Reassessment of the response to Marine Safety Recommendation M95-10
Demonstration of BRM by all navigation officers prior to receiving a Continued Proficiency Certificate
The Transportation Safety Board of Canada (TSB) has released the final report on its Safety Study of the Operational Relationship Between Ship Masters/Watchkeeping Officers and Marine Pilots. This study examined safety deficiencies associated with teamwork on the bridge, including communications between marine pilots and masters/officers of the watch (OOW) on Canadian and foreign vessels, over 5,000 gross registered tons, that were under the conduct of pilots in Canadian pilotage waters.
The study was done in two phases. The first phase involved analyzing 273 occurrences where vessels were under the conduct of a pilot in Canadian pilotage waters; most of these involved misunderstandings, inattention or a lack of communications. Vessels greater than 5,000 gross registered tons were involved in 87% of these 273 occurrences.
The 273 occurrences were made up of five types:
The Board, concerned by the frequency and potential consequences of such occurrences, conducted a preliminary examination consisting of a review of these 273 occurrences. For each occurrence, the most significant factor contributing to the occurrence was identified.
There were 200 accidents identified as involving human factors, and 84 (42%) involved misunderstanding between pilot and master, inattention by the pilot or the officer of the watch (OOW) or a lack of communication between the pilot and the OOW. In addition, 91 (46%) involved misjudgment by the pilot or master. Breakdowns in communication or teamwork on the bridge appear to be implicated in many of these marine occurrences.
As a result of its preliminary examination, the Board decided to study the conditions or practices which lead to such breakdowns, with a view to identifying safety deficiencies.
In the second phase, a questionnaire was distributed to 1,300 individuals including pilots, masters and ship officers to identify issues relevant to the interaction among the bridge team. After the responses to the questionnaire were analyzed, supplemental interviews were conducted with representatives from pilotage authorities, the shipping industry and the Canadian Coast Guard. In addition, recent occurrences were reviewed in light of the information gleaned from the results of the questionnaire. Some of the key findings that came out of the study included: inadequacy of bridge teamwork; reluctance of bridge crew to question pilot's decisions; inadequacy of information being passed between pilots and masters/OOWs and masters/OOWs and pilots; misperceptions that the other party has the necessary information; inadequate knowledge of the operating language preventing effective communication between the pilot and bridge crew; disagreement on the extent to which the OOW monitors the vessel's conduct while under the control of a pilot; and the absence of Bridge Resource Management (BRM) training in Canada.
The Board found that differences in perceptions and expectations between pilots and masters/OOWs contribute to a lack of mutual understanding between the groups. Because of the potentially serious consequences of these misunderstandings, the Board felt that strong measures were required to improve bridge team effectiveness through enhanced information exchange and made two recommendations to that effect: one concerning a formal exchange of information between the master and the pilot before the pilot commences duty, and the other concerning training for Canadian pilots and ship officers to include practice on hand-over procedures.
The TSB considers that close and continuous monitoring of a vessel's progress following an agreed passage plan is essential for the safe conduct of a vessel. In order for OOWs to effectively monitor the vessel's movements, they should know the pilot's passage plan. In December 1994, the TSB issued a recommendation to Transport Canada (TC) to require pilotage authorities to publish official passage plans for compulsory pilotage waters in order to facilitate monitoring of the pilot's actions by the vessel's bridge team. The Board has now further recommended that pilots, as part of their hand-over briefing, obtain the master's agreement to the intended passage plan and invite the OOW to monitor the vessel's position at regular intervals with respect to the agreed plan. BRM, the managing of human and technical resources in an operational marine environment, is a function comprising several elements. These include the application of effective communication, the use of briefings and debriefings, and the creation of an environment where all members of the bridge team feel free to question assumptions and actions.
TSB Recommendation M95-10 (October 1995)
Misunderstanding among the bridge team, lack of adequate information exchange, incomplete understanding of the intended manoeuvres, loss of situational awareness, absence of monitoring of the ship's progress, etc., as evidenced by the Canadian marine occurrence experience, are symptomatic of more fundamental problems in bridge practices. Such factors suggest deficiencies in the effectiveness of current bridge team management practices in compulsory pilotage areas.
