Marine Investigation Report M91C2004

On 18 March 1991, at approximately 1320, when heading out of Long Point Bay, the CCGS "GRIFFON" collided with the inbound Canadian fishing vessel "CAPTAIN K". Visibility was severely restricted by fog. The "CAPTAIN K" sank almost immediately; the bodies of all three crew members were recovered later from the wreck when the "CAPTAIN K" was salvaged. The fishing vessel was extensively damaged and declared a constructive total loss; the Canadian Coast Guard vessel suffered minor scrapes.

The Board determined that the "GRIFFON", operating at full service speed in reduced visibility, without the use of fog signals, did not correctly identify a radar target ahead of the vessel and take collision avoidance action before the target entered the area of sea clutter. Contributing to the collision was the fact that the "CAPTAIN K" was operating without a serviceable radar.

1.1 Particulars of the vessels

	"GRIFFON"	"CAPTAIN K"
Official number	328110	158606
Port of registry	Ottawa, Ont	Nanticoke, Ont.
Flag	Canadian	Canadian
Type	Type 1100, Major navaidsFootnote 1 Steel trawler, of Lake	tender/light ice-breaker Erie design
Gross Tons	2,212	11.97
Length	71.3 m	18.3 m
Draught	F: 2.74 m	F: 0.9 m
(estimated)	A: 5.0 m	A: 1.8 m
Built	1970, Lauzon, Quebec	1936, Port Dover, Ont. (Re-built) 1940, Port Dover, Ont.
Propulsion	Diesel Electric, two electric motors671 Detroit diesel engine of 1,471 kW each (2,000 SHP)149 kW	(200 BHP) driving a driving twin fixed-pitch propellerssingle fixed-pitch propeller
Owner	Government of Canada	Lynn-Dover Foods Ltd. Port Dover, Ont.

1.2 Description of the vessels

1.2.1 "GRIFFON"

A light ice-breaker/navaids tender, the "GRIFFON" is the type of vessel used by the Canadian Coast Guard (CCG) for buoy handling and small- to medium-ship escort in all areas of southern Canada and the sub-Arctic. During most of the navigational season, the "GRIFFON" operates out of the CCG District Base in Prescott, Ontario. Her primary duty is the placement, servicing and removal of navigational buoys in the upper St. Lawrence River, in western Lake Ontario and in eastern Lake Erie in the vicinity of the Welland Canal. The vessel also services other aids to navigation, takes part in light-station re-supply and maintenance, and carries out ice-breaking duties. In accordance with the policy for all CCG vessels, the "GRIFFON" is assigned to search and rescue (SAR) operations as circumstances demand. The "GRIFFON" can carry a helicopter which extends the range for ice reconnaissance, SAR and medical evacuation missions. The vessel has a listed service speed of 11 knots (kn). The "GRIFFON" has a normal complement of 38 and, although she was only carrying 29 crew members at the time of the collision, there was a full complement of navigating officers on board.

1.2.2 "CAPTAIN K"

The "CAPTAIN K" was typical of the many fishing tugs^{Footnote 3} based in Port Dover in Long Point Bay and engaged in commercial fishing operations on Lake Erie. She was of all-welded steel construction, with a single-chine hull and partially enclosed superstructure extending from bow to stern. There was a single steel working deck, and the hull was not subdivided. The main engine was located directly below the wheel-house, near amidships, and was operated by a single-lever, Morse-type control fitted to port of the helmsman's centre-line steering position. The service speed was 8 kn. All navigation and communications equipment was arranged across the forward part of the wheel-house within reach of the helmsman's chair. The crew's bunks were located immediately aft, to port and starboard, at superstructure deck level, which allowed only one metre of head clearance in the bunks. The only entrance to the wheel-house was a door on the port side from inside the superstructure; no exit hatch was fitted in the wheel-house deckhead, and the wheel-house windows did not facilitate escape. The "CAPTAIN K" was rigged for port- and starboard-quarter stern trawling.

1.3 History of the voyages

1.3.1 "GRIFFON"

The "GRIFFON" had been assigned to recommission navigational buoys for the 1991 navigational season. Arriving in Port Colborne in Lake Erie on the evening of Friday, 15 March 1991, the vessel remained alongside in the port over the weekend. The chief officer (C/O) remained on board as part of the security watch, while the master and the second officer (2/O) were among those who went home, returning to the vessel at 0030^{Footnote 4} , Monday, 18 March. The third officer (3/0) joined the vessel at that time.

The "GRIFFON" departed Port Colborne at 0806, Monday, 18 March, under the conduct of the master, to commence commissioning buoys in the Long Point Bay area. At about 0930, the fog set in. Several buoys were to be commissioned and the "GRIFFON" worked up to full service speed between buoy deployments in the frequently restricted visibility. At approximately 1150, in fully restricted visibility, the 3/O relieved the fourth officer (4/O) on the bridge, and the 4/O went below. The 2/O, who was also on the bridge, remained to assist with the last buoy placements. Shortly after placing buoy "N" at 1245, the vessel was manoeuvred clear of the buoy on a westerly heading and the master handed the conduct of the vessel over to the 3/O. The chief engineer (C/E), who had come up to the bridge at about 1240 to take an incoming call on the cellular telephone, spoke on the phone for about seven minutes and then remained on the bridge after the call was completed.

The 2/O left the bridge at about 1250 and the C/O arrived on the bridge at about 1255/1300. This left the master, C/O, 3/O, C/E and helmsman on the bridge.

From the wheel-house, the C/O observed the deck crew preparing the next buoy which was to be laid in a position approximately 10 miles south of Port Stanley. The master left the bridge to go below to his quarters at a time estimated to have been shortly after 1300. A discussion ensued among the officers on the bridge. The C/O assumed the temporary role of look-out, with the intention of being relieved by one of the crew working on deck.

Visibility was restricted to an estimated 50 to 100 m, with wave heights of about 0.5 m, and the "GRIFFON" was proceeding at full service speed revolutions, averaging 11½ kn since buoy "N", on a gyro (G) course of 153°, gyro error "nil". The starboard radar was on and fog signals were not being sounded. The helmsman suddenly saw an approaching vessel and exclaimed that they were about to hit something. Without direction from either of the navigating officers, he altered the steering lever hard over to starboard. A moment later, with the helm reportedly already hard over to starboard, the C/O ordered hard-a-starboard helm and the 3/O simultaneously ran to the engine controls to put them both to full astern. At that same instant, a collision occurred with what was observed to be a fishing vessel of Lake Erie design that was subsequently identified as the "CAPTAIN K". The time of 1320 and an estimated collision position of 42°36′N, 80°02.7′W were noted by the "GRIFFON". The C/O sounded the general alarm and then broadcast "standby lifeboat" on the vessel's public address system.

Immediately after the impact, the "CAPTAIN K" was seen to be down by the head and rapidly sliding stern first along the starboard side of the "GRIFFON". The "CAPTAIN K" was at an angle of approximately 20 to 30° with her stern away from the "GRIFFON". No signs of life were seen by the "GRIFFON" deck crew who rushed from their tasks to the starboard side to observe the fishing vessel. Until he saw the fishing vessel through the starboard window of his cabin, the master thought that a buoy had been dropped on deck. He then rushed to the bridge. Despite the propellers of the "GRIFFON" turning full astern, the "CAPTAIN K" was some way astern of the "GRIFFON" when the fishing vessel foundered, within an estimated 30 seconds from the time of impact. The "GRIFFON" commenced her own SAR activity and appointed herself "on- scene commander".

1.3.2 "CAPTAIN K"

On the morning of Monday, 18 March 1991, the "CAPTAIN K" left Port Dover at approximately 0600 in order to reach the main fishing grounds off Long Point before full daylight. The destination was an area south-west of Long Point, centred approximately on position 42°28.7′N, 80°11.4′W, where she would fish with the local fleet which consisted of about 20 boats at that time of the year. They were fishing for smelt using fine-mesh trawls, and the "CAPTAIN K" commenced trawling in a NE-SW pattern at about 0800. Sporadically that morning, the "CAPTAIN K" was seen visually by other fishing vessels, notably the "C.J. WEAVER" and the "INGRAM", and was in communication with them. At about 0930, the visibility started to deteriorate in fog, and by 1100 the fog had reduced visibility to less than an estimated 100 m. At about 1115, the trawl doors of the "CAPTAIN K" became crossed and it was decided to haul them in. In addition, fishing had been poor up to that point, as only one tote had been filled. Around 1130, the "CAPTAIN K" indicated to the "C.J. WEAVER" by very high frequency radiotelephone (VHF R/T) that she was finished fishing for the day and was heading back toward port but, if possible, would still try to catch some fish in Long Point Bay. Further VHF R/T calls were made between the "CAPTAIN K" and Omstead Fisheries at Port Dover between approximately 1200 and 1215, about the time when the "CAPTAIN K" was rounding Long Point. The calls were to advise the fish plant of the vessel's progress and the estimated time of arrival in port.

Over the period of time involved, between 1215 and some time after 1320 (the time of notification that a fishing vessel had been struck and sunk), the "C.J. WEAVER" repeatedly tried to call the "CAPTAIN K" on VHF R/T without success.

1.4 Injuries to persons

1.4.1 "GRIFFON"

The collision caused no injuries on the "GRIFFON".

1.4.2 "CAPTAIN K"

All three of the crew members on the "CAPTAIN K" died.

The autopsies performed on the three bodies by the Simcoe County Coroner revealed that two crew members died almost instantaneously at the time of the collision. Their bodies were found in the bunk area of the wheel-house, aft of the steering position, where the full force of the collision was taken. The operator, who was found near the steering position, had sustained massive injuries and drowned shortly thereafter.

1.5 Damage

1.5.1 General

The fact that the "GRIFFON" was designed as an ice-breaker contributed to the extensive damage sustained by the fishing vessel and explains why there was virtually no damage to the CCG vessel.

1.5.2 "GRIFFON"

Following the collision, heavy deposits of white paint and scrape marks up to the 5.5 m (18 ft) draught mark on the port side aft of the stem were observed over a length of about 2 m. On the starboard side, there were white paint marks and scrapes up to the 4.9 m (16 ft) draught mark at the stem and extending back as far as amidships. The vessel was not holed.

