigate Chesterfield Narrows safely at night.

"It's much easier to navigate if you can see where you're supposed to go because the water from the surface all looks the same, especially at night," said Jolliffe.

The TSB says that following the Nanny's 2014 grounding, Det Norske Veritas - Germanischer Lloyd (DNV-GL) conducted a review of the safety management system of Coastal Shipping Limited. Based on those findings Coastal Shipping sent a memo to all their vessels informing them of various safety measures including keeping the deck log up-to-date hourly and adhering strictly to rest hours.