A lack of teamwork on the bridge of vessels in Canadian pilotage waters is continuing to compromise safe navigation. The recent occurrences involving the "CONCERT EXPRESS", the "LAKE ANINA", the "MALINSKA", the "HALIFAX" and the "IRVING NORDIC" all point to a lack of communication and cooperation as contributing factors in the occurrences.
As it has stated in the past, the Board continues to believe that increased emphasis on information exchange and coordination could improve bridge team management and therefore advance safe navigation. Systematic instruction of ship officers and marine pilots in operating practices and procedures designed to facilitate information exchange and coordination among all members of the bridge team is required.
The overwhelming majority of pilots, masters and bridge officers who responded to the Board's questionnaire rated teamwork as important as technical proficiency for safe navigation. However, less than half of those who responded stated that they always worked as a team. The accident record confirms that current bridge procedures and practices frequently reflect an absence of teamwork.
In rejecting the Board's Recommendation M94-34 regarding passage planning, the Department of Transport stated (22 March 1995):
However, it is believed that a more effective bridge resource management regime (including enhanced communication between the pilot and the officer of the watch), rather than a voyage plan, may potentially have contributed to the incident being avoided.
The Board notes the intention of the Department of Transport to develop optional training courses in Bridge Resource Management. However, the Board is concerned that optional training might not have the desired effect within the industry. Not all the major constituents of the marine industry have indicated strong support for such training.
Bridge Resource Management, the managing of human and technical resources in an operational marine environment, is a function comprising several elements. These include the application of effective communication, the use of briefings and debriefings, and the creation of an environment where all members of the bridge team feel free to question assumptions and actions.
As a result of the problems identified in this study relating to the absence of handover briefings, the ineffective monitoring of the vessel's position and in view of the frequency of occurrences involving demonstrated breaches of sound teamwork principles, the Board recommends that:
The Department of Transport require that all ship officers demonstrate skills in Bridge Resource Management before being issued Continued Proficiency Certificates.TSB Recommendation M95-10
Transport Canada's response to Recommendation M95-10 (January 1996)
The current Masters and Mates Examination Regulations do not deal with Continued Proficiency. The "Certification Regulations" which have been published in the Canada Gazette Part 1 deal with Continued Proficiency. These latter Regulations, once in effect, will initiate the Continued Proficiency process for Canadian certificates of competency.
The section of the Certification Regulations dealing with Continued Proficiency does not currently require any demonstration of proficiency for serving seafarers. Appropriate Continued Proficiency examinations or courses are only required by those seafarers who do not qualify under the service options.
There has been some informal discussion at CMAC meetings on the requirement for some type of compulsory courses or examination in safety critical items, as a part of the Continued Proficiency process. These, however, have not yet been formalized to the extent they have become an agenda item for a sub-committee meeting.
The Minister of Transport accepts the recommendation.
The Department of Transport will promote the development and provision of Bridge Resource Management training courses by marine training institutions in Canada. There can be a requirement for prior completion of an approved Bridge Resource Management training course when they are available in Canada. The Department of Transport will phase in this requirement consecutively for certificate groups (MM, CFGS, ONl, CNl, and CP for this group), (ON2, CN2, WKM, and CP for this group), and (CFLR, 1MFLR, CHT350, CHT350S, and CP for this group), (CFV1, CFV2, and CP for this group).
TSB assessment of the response to Recommendation M95-10 (March 1996)
Recommendations M95-09 and M95-10 state that current radar courses address issues related to BRM training, recent discussion by the staff with a radar instructor from the Institute Maritime du Quebec (IMQ) pointed out that very little time is actually devoted to BRM during the SEN I and SEN II courses. (SEN I course focuses on anti-collision while SEN II course includes radar navigation and anti-collision.) Consequently, the IMQ is preparing BRM courses as distinct training for pilots, ship masters and officers. Furthermore, although there are presently no compulsory requirements for BRM training, TC intends to promote the development and the provision of BRM training courses and plans to phase in such requirements starting with higher level certificates.