1.5.3 "CAPTAIN K"

The vessel was extensively damaged. An inspection was conducted after salvage and a report on the condition of the vessel, detailing the damage, was prepared. Items of significance were as follows:

• The "imprint" of the damage confirmed witness statements that, in relative terms, the "CAPTAIN K" was crossing the "GRIFFON's" bow from starboard to port.
• The steering gear system was in good order and the rudder was found at 3° to port.
• The engine control was found in the full-astern position.
• The engine instrument panel was crushed, but laboratory examination showed that the instruments indicated normal full-astern performance.
• The main engine was stripped down for examination and found in normal condition, which was consistent with the engine having stopped due to the sudden immersion in water of the combustion air intake.
• Five electrical switches mounted on a panel were all found to be in the down (off) position but, due to the extensive damage, their functions could not be determined.
• The on/off status of the navigation lights could not be determined.
• The status of the electrically operated horn could not be determined.
• The vessel was well equipped with navigational aids but they were so extensively damaged that it was not possible to determine their operational status, except as follows:
• the radar display (Si-Tex), the single radar equipment aboard, was switched off;
• the portable citizen's band (CB) radio was switched off; and
• the VHF transceiver (Royce) was switched on, mid-volume range, channel 22.
• Various emergency equipment was recovered.
• There was no evidence to show if the vessel was fitted with a radar reflector of approved design.

1.5.4 Damage to the environment

A small quantity of diesel oil was released when the fishing vessel sank but it quickly dispersed.

1.6 Personnel information

1.6.1 "GRIFFON"

1.6.1.1 Master

The master held an Ocean Navigator - ON I Certificate of Competency issued in 1979 and had taken a Simulated Electronic Navigation - SEN II course in 1979. He stated that it was rare for him to go on a training course.

The master has been employed in a seafaring capacity since 1951, all his working life. He had been with the CCG since 1976; had been employed as master since 1983, and appointed master on the "GRIFFON" later that same year. Before joining the CCG, he had served as a deck officer on commercial vessels.

1.6.1.2 Chief officer (C/O)

The C/O held an ON II Certificate of Competency issued in 1988 and a Coast Guard Command Certificate. He had taken a SEN II course in 1987 and a SEN II/ARPA (Automatic Radar Plotting Aid) course in 1990.

The C/O had been employed with the CCG since leaving the CCG College as a cadet in 1984. He had been appointed permanent C/O in December 1990, and had sailed on the "GRIFFON" as an officer for over five years.

1.6.1.3 Third officer (3/O)

The 3/O held an ON II Certificate of Competency. He had taken a SEN II course in 1985.

The 3/O had been employed as a deck officer with the CCG since leaving the CCG College as a cadet in 1986. He had been on the "GRIFFON" since November 1990. He had recently returned to the ship after six weeks ashore.

1.6.2 "CAPTAIN K"

1.6.2.1 Operator

The operator of the "CAPTAIN K" held a Fishing Master's Class IV Certificate, issued 01 March 1985, and had taken the Marine Emergency Duties - MED I course in January 1985. He had completed three-quarters of a Power Squadron Celestial Navigation course in 1989-1990.

A plumber by trade, he had been engaged in that type of employment throughout most of his working life, commencing in 1959. The operator of the "CAPTAIN K" had only been employed in the fishing industry for the previous 3½ years, operating the vessel for the owner. This was his first seagoing and boat-handling experience.

1.6.2.2 Crew

The two crew members did not hold, nor were they required to hold, marine qualifications.

1.7 Vessel Certification

1.7.1 "GRIFFON"

The vessel was manned and held current certificates in accordance with the existing rules and regulations.

1.7.2 "CAPTAIN K"

The vessel, which was less than 15 gross registered tons (GRT), was not required to have any certificated crew nor to be inspected by the Ship Safety Branch of the CCG. The vessel was required to comply with the applicable Small Fishing Vessel Inspection Regulations and, as far as the inspection of the wreck would permit, the vessel was noted to have complied.

1.8 Operation of vessels in poor visibility

The conduct of vessels is governed by the Collision Regulations and vessels must take particular precautions when navigating in reduced visibility.

1. Every vessel shall proceed at a safe speed having due regard to the prevailing circumstances and conditions of restricted visibility. A vessel which detects by radar the presence of another vessel shall determine if risk of collision exists and shall take avoiding action in ample time.
2. Every vessel shall at all times maintain a proper look-out by all available means to make a full appraisal of the risk of collision.
3. Every vessel should sound appropriate sound signals in restricted visibility.
4. Any vessel may use sound signals to attract the attention of another vessel.
5. Proper use should be made of radar, including radar plotting, to determine the risk of collision and assumptions should not be made on scanty information. When in doubt, risk of collision should be deemed to exist.

1.9 Navigation and bridge watch

1.9.1 "GRIFFON"

1.9.1.1 Operating Conditions

The "GRIFFON", which was operating in predominantly foggy conditions, initially within 3.5 nautical miles (M) of the shore, proceeded at full service speed between recommissioning of buoys during the morning hours of 18 March 1991, and did so up until the time of the collision that afternoon. At about 1300, some 20 minutes before the collision and before he left the bridge, the master checked the starboard radar but did not see any targets of concern on the display. The range scale used was alternated between the 6- and 12-mile range. He established the following operating conditions of the "GRIFFON" while proceeding to the position off Port Stanley:

1. vessel to proceed at full service speed;
2. fog signals not to be sounded until another vessel's fog signals heard or a radar target ahead detected; and
3. look-out to be posted on the bridge, once a deck crew member became free from the buoy preparations on the main deck.

There was a schedule of buoy placements to be made before the opening of the Seaway. The master indicated that his decision to proceed at full speed was influenced by the forecast of deteriorating weather, a desire to complete the task in daylight, and a wish to minimize overtime.

No reason was given for the master's decision not to have the fog signal sounded. The whistle, with automatic control for under-way operation, is mounted on to the funnel above the accommodation and immediately behind the bridge. The deck crew were working on the deck forward of the bridge, rigging a two-ton buoy with chain and a two-ton sinker, using the derrick.

With respect to posting a look-out, there was conflicting evidence as to whether the master gave a direct order to the C/O to assume that duty or if the C/O assumed the duty by himself. The C/O indicated that, while waiting for the deck crew look-out, he had assumed this function.

The master left the bridge some time shortly after 1300, and he remained away until the collision. The master, who had been on the bridge since approximately 0800, had not had a break to use a washroom and had not had lunch. The vessel has a washroom abaft, at the same level as the bridge.

It is traditional for the master to stay on the bridge in reduced visibility conditions in restricted waters, particularly if the vessel is proceeding at any speed. When the master requires a break, he normally passes the conduct of the vessel to the most senior navigating officer. However, in this case, the vessel's main function was to lay buoys, the preparation and deployment of which was the C/O's responsibility.

1.9.1.2 Bridge watch procedures

Under normal circumstances, there is no specified period of time allowed for handing over a bridge watch. Customarily, the relieving officer arrives on the bridge 10 minutes before his watch and the officer handing over responsibility will leave only when both officers are satisfied that the situation is in hand and that all relevant information has been communicated.

On the day of the occurrence, the 3/O arrived on the bridge about 10 minutes before his watch and took over the full responsibilities of the officer of the watch (OOW) in two phases. The 3/O relieved the 4/O as OOW while the master was on the bridge, in charge of manoeuvring the vessel in the buoy placement operations. The 2/O, who was on the bridge assisting the master with the navigation of the vessel, observed a radar echo ahead as the vessel was swinging to a heading of 153°(T) and he stated that he brought the echo to the 3/O's attention at that time. When the 2/O left the bridge shortly thereafter, he did not formally hand over the watch to the 3/O as he had not been in charge of the watch.

1.9.1.3 Target acquisition

The single radar display in use was in relative-motion gyro-stabilized mode, fitted with a reflection plotter, and, it was stated, its ranges were constantly changed to search for targets. The officers stated that they had seen a radar target ahead of the "GRIFFON", but the evidence given was non-specific and the rough bridge logbook had minimal information to correlate times. According to the initial evidence presented by the OOW, he observed only five targets on the radar which required plotting, four of which turned out to be private well-head markers in Long Point Bay, and the fifth, a target inbound "right off Long Point". It was stated that these were plotted by china-graph pencil on the reflection plotter. There is conflicting evidence in this regard, as it was stated that the plots were erased by an unknown person the day after the accident, but another stated that no such plots were seen immediately after the collision during the SAR mission. Approximately six hours after the collision, a "recollection plot" was made by the OOW, but the time it is meant to represent is not as stated on the plot. The distance shown off Long Point is about 8.6 miles, but the collision position is known to have been about 4 miles off Long Point. Hence, the plot would more accurately represent a time of 1255 rather than 1320 as plotted. The OOW stated that the plot represented a time of 1250. Four of the targets were shown to move in a direction reciprocal to the "GRIFFON's" course, and the one off Long Point is plotted as showing no relative movement. The times over the period of plotting could not be accurately given.

Other evidence given was that in the plotting of the ship's position, with the 2/O at the radar and the 3/O plotting at the chart, the 2/O stated that there was a faint echo under the heading- line and that this fact was acknowledged by the 3/O, who was OOW. It was further stated that the target was at approximately three miles; that it was under the radar heading marker as the vessel was swinging to a heading of 153°(T); that the object was not moving; and that it was a private spar buoy marking the limit of the fishing grounds. It was stated that the course was re- adjusted back to 153°(G) from 150°(G) at 1300 but the time could not be confirmed as the adjustments were not entered in the rough logbook. The "fifth" target, off Long Point, if observed at about 1255, was apparently neither re-acquired nor identified at a later time before the collision.

No radar target of the "CAPTAIN K" was identified.

1.9.1.4 1300 Logged Position

According to the evidence, the vessel was initially to the west of the course line, necessitating the temporary adjustment to the course from 153°(G) to 150°(G). A plot of the 1300 position given in the logbook, Bluff Point 200° x 6.7 M, puts the vessel 0.5 M to the east of the intended course from buoy "N" to a position 1.6 M off Long Point. Later evidence is that the distance off Bluff Point should have been plotted as being 6.4 miles rather than 6.7 miles, but that would put the "GRIFFON" further to the northward at 1300, making the plotted distances between that position and the sink or collision position even more unexplainable.

1.9.1.5 Blind pilotage regime

In order to adequately conduct blind pilotage, a minimum of two officers is required but three officers is the optimum level. One officer is to have the conduct of the vessel and the other officer(s) would ensure that all relevant information is passed to the person who has the conduct. One officer would give undivided attention to the radar to ensure continuity and assistance with navigation as well as collision-avoidance duties. If a third officer is involved, this person would assume plotting and other normal navigational duties to ensure that the person having the conduct is able to concentrate on decision-making and ship-handling requirements. There is no evidence that such a system was in operation in this case.

The use of a radar picture superimposed on an electronic chart greatly simplifies this task; such equipment has recently been fitted to several Canadian commercial vessels and is undergoing evaluation in the CCG.

1.9.1.6 Emergency collision avoidance

As there was no manoeuvring diagram available for the "GRIFFON", none was posted on 18 March 1991; such a diagram is required by regulation. Manoeuvring characteristics are, however, included in the Master's Standing Orders for Deck Officers. There is no formal training provided in crash stops or techniques for handling the main engine and rudder. These manoeuvres are intended to be acquired as part of the general learning experience of the deck officers.

In the emergency situation, the helmsman altered course hard-to-starboard, although it is not his function to do so until so instructed. Alterations to port are normally avoided but are permitted in an emergency.

1.9.1.7 Disagreement with standards of operation

The navigating officers were unable to state a clear course of action to take if they strongly disagreed with the master's operation of the vessel. The CCG had no specific instructions on how the officers should deal with such an eventuality.

Evidence from the officers indicated that it was their perception that, in recent months, the master was not receptive to their input with respect to the conduct of the vessel, if that input was contrary to the master's judgement.

In particular, some of the navigating officers had some concern about not sounding the fog signal, but they did not believe the master would be receptive to their concern.

1.9.1.8 Familiarity with local fishing activities

The fleet of fishing vessels based in Port Dover in Long Point Bay was engaged in commercial fishing operations on the day of the occurrence. The master indicated that he was aware that a fishing fleet operated out of Port Dover. The master reported that when the collision occurred, his first thought was that the deck crew had dropped one of the buoys on to the deck.

The 3/O indicated that, although he was aware of the fishing fleet, he was of the opinion that the fleet had not resumed fishing operations following winter shut-down. Further, knowing that both the Seaway and the Welland Canal were closed, he assumed that there was no other traffic in the area. No briefing about fishing fleet traffic was given by the master to the bridge officers.

1.9.2 "CAPTAIN K"

There is no record of the course(s) steered from Long Point. Without the use of radar, it would be normal to follow Loran line 9960-Z-58600 from Long Point toward Port Dover; if she did so, the vessel would have passed about eight cables off the point.

The speed of the "CAPTAIN K" before the collision is not known. However, her full service speed was 8 kn. If, after rounding Long Point, the vessel did not deviate from the direct course in order to fish, it is calculated that she would have had a steaming speed of less than 4 kn. When searching for fish electronically, it would be normal to be at reduced speed.

No bow wave was noticed by the crew of the "GRIFFON" and, from the position of the engine controls on the recovered wreck, it was determined that "full astern" had been selected before the collision.

The crew members of the "GRIFFON" reported that they had not heard any fog signal from the approaching fishing vessel.

From the positions of the victims when recovered, it is apparent that the operator was in charge of the navigation while also manually steering the vessel and keeping a look-out without any assistance from other crew members.

1.9.3 Look-out

A proper look-out has been defined as a person specially charged with the duty of observing and reporting lights, sounds, obstructions, etc. and having no other duties that would detract from this function. The OOW or helmsman should not be used as look-out except under exceptional circumstances. The bow is the optimum position for stationing a dedicated look-out on a vessel under way, such that attention is not diverted by distractions and, at the same time, have available a reliable means of communication with the OOW.

1.9.4 Use of wheel-house windows

1.9.4.1"GRIFFON"

There was conflicting evidence during the investigation as to whether or not any of the doors or windows were open in the wheel-house of the "GRIFFON". As with any vessel of such a design, when windows or doors are closed and the main engine is operating at full speed, it would be more difficult for a look-out stationed in the wheel-house to hear sound signals than it would be for a look-out stationed outside. The ambient noise in the wheel-house is also distracting.

1.9.4.2"CAPTAIN K"

Under way aboard tugs of similar design to the "CAPTAIN K", it was found that noise levels were high. It was stated that from the wheel-house, the "CAPTAIN K" would only have been able to begin to hear the Port Dover pier fog signal from approximately ½ mile away, when the forward centre wheel-house window was open. Because of damage, it could not be ascertained if the wheel-house windows were open on the fishing vessel at the time of the collision.

1.10 Shipboard navigation equipment

1.10.1 Radar--General

Radar serves both as a navigational position-fixing aid and as an anti-collision aid. When used for collision avoidance, radar information is most useful when recognized plotting methods are employed.

The two main wavelengths used are 3 cm (10,000 megacycles per second) and 10 cm (3,000 megacycles per second). Each has its own advantages. A simple generalization might be that 10 cm wavelengths penetrate rainstorms better than 3 cm wavelengths, while the 3 cm wavelengths give better discrimination, i.e. a more precise picture, better suited to river and channel navigation. CCG trials some years ago determined that the installation of two 3 cm units better met its requirements aboard a vessel in restricted waters.

Because the strength of echoes depends on the material of construction, the aspect and position of the targets as well as their size and shape, certain low-lying targets and small vessels can be missed completely or produce intermittent returns. The microwaves used for radars can be reflected by precipitation and waves, and when this occurs, such phenomena can obscure small targets. The anti-rain and/or anti-sea clutter controls can be utilized to reduce the undesired echoes. Caution must be exercised in this operation as other shorter-range targets will be attenuated if these controls are set too high.

The loss of radar targets in the upwind arc of sea clutter return continues to be the most serious shortcoming in the use of marine radar. The stronger the wind, the greater the sea clutter. It should be noted that the "GRIFFON" logged the wind at 1200 as 15 to 20 kn which is in excess of other reports for the surrounding area. There is no specific wind speed logged by the "GRIFFON" at the time of the accident.

The normal practice is to observe targets, particularly small intermittent targets, outside the area of sea clutter return, and to either take major avoidance action or track them very intently, often by china-graph marking on a reflection plotter, down through the sea clutter, until the target is past and clear. If visual attention is broken when the target is in an area of sea return, it is often impossible to identify it again.

Unless a radar set is properly tuned and the controls are set for optimum performance, best results will not be obtained and small targets could be lost.

On a conventional cathode ray tube (CRT) radar screen, the heading marker is enhanced at every sweep of the trace but can be temporarily removed to enable a target right ahead to be more easily scrutinized.

1.10.2 "GRIFFON"

1.10.2.1 Equipment fitted

The "GRIFFON" was fitted with:

• two radars, 3 cm (X-band) sets
• one radio direction finder
• two echo-sounders
• one Loran C
• one gyrocompass
• one autopilot
• one magnetic compass
• two VHF R/Ts, one single side band (SSB) R/T and one cellular telephone.

1.10.2.2 Radar equipment

The conventional CRT displays fitted on the "GRIFFON" required the use of a hood and visor in daylight conditions. This effectively restricts the viewing of the display to one person at a time. In reduced visibility and confined waters, when one officer has the conduct of the vessel and another is assisting with the navigation, it is desirable that each officer have a display to view. The "GRIFFON" had two displays but did not operate them simultaneously because of mutual electronic interference. There was an interference rejection circuit (defruiter) which reduced the mutual interference to an acceptable level, but it was not switched on. Some officers were not aware of this circuit and others chose not to use it.

The radar system did not include an ARPA, nor was it required by regulation for this vessel. The main purpose of ARPA is to assist in open-water collision avoidance. It is not effective for collision avoidance with intermittent targets at relatively close range in sea clutter conditions.

1.10.2.3 Starboard radar tests

The following operational and technical specification checks were carried out as part of this investigation:

19 March 1991, at anchor in Long Point Bay.

A general operational check was made and no abnormalities were observed.

20 March 1991, at anchor in Long Point Bay.

Practical observations were made of a similar fishing vessel to the "CAPTAIN K" in what were considered to be similar sea conditions to the day of the occurrence, but there was no fog. Target discrimination was clear on practically all range scales; however, as the fishing vessel came within 120 m on the 1.5 M range scale and to within 0.6 M on the 3 M range scale, the target was becoming non-discernible in the sea clutter.

21 March 1991, alongside at Port Colborne.

Technical performance checks were carried out against the equipment's specification, and results showed the equipment to be within the established standards.

27 March 1991, at sea in Lake Ontario.

Following close observation of the display at the Relief Master's request, the radar echo of the Ocean Data Acquisition System (ODAS) buoy off Point Peter was becoming difficult to pick out in the sea clutter at 2.4 M, was very difficult to detect below 1.4 M and was indiscernible below 0.8 M. The radar echo of "MM 2" buoy off Main Duck Island could not be detected below 1 M. Sea and weather conditions for these observations were considered similar to those at the time of the collision, except that there was rain/mist rather than fog and the wind speed was 20 to 25 kn. Both buoys were equipped with radar reflectors.

17 April 1991, alongside at Prescott.

Following the Relief Master's observations, a further set of technical performance checks were made of the radar and, again, it was found normal.

For all the above tests, it was not possible to ensure exact duplication of the settings of the controls as they were at the time of the collision; there are several controls which interact with each other and no record is kept of the settings. Weather conditions were considered similar to those at the time of the occurrence for the operational checks, but not identical, and there was no fog. No maintenance had been carried out on the set.

In summary, all checks on the set found it operating normally for its type and specification.

1.10.2.4 Port radar tests

Similar tests were carried out on the port radar, although its operation was not in question, and the set was found to be functioning normally.

1.10.2.5 Radar reflector evaluation

23 April 1991, at sea, south of Amherst Island, Lake Ontario.

In the interests of safety and in order to comply with Rule 40 of the Collision Regulations, the "CAPTAIN K" was required to have a radar reflector but was not so fitted; however, she was exhibiting a metal fishing signal, which appears similar in construction. Practical tests were conducted by the TSB, using the "GRIFFON's" starboard radar set and a steel fishing vessel proportionally smaller than the "CAPTAIN K" to compare the radar reflectivity of the fishing signal and the standard radar reflector.

Weather conditions for the tests were considered to be similar to those at the time of the collision, except that there was no fog and the wind speed varied between 14 and 20 kn.

Three tests were conducted from different relative directions, but within the sea clutter arc. The fishing vessel was discernible down to ranges of 0.31, 0.35 and 0.41 M respectively. There was no appreciable difference in the radar echo between the three operational conditions, namely:

1. no reflector of any type,
2. fitted with a radar reflector, and
3. fitted with a metal fishing signal.