Concerning recommendation M95-ll, TC and Pilotage authorities intend to promote the inclusion of a BRM training course for applicants and holders of pilot licences and pilotage certificates. So far, TC prefers to include such a requirement in the certificates of competency and continued proficiency endorsements. Although TC's response does not provide any specific action plan and falls short of compulsory BRM, it is viewed as a positive approach.
The TSB considers TC's response to M95-10 (and M95-09 and M95-11) to be Satisfactory in Part.
Transport Canada's response to Recommendation M95-10 (January 2014)
According to the STCW Convention, there is no requirement to mandate BRM training for the renewal of certificates of competency. The BRM is only mandated for the issuance of a certificate of competency.
However, in accordance with Regulation I/14 of the STCW Convention and sections 205 & 206 of the Marine Personnel Regulations, companies are responsible for the assignment of seafarers for service on their ships and must ensure that seafarers assigned to any ships have received refresher and updated training as required by the Convention and that the seafarers assigned to any of their ships, are familiarized with their specific duties and all ship arrangements, installations, equipment, procedures and ship characteristics that are relevant to the routine or emergency duties.
TSB reassessment of the response to Recommendation M95-10 (March 2014)
Among the STCW Manila amendments in 2010 was the requirement to introduce mandatory training in resource management, leadership and teamworking skills at the operational level, and leadership and managerial skills at management levels. Seafarers holding certificates issued in accordance with the provisions of STCW will have to complete the necessary training to obtain their certificate of competency by 01 January 2017. While it is noted that TC is taking measures to ensure that seafarers seeking new certificates of competency will be required to have BRM training, there was no information to indicate whether holders of the existing certificates of competency will be grandfathered, and thus not required to have any BRM continued proficiency training.
Therefore the assessment of the response to recommendation M95-10 remains Satisfactory in Part.
Transport Canada's response to Recommendation M95-10 (December 2014)
Transport Canada's response reiterated information provided in its response of January 2014 and indicated the following:
According to the STCW Convention, there is no requirement to mandate BRM training for the renewal of certificates of competency. The BRM is only mandated for the issuance of a certificate of competency.
However, in accordance with Regulation I/14 of the STCW Convention and sections 205 & 206 of the Marine Personnel Regulations, companies are responsible for the assignment of seafarers for service on their ships and must ensure that seafarers assigned to any ships have received refresher and updated training as required by the Convention and that the seafarers assigned to any of their ships, are familiarized with their specific duties and all ship arrangements, installations, equipment, procedures and ship characteristics that are relevant to the routing [sic]or emergency duties.
Drafting of the MPR began in September 2014. TC is aiming to publish in the Canada Gazette part I the proposed amendments to the MPR by the end of 2015. Once in force, this will apply to new and renewed certificates.
TSB reassessment of the response to Recommendation M95-10 (March 2015)
TC's response indicated little new substantive information. In accordance with the international STCW Convention requirement for BRM training, which is for new certificates of competency only, the proposed amendments to the Marine Personnel Regulations will require BRM training to be mandatory for obtaining new certificates of competency. However, taking into account that companies are also responsible under the Convention to ensure that crews receive refresher and updated training, and for effective communication on board the vessel, and recognizing that there are more seafarers who have received BRM training since the recommendation was issued, once TC amends the regulations to give effect to the STCW requirement for BRM training, the safety deficiency identified in the recommendation will be substantially mitigated.
Therefore the assessment of the response to recommendation M95-10 is changed to Satisfactory Intent.
Transport Canada’s response to Recommendation M95-10 (March 2016)
Transport Canada’s response indicated that it is in the process of amending TP 4958, Simulated Electronic Navigation Courses. The amendments will require BRM competency and knowledge to be added to the Simulated Electronic Navigation (SEN) at the operational level training course (for OOWs) and at the management level (for masters and mates). A status on the amendment is to be presented at the April 2016 meeting of the Canadian Marine Advisory Council, and it is expected that a draft of the TP will be available by September 2016.
The response also noted that drafting of the Marine Personnel Regulations began in September 2014 and TC is aiming to publish its proposed amendments to the MPR by the end of 2016. Once in force, the amendments to the MPR will apply to both new and renewed certificates.