It was noted that the echo size was enhanced when the vessel was beam-on rather than end-on. The overall performance was similar to the previous tests on 20 March 1991.

Other tests made over the years under different circumstances have consistently shown that the reliability factor for radar detection of a smaller target vessel under varying weather conditions is enhanced by the fitting of a radar reflector.

1.10.2.6 Use of cellular telephone

At the time of the occurrence, the CCG had no restrictions or recommendations on the siting or use of cellular telephones for vessels such as the "GRIFFON".

The master had prepared a set of instructions regarding the use of the cellular telephone, but these did not place any limitation on when the phone could be used.

The cellular telephone was located on the bridge of the "GRIFFON" adjacent to the chart navigation area and next to the starboard radar, such that a person answering the phone physically and audibly intruded in the bridge navigation area.

1.10.3 "CAPTAIN K"

1.10.3.1 Equipment fitted

The "CAPTAIN K" was fitted with:

• one radar
• one echo-sounder/fish-finder
• one Loran C
• one magnetic compass
• three VHF R/Ts.

1.10.3.2 Status of the radar equipment

The fishing vessel was not required to fit radar.

A practice of local fishermen is not to use the radar in clear visibility except to supplement the Loran C in ascertaining their position. The radars are, however, used in restricted visibility. The radar had been examined two weeks before the collision by a service technician; the examination took l5 minutes approximately. When the radar was switched on, within the harbour, the radar picture was a rough blur of targets on the lowest range scale and gave no useful information on higher ranges. The radar had been in this condition for the previous six months and was stated to be incapable of giving any useful information. The technician had indicated that the radar could be repaired by installing a new magnetron for which he could acquire a spare, but repairs had not been authorized by the owner. The operator had expressed concern to the owner about operating the vessel with an unserviceable radar. The rotary on-off switch was in the "off" position at the time of the collision.

1.10.4 Local use of radar reflectors

Port Dover fishermen generally feel that radar reflectors are not necessary. It was stated that steel fishing vessels show up sufficiently well on radar without the fitting of reflectors. During a visit to Port Dover, it was found that no radar reflectors were fitted to the fishing vessels in port.

1.11 Angle of approach and of impact

From the "GRIFFON's" logged position at 1300 to the position of the collision, the vessel made good a course of 158°(T). Over this period of time, the vessel was steering 153°(G).

The inbound course from an estimated passing-off distance of 0.8 M off Long Point to the position of the collision is 345°(T). That course follows the Loran C line 9960-Z-58600, but it is not known if the "CAPTAIN K" was navigating by these means or, in fact, what courses were steered.

There is no definitive evidence as to the aspect presented by the "CAPTAIN K" when first sighted from the "GRIFFON". An assessment of the damage to the "CAPTAIN K" indicated that the "GRIFFON" struck the fishing vessel at an angle of 60 to 80° on the port bow.

1.12 Emergency equipment

1.12.1 "GRIFFON"

The vessel is equipped with a conventional 24-man lifeboat and a Boston-whaler type Man Overboard Boat (MOB). The life-saving equipment carried conformed to the applicable regulations.

1.12.2 "CAPTAIN K"

The "CAPTAIN K" conformed to the applicable regulations, also carrying more than the minimum number of required lifejackets. In common with approximately 50 per cent of the local fishing vessels, the "CAPTAIN K" carried a heavily constructed galvanized steel lifeboat with built-in flotation tanks. These "Tilburys", as they are known, are approximately 3.7 m long, cumbersome, heavy and difficult to manhandle into the water once unsecured. The boat was secured by lashings upside down behind the wheel-house aft of the "A" frame of the "CAPTAIN K". The impact of the collision crushed the wheel-house port access, thereby preventing any exit by the crew to free the lashings, but the impact/sinking caused the lifeboat to be released.

There are no regulations requiring vessels such as the "CAPTAIN K" to carry an inflatable liferaft or immersion suits.

1.13 Radio communications

1.13.1 "GRIFFON"

The "GRIFFON" had no communication with any other vessel that day, before the collision. The VHF R/Ts on the vessel were monitoring channel 16, the international calling and distress frequency, and channel 13, the bridge-to-bridge frequency for that sector of Lake Erie. All R/Ts were in good working order.

1.13.2 "CAPTAIN K"

It is not known which VHF R/T channels were monitored by the "CAPTAIN K" but, when recovered after salvage, the VHF R/T (Royce) was found to be on channel 22, a frequency not commonly used. Being a vessel less than 20 m in length, the "CAPTAIN K" was not required by regulation to be fitted with a VHF R/T but, when so fitted, the vessel must be licensed, the radio operator must possess the required certificate and, in the interest of safety, the vessel should monitor the international calling and distress frequency, channel 16, and maintain a listening watch on the bridge-to-bridge channel for the area in which she is operating. Because of the heavy damage caused by the collision, it was not possible to determine if the three VHF R/Ts were in good working order.

The "CAPTAIN K" had been in VHF R/T communication with other fishing vessels that morning while fishing south-west of Long Point, and with the fish plant at Port Dover while rounding Long Point inbound. The communication with the fish plant was on VHF channel 7A, and with the other trawlers, on VHF channel 18, the channel monitored by that fleet. A separate local fleet, the gill-net fishing vessels, monitors channel 6. Commercial vessels with local knowledge will initiate security calls on channels 6 and 18 in addition to channel 16, when transiting the area. The "GRIFFON" was not monitoring either channel 18 or channel 7A and was therefore unaware of traffic involving the "CAPTAIN K". Unless the radio was tuned to channel 22 at the time, it is not known why the "CAPTAIN K", after rounding Long Point, did not respond to VHF R/T calls from the "C.J. WEAVER".

1.13.3 Notices to shipping (Notships)

Before the collision, the "GRIFFON" had made calls to the Sarnia Coast Guard Radio Station (CGRS) on VHF channel 82A. The first was her morning status report via the nearest CGRS, to the regional head office, the home base and Vessel Traffic Services (VTS) Sarnia. Other calls were to advise which buoys had been re-commissioned to enable the required Notships to be issued.

The Notships are broadcast on the continuous navigational channels VHF 21B and 83B, and notice to this effect is first made on channel 16. It is not known if the "CAPTAIN K" heard the first Notship broadcast at 1213 which, in turn, could lead to a deduction that there was a CCG vessel operating in Long Point Bay. The second Notship was broadcast after the occurrence.

1.14 Search and rescue (SAR)

Immediately after the collision, the "GRIFFON" remained as close to the collision position as possible, and the master designated the vessel "on-scene commander". The vessel had the MOB in the water at 1322 and commenced a search. No immediate report of the collision was made. At 1327, a small suitcase was found floating together with other debris indicating the approximate sink position of the fishing vessel. At 1330, a cellular telephone call was made by the "GRIFFON" to the Rescue Coordination Centre (RCC) at Trenton reporting the distress and ongoing rescue efforts.

At 1332, the "CAPTAIN K's" steel skiff was recovered. At 1338, a call was made by RCC Trenton to Sarnia CGRS (VBE). At 1341, VBE transmitted a "Mayday Relay" which was retransmitted as a "Mayday" at 1343. Local fishing vessels responded and the "C.J. WEAVER" reported at 1402 that she was in the middle of an oilslick at the collision scene. Visibility remained at 1/8 mile or less. The fishing vessels on the scene quickly identified the missing vessel as the "CAPTAIN K".

A fishing vessel, which located the sunken vessel by echo-sounder, marked the location with a buoy.

Canadian SAR aircraft were off the ground by 1415, but the low ceiling prevented them from dropping a datum marker buoy as intended. USCG aircraft were off the ground by 1419 and another USCG aircraft was airborne with a specially equipped SAR technician (swimmer) at 1508. Canadian aircraft were not equipped with heat sensors, but one of the USCG aircraft was so fitted. After problems with the low ceiling, the US helicopter was able to deploy a datum marker at 1545.

The SAR report is available from the appropriate authorities.

1.15 Diving and salvage operations

On 23 March 1991, under the direction of the TSB and the Ontario Coroner's Office, an underwater visual inspection of the "CAPTAIN K" was conducted, using divers and a mobile remotely operated vehicle (ROV). The "CAPTAIN K" was lying in approximately 42 m of water, in position 42°36′56.9"N, 80°02′53.4"W. Video from the cameras showed massive structural damage topside, and to the mid-section and forward part of the wheel-house on the port side.

Due to adverse weather conditions, the salvage operation was delayed until 31 March. Diving commenced on site at about 0825 that day, and it was found that the vessel had changed her attitude and orientation.

At 0922, the vessel broke surface and, after water was pumped out, the "CAPTAIN K" was lifted out of the water at 1115 and placed on the deck of a barge. The barge was then towed to Port Maitland.

1.16 Environmental information

1.16.1 Weather information

1.16.1.1 Weather forecast

The marine weather forecast for the area including Long Point Bay issued by Environment Canada at 0400 local time on 18 March 1991, predicted winds SE at 15 to 20 kn, veering to SW in the morning and NW at 20 kn in the afternoon. Rain and fog patches ending in the afternoon. Waves in ice-free areas 1 to 2 m. This was similar to the US forecast.

1.16.1.2 Weather as stated by the "GRIFFON"

At the time of the collision, the weather was variously stated to have been: wind light with 0.6 to 1 m waves or low swell. The visibility was estimated at 50 to 100 m, with an air temperature of 8°C and a sea temperature of 1°C.

1.16.1.3 Weather as recorded by local stations

At 1200, the Ministry of the Environment, Port Dover, approximately 13 miles to the north-west of the collision position, observed variable winds at 2 to 3 kn with an air temperature of 10°C and fog. Very similar observations were made at 1600. The Nanticoke weather station, approximately 11 miles to the north of the collision position, reported winds westerly at 5 to 10 kn over the same period.

1.16.1.4 Difference in wind speed

There is a considerable difference in wind speed recorded on the north shore of Long Point Bay and that recorded by the "GRIFFON" at 1200. However, the wind speed of 15 to 20 kn as logged was reportedly not adjusted for the vessel's speed and should have read 4 to 9 kn. The area of Long Point Bay was at the confluence of two frontal systems overlapping coincidentally at the centre of the bay.

During such periods, the winds may be expected to come from different directions for short durations as the pressure drops. This causes a confused sea, poor weather conditions and, on this day, fog. The fog formed around 0930 and remained until late afternoon. The weather experienced on 18 March 1991 was similar to the previous day's forecast.

1.16.2 Water current

Typical surface drift on 18 March 1991, for the northern half of Long Point Bay, for the climatic conditions over that period of time, would be expected to be north-easterly 0.3 to 0.6 kn.

1.17 Vessel traffic services (VTS)

1.17.1 Role

The responsibility of the VTS system is to protect the marine environment and to improve the safety and efficiency of marine traffic movement.

1.17.2 Lake Erie operation

West of Long Point, the responsibility for VTS rests with the CCG VTS Centre in Sarnia; it is a year-round operation. East of Long Point, including Long Point Bay, VTS is the responsibility of the St. Lawrence Seaway Authority, Welland Canal Operations Centre. The centre does not operate when the Seaway is closed during the winter months and was not operating on 18 March 1991. There is no requirement for vessels below 20 m to report to VTS Sarnia, but they may do so voluntarily; vessels not actually transiting the Welland Canal do not have to report to the Welland Control Centre, but they are encouraged to do so.

1.18 Management

1.18.1 Safety management system (SMS)

1.18.1.1 General

A relatively new concept in marine operations establishes a regime designating a manager ashore to be jointly responsible with the master for a vessel's safety; each has his own set of written instructions. The principle is controversial as some in the industry claim that it diminishes the master's absolute responsibility for the ship. Even more controversial is the part of the scheme that requires an operational audit of the master's navigational practices, with some in the industry claiming that this destroys the master's credibility in front of the crew. However, many companies have had such a system in place for the last few years. The IMO has a draft resolution in place proposing such a code for international implementation in a phased manner, initially on a voluntary basis. The draft IMO International Safety Management (ISM) Code has these key elements:

1. A safety and environmental protection policy;
2. Company responsibilities and authority;
3. Designated person(s);
4. Master's responsibility and authority;
5. Resources and personnel;
6. Development of plans for shipboard operations;
7. Emergency preparedness;
8. Reports and analysis of non-conformities, accidents and hazardous occurrences;
9. Maintenance of the ship and equipment;
10. Documentation;
11. Company verification, review and evaluation; and
12. Certification, verification and control.

1.18.1.2"GRIFFON"

The CCG Fleet Systems Branch is an operator of many and varied vessels. In the case of the "GRIFFON", it has well documented managerial accountabilities at all levels and well defined and documented lines of authority. The "GRIFFON" master's job description placed heavy emphasis on safety; he reported to the district manager in Prescott. The district manager's job description made no specific mention of safety as a responsibility, but general reference was made to "effective management, etc.". The Regional Manager, Fleet Systems, to whom the master indirectly reported, had a job description which reflected the fact that 21 vessels of mixed types, with approximately 400 seagoing personnel, were his responsibility; the job description mentioned "developing safety standards, and directing the establishment and monitoring of accident prevention programs", but had no other emphasis on safety. There are many Fleet Orders and Bulletins related to safety but these have normally been issued in response to a particular situation. There are well established procedures for reporting accidents and a comprehensive training program.

The CCG national policy is set at head office, after consultation with those concerned, but the organization is strongly regionalized, and the interpretation and degree of emphasis for the policies vary from region to region. On 09 April 1990, the Director General, Fleet Systems, circulated for comment to the Regional Fleet Managers the United Kingdom's Merchant Shipping Notice M 1188, which included the International Shipping Association's recommended SMS code. Other international safety standards were examined by the Fleet Systems Branch in May 1992 and, later that year, a draft Fleet Management Standard was circulated for comment.

In March 1991, the CCG did not have a formal SMS in place, nor the documented internal audits and management reviews of navigational practices envisaged in such a SMS.

1.18.1.3"CAPTAIN K"

The "CAPTAIN K" had no SMS in place, nor would it be realistic to expect the owner of one or two fishing vessels to have such a scheme. It was considered that shipboard operational safety was the responsibility of the operator, with support of shore management when so requested.

1.18.2 "GRIFFON" Operating environment

The "GRIFFON" was known by some crew members as an "unhappy ship", due mainly to an underlying situation caused by the operating schedule. The vessel often had a demanding workload throughout the Great Lakes. Apart from annual leave and a short winter self- maintenance period, the only break for the crew in shipboard routine was on weekends when, normally, the vessel did not work; it often proved difficult for the crew to get home and back in that time. Tight fiscal policies, particularly on overtime and fuel, and many crew changes, contributed to the situation. The fleet manager and an operational service officer were situated in Toronto, and a superintendent and a district manager were at the Prescott base. All four individuals were responsible, to varying degrees, for the day-to-day shore operation; this left the master to prioritize his responsibilities to each person.

1.18.3 "GRIFFON" Bridge resource management (BRM)

The crew of the "GRIFFON" had not received any training in BRM, nor was such training required. The essence of BRM is the effective utilization of all available resources to ensure the safe completion of the operation. BRM addresses the management of attention, operational tasks, stress, attitudes and risk. Optimizing the management of these elements will have a direct effect on four factors critical to the successful outcome of any operation, namely, recognizing and defining the nature of the problem encountered (situation awareness); reflecting on and regulating one's own judgements or decisions (metacognition); involvement of others in the problem solving (shared mental models); and understanding what must be done, in what priority, and what resources are required and available (resource management).

BRM recognizes that there are multiple determinants of mission effectiveness and safety, such as individual, organizational and regulatory factors. Concepts inherent to BRM provide practical guidance to optimize these factors. Selection of personnel more predisposed to team activity represents a long-term, but effective, strategy. Management must develop a culture and norms that support a team approach, including role models who practise and reinforce such an approach. Finally, the regulators can provide support by at least encouraging a team approach to mission effectiveness, if not by actively supporting BRM training.

1.19 Medical Information

1.19.1 Policies and Functions of Health and Welfare Canada (H&W)

Policy regarding occupational medicine for personnel employed by the federal government is set out by the Treasury Board, under the Financial Administration Act. The responsibility for administering the program, which includes assessment of fitness for duty, has been delegated by the Treasury Board to the Public Service Health Directorate of Health & Welfare Canada (H&W) (renamed Health Canada in 1993). The medical standards for CCG personnel at the time of the accident were developed by H&W in 1985 and are contained in the publication entitled, the Physician's Guide. Standards were revised in 1992 and published in the subsequent Occupational Health Assessment Guide.

The principal objectives of occupational medical evaluations and expectations of the system, as stated in the Physician's Guide, were: "to act as a means of preventing illness and disability arising out of, or aggravated by, condition of work; to establish that individuals are able to continue working without detriment to their health or safety or to that of others; and to establish the conditions under which certain individuals with illnesses or disabilities are able to continue working."

The Physician's Guide also specifies that: "health evaluations are generally provided in respect of specific occupations which have an inherent element of risk to the health or safety of an employee; where an employee's action could result in a threat to the health and safety of another; ... and where a public service standard policy directive or guideline provides that such evaluations may be requested at the discretion of departmental management or H&W."

As a result of the health evaluation, the employing department would receive a non-medical interpretation or report, indicating the employee's ability to perform the required work. The report would not contain a diagnosis or provide any reasons for the conclusion drawn. However, if work limitations were identified, the statement would incorporate advice to management concerning the adaptation or selection of work, or the placement or re-assignment of the employee as well as the estimated duration of such limitations.

Health evaluations were to be conducted at specified intervals but, in individual cases, H&W could recommend more frequent investigations or evaluations.

The number of physicians available to perform medical assessments and other duties in the Ontario region which dealt with the "GRIFFON" has been reduced over the years from four full- time positions to one full-time position and one part-time assistant. In 1991, the medical officer reviewed the medical records of 2,656 government employees, along with his other responsibilities.

1.19.2 Government employee assistance program (EAP)

Departments were able to arrange special health evaluations through an Employee Assistance Program (EAP) when impaired work performance was thought to be due to health problems. The responsibility to provide the EAP, implemented by the Treasury Board, has been delegated to the departments, in this case, Transport Canada (TC). Due to reduced H&W resources, the high level of EAP confidentiality, and personnel changes in the TC EAP officer's position, there was little dialogue between the CCG H&W physician in Toronto and the TC EAP officer.

1.19.3 "GRIFFON" Crew: fitness for duty

1.19.3.1 Master

In May 1990, the master was off work for five weeks due to stress precipitated by the abrupt cancellation of a planned vacation. As a result of this incident, the master went to a physician, with problems of sleeplessness, job-related fears, stress and depression. After discussion of his symptoms and a brief examination, he was given instructions to stay off work indefinitely. The master's family physician saw him in July and noted that his condition had improved and that he was returning to work.

In September 1990, the master again went to his family physician. He was experiencing stress and insomnia, although the family physician's medical record of the visit did not state why. He was treated with a month-long course of the antidepressant medication Prozac.

The occupational medical officer at H&W was not notified at the time of these diagnoses and treatments, nor was there any legal requirement to do so.

At this point, the various officers in the CCG to whom the master reported had no knowledge of his being under stress or depressed. The master continued his duties onboard the "GRIFFON" while under medication for the said one-month period in September 1990.

On 16 October 1990, the master's routine medical assessment for H&W was performed by a designated physician. The master accurately filled in the questionnaire regarding his health. He discussed his recent medical history, including stress, depression and medication. The examining physician did not communicate with either the family physician or the H&W medical officer. The master, who had always been assessed as "fit for duty", was again declared medically fit. At no time did he make use of available EAP counselling.

Over the years, according to officers aboard ship and a shore superintendent who worked with him, the master had gradually become withdrawn and difficult to approach. This description contrasted markedly with the jovial and approachable behaviour from a few years before the collision, as described by the H&W medical officer and the master's colleagues.

In March 1991, just days before the collision, the H&W physician supervising the health records of the crew of the "GRIFFON" reviewed the master's file. He remembered the master from previous medical examinations which he had performed himself and from visiting the ship. He felt that the master was well able to overcome a transient period of depression that had apparently responded well to medication, especially when such a recovery had already been confirmed by the designated examining physician. No specific monitoring was requested. The master's next medical examination for fitness for duty would have been scheduled for October 1991.

1.19.3.2 Officers

Medical examinations were performed on the officers and crew of the "GRIFFON" by physicians designated by the H&W Medical Officer of Health.

All those involved in the accident, except the helmsman, had received their scheduled medicals and all were found fit to work.