TSB reassessment of the response to Recommendation M95-10 (March 2016)
Once the changes to TP4958, Simulated Electronic Navigation Courses are in force, mandatory training in BRM will be incorporated into all SEN courses, which is required for new and renewed certificates. Once TC requires all ship officers to demonstrate skills in BRM before being issued Continued Proficiency Certificates, the safety deficiency underlying this recommendation will be addressed.
Therefore, the assessment of the response remains Satisfactory Intent.
Transport Canada's response to Recommendation M95-10 (May 2016)
TC Marine Safety and Security presented the status of TP4958 at the April, 2016 CMAC. A draft of the TP4958 will be available by September 2016. In addition, there will also be a draft Leadership and Teamwork TP available in September 2016. The competency and knowledge outlined in the STCW 2010 with the Manila Amendments for Bridge Resource Management will be met at the operational level (Officer of the Watch) once a candidate has completed the Leadership and Teamwork training course (LTW) and Simulated Electronic Navigation at Operational Level (SEN-O) training course. Candidates at the Management level (Master and Chief Mate) will review the competency and knowledge for Bridge Resource Management in the Leadership and Managerial Skill course (LMS) and Simulated Electronic Navigation at Management Level (SEN-M).
TC Marine Safety and Security is aiming to publish the Marine Personnel Regulations in the Canada Gazette part 1 by mid-2017. Once in force, the Leadership Training Courses will be mandatory only for a new Certificate of Competency.
In the interim a policy will be developed. This policy will require any candidate wishing to acquire a new or higher level Certificate of Competency to complete the require Leadership training course. It will also require the candidate to complete the required simulated electronic navigation training course for that level.
Transport Canada's response to Recommendation M95-10 (December 2016)
TC Marine Safety and Security presented the status of TP4958 at the April 2016 CMAC. A draft of the TP4958 is available for Course Providers to elaborate the new training. In addition, a draft TP of Leadership, Teamwork and Managerial Skills has been provided to Course Providers to elaborate the new trainings (sic) in Leadership and Teamwork and Leadership and Managerial Skills.
The competencies and knowledge related to watchkeeping officers outlined in STCW Convention (including 2010 Manila Amendments) for Bridge Resource Management will be met at the Operational level (Officer of the Watch) once a candidate has completed the Simulated Electronic Navigation training course at Operational Level (SEN-O) and the Leadership and Teamwork training course (LTW).
The competencies and knowledge related to Masters and Chief Mates outlined in STCW Convention (including 2010 Manila Amendments) for Bridge Resource Management will be met at the Management level once a candidate has completed the Simulated Electronic Navigation training course at Management Level (SEN-M) and the Leadership and Managerial Skills course (LMS).
Marine Safety and Security is aiming to publish the revised Marine Personnel Regulations (MPR) in the Canada Gazette, Part I by 2018. Once the MPR in force, Leadership, Teamwork and Managerial Skill training Courses will be mandatory for a candidate who wish (sic) to obtain a new Certificate of Competency (CoC) or to upgrade his current CoC to a higher CoC.
In the interim, a policy has been developed by TC Marine Safety and Security to implement, immediately after January 1st 2017, the mandatory requirements for Leadership, Teamwork and Managerial Skill training Courses. This policy requires that any candidate wishing to acquire a new CoC or to upgrade their current CoC to a higher CoC complete the relevant Leadership, Teamwork and Managerial Skill training Course.
TSB reassessment of the response to Recommendation M95-10 (March 2017)
TC has revised TP4958 to elaborate the new training required for “Leadership, Teamwork and Managerial Skills” which will be mandatory for any candidate who wishes to obtain a new Certificate of Competency (CoC) or to upgrade his current CoC to a higher CoC. Once the proposed TP4958 training curriculum is in force, the deficiency identified in M95-10 will be addressed. As of 01 January, 2017, TC has a policy in place that requires any candidate wishing to acquire a new CoC (i.e., for the first time) or to upgrade their current CoC to a higher CoC complete the relevant Leadership, Teamwork and Managerial Skill Training Course.
However, those candidates who are wishing to renew their CoC (required every five years) will still not be required to obtain training in BRM. Therefore, the assessment of the response has been changed to Satisfactory in Part.
Next TSB action
The TSB will monitor the progress of TC's proposed action.
This deficiency file is Active.
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