1.19.3.3 Helmsman

The helmsman had been employed for approximately four months on a temporary basis without undergoing the required pre-placement medical examination, or medical assessment as fit for duty by H&W. The CCG stated that, due to a backlog of work, it takes several weeks for a new employee to be medically cleared for placement. During his time of employment, the helmsman had taken the initiative to gain experience and training at the helm. According to the way he discharged his duties, there was no evidence of any medical problem.

1.19.3.4 Post-accident medical information

There was no post-accident medical review of the bridge crew to detect conditions detrimental to performance. There were no specimens requested for drug testing and no examinations to detect performance impairment, nor was this required by law. The H&W medical officer volunteered his services, but he was told by the CCG that they were not required. A TC EAP counsellor came on board the vessel for three days and provided critical incident stress management.

After the collision, the master acted in a caring and compassionate manner in consoling his bridge officers and crew. He also advised them to co-operate fully with investigating authorities. When his professional duties were finished, the master showed signs of very severe stress, according to the EAP counsellor.

1.19.4 "CAPTAIN K" Crew: fitness for duty

1.19.4.1 Policy

There is no requirement for fishermen to have a medical examination to work at sea.

1.19.4.2 Operator

Reference to the operator's medical records reveals no abnormalities. The evidence available indicates that he was well rested and was not subject to any significant stressors.

1.19.4.3 Crew

There were no indications of any medical abnormalities which might have contributed to the accident.

2.1 Introduction

Given that the available evidence indicates that the crews of both vessels had the appropriate qualifications and experience, the analysis focuses on why the operating practices in effect at the time of the collision were perceived to be appropriate. The analysis also deals with the available evidence regarding the fitness for duty of the navigating personnel and any potential impact on the operation of the vessels.

2.2 Expectations and operating practices

2.2.1 General

There is evidence in the operating practices of both vessels that neither vessel expected to encounter another vessel in the area. Operating procedures, amounting to system defences against just such incorrect expectations, have been developed, particularly for the type of weather conditions encountered. These procedures involve the use of appropriate signals, electronic navigational systems, look-outs and speeds. In this case, the approved operating procedures were not followed, in varying degrees, on either vessel.

2.2.2 "GRIFFON"

2.2.2.1 Operation

The "GRIFFON" was directed by the master to operate at full service speed; a bow look-out was not designated, and direction was given not to sound the fog signals. In addition, the lack of radio security calls and of effective BRM on the part of the "GRIFFON", including the non- utilization of a blind pilotage regime and crew briefings, further reduced system effectiveness.

The master's disabling of system safety measures is consistent with a mental model that precluded the likelihood of meeting other traffic en route. While the master was familiar with the area and was aware that a fleet fished out of Port Dover, it appears that he did not expect the fleet to be operating. The master's perception that there was a requirement to complete the task so that overtime was minimized and so that the impending worsening weather was avoided may have worked to prevent him from considering that these actions were not prudent. Stress may also have narrowed the scope of the master's focus and affected his judgement such that he ordered the vessel to proceed at speed, before the collision, without taking adequate safety precautions under the circumstances. So robust was his mental model that, on hearing the noise of the collision, the master assumed that the deck crew had dropped a buoy on to the deck; it took the actual sighting of the "CAPTAIN K" through his porthole to cause the master to reexamine his premise.

2.2.2.2 Bridge resource management (BRM)

The manner in which the "GRIFFON" was operated before the occurrence had been decided by the master. The C/O or 3/O, although concerned about the operating procedures, did not question the master's decision. The lack of assertiveness on the part of the 3/O, not atypical in maritime operations, allowed the vessel to be operated according to the situational awareness of only the master. BRM principles advocate that crew members share information to ensure as much as possible that all relevant factors are taken into account in the decision-making process; such a principle is a catalyst for other officers to be assertive when faced with a perceived unsafe situation. The crew of the "GRIFFON", including the master, had not been trained to practise the principles of BRM. In the absence of assertive inquiry on the part of the C/O or 3/O, the master did not reexamine his operating decisions.

2.2.3 "CAPTAIN K"

2.2.3.1 Operation

The fishing vessel was not operating with a designated look-out, and may not have been sounding fog signals. The two crew members were in their bunks and could be expected to be no more fatigued than the operator; one of them could have been designated as look-out.

If the radar had been in operation, it is probable that the operator would have had early knowledge of the approaching vessel and, if sensing a potential collision situation, he could have called the "GRIFFON" on VHF R/T to agree on avoidance action.

2.3 Distractions to navigation on the "GRIFFON"

2.3.1 Use of cellular telephone

The location of the cellular telephone on the bridge of the "GRIFFON", adjacent to the chart navigation area and next to the starboard radar, was such that a person answering the phone was a physical intrusion in the navigation area. Conversations are a distraction when important navigation decisions are being formulated based on information read from the adjacent radar set and other instruments.

Such was the situation when the "GRIFFON" departed buoy "N". The 2/O stated that, while the C/E was talking on the phone, he had indicated a target on the heading marker to the 3/O who was adjusting the vessel on to a new course. A distraction may have resulted from the casual conversation.

2.3.2 Essential crew on the bridge

On completion of the cellular telephone call, there was no operational requirement for the C/E to remain on the bridge. No particular useful information regarding ship navigation was provided by him, but his presence provided the opportunity for the other officers to engage in conversation.

The C/O came up to the bridge but had no dedicated task before doing so. Once on the bridge, he nominally acted as look-out but also proceeded to join in the conversation.

Under the critical operating circumstances such as those prevalent at the time, it is important that only personnel essential to the navigation of the vessel be on the bridge, and these individuals must know and diligently practise their precise responsibilities.

2.4 Traffic awareness

It is not known whether the "CAPTAIN K" heard any of the radio traffic that could have indicated that the "GRIFFON" was operating in the area. The initial advice by the "GRIFFON" was on VHF channel 82A, a channel unlikely to be monitored by the fishing vessel. Therefore, it is unlikely that the "CAPTAIN K" heard the Notship put out by the Sarnia and Toronto CGRS from which the vessel might have deduced that a CCG buoy tender was working in the area. Not being in a mandatory VTS zone, the "GRIFFON" was not otherwise reporting her movements.

The "GRIFFON" was not monitoring, nor was she required to be, either VHF R/T channel 18, the inter-fishing vessel channel for the area, or channel 7A, the channel used by the "CAPTAIN K" to communicate with the fish plant and, therefore, did not overhear any transmissions involving the "CAPTAIN K". In the absence of crew briefings about the operational environment, of security calls, and of monitoring of other radio channels, both vessels lacked situational awareness of vessel traffic in the area.

2.5 "GRIFFON" Radar operation

2.5.1 Sea clutter return

There was some sea clutter reported on the radar which could be a probable explanation for the "GRIFFON" not being aware of the presence of the "CAPTAIN K" and for a small intermittent echo ahead not being tracked outside the clutter area. Once inside the sea clutter, it would have been virtually impossible for such a target to be noticed.

2.5.2 Radar plotting

It is difficult to understand how vital evidence, such as the plot on the reflection plotter, was erased. The fact remains that an approaching steel fishing vessel, known to be a typical radar target for her size, was not tracked on the radar. Although the OOW stated that he spent a considerable amount of time at the radar before the collision, this suggests that proper use was not made of the radar in that no continuous and dedicated search for targets was undertaken or no proper radar plotting was made of the echoes seen. The other possibility is that the radar controls were not correctly adjusted, but this is unlikely because small well-head marker buoys were seen.

There are several discrepancies in evidence, one being the statement that the four well-head markers were plotted to move reciprocally on a relative plot, but the inbound target off Long Point was plotted as stationary. The initial testimony by the OOW indicated that he thought that the echo off Long Point (at a time presumed to be about 1255) was inbound but no plots were made to establish this. An "inbound" target cannot be presumed to be "stationary". His later testimony indicates that the target was only seen a few minutes before the collision. The "recollection plot", as submitted several hours after the accident, is inconclusive, but if one assumes that the echo off Long Point was observed at 1250, then it is possible that this echo was that of the "CAPTAIN K".

2.6 "GRIFFON" 1300 logged position

There is no appreciable current in Long Point Bay. The 1300 position, as logged aboard the "GRIFFON", at 200° x 6.7 M off Bluff Point, would indicate that in order to reach the sink position of the "CAPTAIN K" or the collision position, as reported on the reporting form, the "GRIFFON" would have had to average 15.3 or 15.75 kn respectively. Based on a distance of 6.4 M off Bluff Point, the speeds would have had to be 15.75 or 16.2 kn respectively. Based on distances of 6.4 and 6.7 miles off Bluff Point and the collision position as originally noted by the "GRIFFON" (42°36′N,80°02.7′W), the vessel would have had to average either 18.45 or 18 kn. Since the top speed of the "GRIFFON" is 12.5 kn, the positions given in the evidence are unexplainable.

2.7 "GRIFFON" Actions of helmsman

Confronted by the rapidly developing dangerous situation, the helmsman did not have the experience to judge properly which alteration to make; his initial training may have given him the inclination to go to starboard when in doubt. Had the C/O and 3/O detected the fishing vessel first, the same decision may have been made by either one. However, if the officer had noticed the propeller wash of the "CAPTAIN K" in the astern mode and/or the lack of a bow wave, he may have altered to port to avoid the fishing vessel. On balance, it is not possible to state if the avoidance action of the "GRIFFON" was correct.

2.8 Radar reflectors

As a vessel of less than 20 m in length, the "CAPTAIN K" should have been equipped with a passive radar reflector.

In this case, tests showed that little difference could be observed in the radar return from a fishing vessel with or without a radar reflector, and with or without a metal fishing signal. However, because of the widely different operating conditions possible on the day of the occurrence and at the time of the tests, it is not possible to say if a radar reflector would have enhanced the radar image of the "CAPTAIN K".

2.9 Non-identification of the "CAPTAIN K" on the Radar Aboard the "GRIFFON"

The "recollection plot", stated to be for approximately 1250 and considered to be at about 1255, shows an echo observed off Long Point. This echo was never re-acquired and was presumed by the OOW at that time to have been "stationary", but "inbound" in earlier evidence. The fact that the collision occurred at 1320 and that the "GRIFFON" was running at about 12 kn would put her some four miles north of Long Point at the time of the "recollection plot".

Meanwhile, the "CAPTAIN K" was stated to have been rounding Long Point at about 1200/1215 with the possibility of stopping to look for more fish. She may have been stationary until about 1245/1255 and under way northbound thereafter, which could account for the "stationary" and "inbound" evidence of the OOW of the "GRIFFON". If the "CAPTAIN K" had been under way at full speed off Long Point at 1250, she would have reached the collision position in the time available (30 minutes) at that speed.

The fact remains that the echo off Long Point was never properly identified and could have been that of the "CAPTAIN K". Since the second radar and "defruiter" were not switched on, this second aid to navigation was not available to detect the "CAPTAIN K".

2.10 Collision angle

The damage sustained by the "CAPTAIN K" indicates that the "GRIFFON" struck the fishing vessel at an approximate angle of 60 to 80° to the fore-and-aft line. The courses steered by the "CAPTAIN K" before the collision are not known; however, if the fishing vessel was steering a course close to that from a position off Long Point to the sink-position, the angle of approach between the two vessels would have been approximately 20°. This apparent discrepancy in collision angle can be explained by the bow wave of the "GRIFFON" sheering the fishing vessel to starboard before impact and, to a degree, by the canting of the "CAPTAIN K's" stern to port under full-astern engine movement with a right-handed propeller.

2.11 "CAPTAIN K" Subdivision

As the vessel was under 15 GRT, she was not required to have, and did not have, watertight bulkheads. If she had been so fitted, the "CAPTAIN K" may not have sunk so rapidly.

2.12 Safety management system (SMS)

2.12.1 "GRIFFON"

Notwithstanding that the CCG is the operator of a large government fleet, a SMS policy had not been introduced at the time of the collision. A SMS policy may have clarified the operational reporting role for the master and may have ensured that the appropriate navigational procedures were instituted as a result of lessons from a previous audit.

2.12.2 "CAPTAIN K"

Although a formal written SMS policy would not be expected for such a vessel, similar principles apply. The operator, in requesting that the radar be repaired, had displayed the necessary responsibility toward safety; however, the owner, by not ensuring that a vital navigational aid was operational, did not provide the operator with the support that would be expected in a well run SMS.

2.13 Medical information

2.13.1 Status of the "GRIFFON's" master

Twice during 1990, the master had responded strongly to stressful events with episodes of emotional instability and symptoms such as insomnia. For a month, in September 1990, he was treated with antidepressant medication. On 19 October 1990, during the master's routine assessment by a designated physician, when the issues of stress, depression and treatment were considered, he was declared medically fit. In March 1991, a few days before the collision, his file was reviewed by the H&W physician who had personally known and examined the master previously, and, in his view, the master had responded well to medication. At that time, the October 1990 assessment of medical fitness for duty was formally approved.

Operational stressors were reduced during the winter months when the "GRIFFON" was laid up at Amherstburg, Ontario. By the date of the collision, the "GRIFFON" had been fully operational for approximately two weeks and the duties and pace of activities were similar to or exceeded those that had existed when the master had previously sought medical attention.

The master's medical condition had the potential to affect ship safety; but, due to a lack of communication and, to some extent, inadequate resources, the programs available were not utilized by the master nor was he referred for counselling.

2.13.2 The Occupational Health Program

The principal objectives of the H&W occupational health program were not achieved due to the lack of communication between the physicians treating the master and those performing the examinations for fitness for duty. The latter physicians did not determine whether it was appropriate for the master to continue to work while on antidepressant medication.

Discussion between the family physician and the designated physician, especially over the suitability of continued employment in an environment that apparently was provoking stress- related symptoms, did not occur.

Ideally, in a pro-active program, personnel from a variety of disciplines can be coordinated by the medical officer to provide such services as workplace hazard assessment, training, wellness programs and medical counselling.

2.13.3 Canadian Coast Guard (CCG) management

CCG management did not regard the master's initial period of depression, resulting from the cancellation of his vacation leave, seriously. They did not request EAP counselling. However, they did not know of any stress recurrences, nor of the treatment with antidepressant medication while on duty. At least in the context of the events preceding the collision, the CCG appears to have been a relatively passive recipient of service from H&W. No communication occurred with those responsible for the Occupational Health Program, nor was there any between EAP and H&W.

3.1 Findings

3.1.1 "GRIFFON"

1. The master endeavoured to complete a buoy program in daylight and before weather deterioration while also considering the requirement to minimize overtime.
2. In visibility reduced by fog, the vessel was steaming at full speed, averaging 11½ knots (kn) since placing buoy "N".
3. Fog signals were not sounded.
4. A radar target observed off Long Point was not properly identified or monitored.
5. There was no systematic blind pilotage regime in place.
6. Course adjustments were not entered in the rough bridge logbook.
7. The position logged for 1300, 18 March, may be in error.
8. The chief officer (C/O) assumed a temporary role as look-out but this role was neither formalized nor properly carried out.
9. The vessel was operating with only one of two radar displays in use.
10. Use of the cellular telephone, installed on the bridge, invited intrusion into the bridge navigational area.
11. Navigation routine was interrupted by a cellular telephone call and by the recipient remaining on the bridge after the call.
12. Three officers on the bridge were engaged in casual conversation before the collision.
13. The radar target of the "CAPTAIN K" was not observed.
14. The helmsman was the first person on the bridge to visually sight the approaching fishing vessel.
15. The helmsman took emergency alter-course action before he could be instructed by an officer.
16. No immediate report of the collision was made.

3.1.2 "CAPTAIN K"

1. There was no dedicated look-out.
2. The radar fitted aboard had not been operational for some six months.
3. The operator was engaged in navigating and manually steering his vessel in reduced visibility.
4. There was only one exit from the wheel-house, which escape route was completely blocked by the damage of the impact.
5. A radar reflector was not exhibited.
6. The engine was at full astern at the time of the collision.
7. No watertight bulkheads were fitted, nor were any required by regulation.

3.1.3 Vessel traffic services (VTS)

There was no VTS system in operation in Long Point Bay on that day.

3.1.4 Canadian Coast Guard (CCG) fleet systems

1. No consolidated Safety Management System (SMS) was in place.
2. No formal Bridge Resource Management (BRM) training program was in place.
3. The master had been on indefinite medical leave and had returned to duty without being examined by a physician with the authority to approve his return to duty.
4. In September 1990, the master had been treated for approximately one month with antidepressant medication, during which time he continued his duties on board without the knowledge or approval of the designated medical authority. On 16 October 1990, he was declared medically fit, and a few days before the collision, the Health and Welfare Canada (H&W) physician was of the view that the master had responded well to medication.
5. It takes several weeks to medically clear a new employee for employment, and the helmsman had not been sent for the required pre-employment medical examination.
6. There was no liaison between the CCG supervising H&W physician and the CCG Employee Assistance Program (EAP) counsellor.
7. There was no policy in place for a formal operational/medical review before re- employment of a person who had been on medical leave because of stress-related problems.
8. There was no policy in place for formal operational/medical monitoring of a ship's crew member who was on a regimen of prescribed drugs.
9. There was no policy in place regarding what action should be taken if officers disagreed with the master's standards of operation of a vessel.

3.2 Causes

The "GRIFFON", operating at full service speed in reduced visibility, without the use of fog signals, did not correctly identify a radar target ahead of the vessel and take collision avoidance action before the target entered the area of sea clutter. Contributing to the collision was the fact that the "CAPTAIN K" was operating without a serviceable radar.

4.1 Action taken

4.1.1 Use and location of cellular telephones

Since the use of cellular telephones on the bridge can greatly detract from the concentration and attention required of the watch personnel for vital navigational duties, a TSB Marine Safety Advisory was forwarded to the Canadian Coast Guard (CCG) in 1992 advising of the need to establish guidelines on the installation and use of cellular telephones or other optional communication equipment aboard Canadian vessels.

Subsequently, the CCG issued Fleet Circular No. FSC2-92 relating to the use and location of cellular communication equipment. The commanding officers of all CCG fleet vessels were instructed to establish guidelines detailing the use of cellular telephones and other optional communication equipment on the bridge, so that their use will not interfere with the safe navigation or operation of the vessel.

Further, the CCG issued Ship Safety Bulletin No. 7/92, "Guidelines Involving the Use of Radiocommunication Equipment Fitted on the Ship's Navigation Bridge". The Bulletin suggests that communication facilities for personal calls be provided in areas other than the navigation bridge. Where such alternative arrangements are not possible, personal and business calls should be kept as brief as possible to avoid distracting the bridge personnel from their duties.

4.1.2 Radar reflectors on small vessels

In view of the increased risk of collision in conditions of reduced visibility and since a passive radar reflector can improve the detectability of small vessels, a TSB Marine Safety Advisory was forwarded to the CCG in 1992 to remind operators of small vessels, particularly fishing vessels, of the requirements for passive radar reflectors laid down in the Collision Regulations.

Accordingly, the CCG issued Ship Safety Bulletin No. 4/92 on "The Fitting of Radar Reflectors on Small Vessels" (an updated version of Bulletin No. 3/81, "Radar Reflectors - A Safety Device for Small Vessels"). The latest Bulletin reminds small vessel owners/operators of the importance of using radar reflectors. It states that small vessels operating in reduced visibility have been run down or swamped by larger vessels because of a lack of detection. It emphasizes the particular importance of radar reflectors for small fishing vessels since many operate in all types of weather, by day and night. It also indicates that small vessel owners/operators wishing to build a radar reflector to meet the required standard can obtain plans from their regional Ship Safety offices.

4.1.3 Notice to shipping/security calls

In view of the need to make local fishing communities aware of CCG fleet activities in fishing areas, a TSB Marine Safety Advisory was forwarded in 1992 advising the CCG to explore means of communicating information to the Port Dover and other fishing communities of CCG activities in their area.

The CCG, recognizing the national implications, discussed this aspect of marine safety at regional Canadian Coast Guard Marine Advisory Council meetings and solicited ideas and suggested improvements from marine and fishing industry representatives.

4.1.4 Non-essential personnel on bridge

Another TSB Marine Safety Advisory in 1992 advised the CCG to consider measures to limit the presence of non-essential personnel on the bridge.

As a result, Fleet Circular No. FSC2-92 (described in 4.1.1) also instructed the commanding officers of all CCG fleet vessels to include in their Master's Standing Orders guidelines restricting the presence of non-essential personnel on the bridge, in the engine-room, control room, winch control room and any other critical operating areas.

4.1.5 Radar on small fishing vessels

Recognizing the safety value of radars as collision avoidance instruments, a TSB Marine Safety Information (MSI) letter was forwarded in 1992 apprising the CCG of the condition of the radar aboard the "CAPTAIN K". The MSI discussed the importance of proper installation, maintenance and correct operation of radars on smaller vessels.

Subsequently, the CCG promoted this aspect of marine safety through its Search and Rescue Prevention Program as well as its Commercial Fishing Safety Advertising Campaigns.

4.1.6 Bridge resource management (BRM)

Following this occurrence, the CCG amended several sections of the Coast Guard Fleet Orders (CGFO). A new CGFO 209.00 on "Nautical Practices and Procedures" was added to the existing CGFO which, inter alia, addresses more effective bridge safety procedures between masters and officers of the watch (OOWs).

Further, it is understood that the CCG has purchased BRM training materials to train its CCG fleet personnel. The first BRM training session for CCG fleet personnel took place in 1994 and follow-up training is continuing.

4.2 Action required

4.2.1 Medical fitness for safety-sensitive positions

In July 1990, the master of the "GRIFFON" returned to work after being off for several weeks due to stress and stress-related symptoms. A couple of months later, he was treated by his family physician with a month-long course of an antidepressant medication. The Health and Welfare Canada (H&W) occupational medical officer was not notified of this diagnosis and treatment, and the master continued his duties aboard the "GRIFFON" while under the medication. The CCG management knew about the master's initial stage of depression; however, apparently neither the management nor the Transport Canada (TC) Employee Assistance Program (EAP) officials were aware of the master's subsequent medical assessment and treatment.

Poor health can affect physical, physiological, and psychological performance, and the use of certain prescribed drugs and over-the-counter medications can also impair an individual's performance, especially in the aspects of judgement, reaction time, and vigilance. As a result, some industry segments have recognized the need for regulations and policies regarding the medical fitness of persons in safety-sensitive positions. For example, Canadian aviation pilots and air traffic controllers are required under the Canadian Air Regulations to undergo medical examinations by designated physicians and to advise their other physicians that they are licenced pilots or controllers. In turn, these physicians must inform a designated medical advisor of any condition of the patient if, in the opinion of the physician, such medical condition is likely to constitute a hazard to aviation safety.

In the United States, following a collision between a U.S. Coast Guard cutter and a freighter, the National Transportation Safety Board (NTSB) recommended standards for the taking of medication by watchstanders on U.S. Coast Guard vessels to ensure that the medication does not impede the individual's ability to perform his/her duties^{Footnote 5}. Further, as a result of the grounding of a passenger-car ferry, the NTSB recommended that ships' officers on U.S. passenger vessels be required to report on any medication taken so that a medical determination of its effect on an individual's ability to perform watchkeeping tasks can be made^{Footnote 6}.

In Canada, the current medical policy and standards for CCG personnel were established by H&W (now Health Canada). Under the policy, medicals are conducted at specified intervals by designated physicians to determine, inter alia, that CCG employees are fit to work without a detriment to safety. Also, special medical evaluations can be arranged through the EAP if work performance is thought to be suffering because of possible health problems.

In this occurrence, extenuating circumstances resulted in limited dialogue between the CCG H&W physician in Toronto and the TC EAP officer concerning the master's medical condition. Notwithstanding these circumstances, there are no formal procedures in the Canadian marine industry that would have ensured that a person capable of determining the master's ability to perform his duties would have been informed of his medical condition. Like the master on the "GRIFFON", other mariners may unknowingly be jeopardizing safety during the conduct of their duties because a medical condition or medication is impairing their performance.

The Board found no link between the master's medical condition or his medication and this accident. Nevertheless, the Board is concerned about the lack of a formal mechanism to identify and monitor persons who are not medically fit for duty and who occupy safety-sensitive positions such as ships' officers and pilots.

In view of the lack of liaison between the H&W physician and the TC EAP counsellor, the lack of communication between the family physician and the designated H&W physician, the lack of formal operational monitoring of a ship's crew member in a safety-sensitive position who was on a regimen of prescribed drugs, and the lack of formal operational medical review before re- employment of a person returning to safety-sensitive duties following stress-related medical leave, the Board recommends that:

4.3 Safety concern

4.3.1 Collision avoidance and bridge operating procedures

The International Chamber of Shipping (ICS) has long recognized that "a failure to keep a good lookout" and "weaknesses in bridge organization" were main causes of marine collisions and groundings^{Footnote 7}. This observation is supported by Canadian marine occurrence statistics. During the 10-year period between 1984 and 1993, nearly two-thirds of the vessel collisions in Canadian waters were attributable, at least in part, to procedural deficiencies and inadequate watchkeeping practices.

In this occurrence, the officers on the "GRIFFON", although properly certificated and endorsed, did not practice basic seamanship, nor perform established collision avoidance procedures. The TSB has recently released two other reports on major occurrences (one on the collision between the "TENYO MARU" and the "TUO HAI" (TSB Report No. M91W1051) and the other on the occurrence involving the "IRVING NORDIC" in the St. Lawrence River (TSB Report No. M91L3012)), in which inadequate watchkeeping practices and a failure to observe collision avoidance procedures were cited as contributing factors.

The Board is concerned that, in spite of the presence of qualified officers on the bridge, non- adherence to well-established navigational procedures continues to be a significant factor in Canadian marine occurrences. Therefore, the Board will place increased emphasis on the marine occurrences involving a "failure to follow established navigational procedures" and focus on the underlying conditions to this divergence from normal behaviour.

This report concludes the Transportation Safety Board's investigation into this occurrence. Consequently, the Board, consisting of Chairperson, John W. Stants, and members Zita Brunet and Hugh MacNeil, authorized the release of this report on 12 July 1995 .

Appendix A - Sketch of the area of the occurrence

Appendix B - Sketch of vessel tracks

Appendix C - Photographs

Appendix D - Excerpts from the regulations for the prevention of collisions

PART B--STEERING AND SAILING RULES

SECTION I--CONDUCT OF VESSELS IN ANY CONDITION OF VISIBILITY

Rule 4

Application

Rules in this Section apply in any condition of visibility.

Rule 5

Look-out

Every vessel shall at all times maintain a proper look-out by sight and hearing as well as by all available means appropriate in the prevailing circumstances and conditions so as to make a full appraisal of the situation and of the risk of collision.

Rule 6

Safe Speed--International

Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropriate to the prevailing circumstances and conditions.

In determining a safe speed the following factors shall be among those taken into account:

(a) By all vessels:

(i) the state of visibility,

(ii) the traffic density including concentrations of fishing vessels or any other vessels,

(iii) the manoeuvrability of the vessel with special reference to stopping distance and turning ability in the prevailing conditions,

(iv) at night the presence of background light such as from shore lights or from back scatter of her own lights,

(v) the state of wind, sea and current, and the proximity of navigational hazards,

(vi) the draught in relation to the available depth of water.

(b) Additionally, by vessels with operational radar:

(i) the characteristics, efficiency and limitations of the radar equipment,

(ii) any constraints imposed by the radar range scale in use,

(iii) the effect on radar detection of the sea state, weather and other sources of interference,

(iv) the possibility that small vessels, ice and other floating objects may not be detected by radar at an adequate range,

(v) the number, location and movement of vessels detected by radar,

(vi) the more exact assessment of the visibility that may be possible when radar is used to determine the range of vessels or other objects in the vicinity.

Rule 7

Risk of Collision

(a) Every vessel shall use all available means appropriate to the prevailing circumstances and conditions to determine if risk of collision exists. If there is any doubt such risk shall be deemed to exist.

(b) Proper use shall be made of radar equipment if fitted and operational, including long-range scanning to obtain early warning of risk of collision and radar plotting or equivalent systematic observation of detected objects.

(c) Assumptions shall not be made on the basis of scanty information, especially scanty radar information.

Rule 35

Sound Signals in Restricted Visibility--International

In or near an area of restricted visibility, whether by day or night, the signals prescribed in this Rule shall be used as follows:

(a) A power-driven vessel making way through the water shall sound at intervals of not more than 2 minutes one prolonged blast.

Rule 40

Radar Reflectors

(a) Subject to paragraph (b), a vessel that is less than 20 metres in length or is constructed primarily of non-metallic materials shall be equipped with a passive radar reflector.

(b) Paragraph (a) does not apply where

(i) a vessel operates in limited traffic conditions, daylight, and favourable environmental conditions and where compliance is not essential for the safety of the vessel, or

(ii) the small size of the vessel or its operation away from radar navigation makes compliance impracticable.

Appendix E - List of supporting technical reports

The following technical reports were completed by the TSB as part of its investigation:

• Survey report on the wreck of the "CAPTAIN K"
• Report of the operational radar tests aboard the "GRIFFON" in Long Point Bay, 20 March 1991
• Report of the radar technical specification tests aboard the "GRIFFON" at Port Colborne, 21 March 1991
• Report of the radar technical specification tests aboard the "GRIFFON" at Prescott, 17 April 1991
• Report of the operational radar tests aboard the "GRIFFON" in Lake Ontario,

23 April 1991

-LP 92/91 - "CAPTAIN K" Instrument Analysis

These reports are available from the Transportation Safety Board of Canada upon request.

Appendix F - Glossary

A

aft

ARPA

Automatic Radar Plotting Aid

beam

on-A ship sideways-to

BHP

brake horsepower

BRM

Bridge Resource Management

CB

citizen's band radio

CCG

Canadian Coast Guard

CCGS

Canadian Coast Guard Ship

C/E

chief engineer

CGFO

Coast Guard Fleet Orders

CGRS

Coast Guard Radio Station

china-graph pencil

Wax pencil for writing on perspex, etc.

CHS

Canadian Hydrographic Service

cm

centimetre(s)

C/O

chief officer

total constructive loss

When the cost of repairs exceeds the vessel's value.

CRT

cathode ray tube

datum marker buoy

A buoy which assists the tracking of the water's set and drift.

EAP

Employee Assistance Program

echo-sounder

Electronic equipment which measures the depth of water and/or detects fish.

end-on

A ship presenting a bow-on or stern-on aspect.

EST

Eastern Standard Time

F

forward

ft

feet

fishing signal

An approved shape, visually indicating that a vessel is fishing.

F.V.

fishing vessel

G

gyro (degrees)

GRT

gross registered tons

heading marker

Electronically generated line on a radar display indicating the ship's head.

H&W

Health and Welfare Canada

IMO

International Maritime Organization

ISM

International Safety Management

interference rejection

Electronic circuit which suppresses, to an acceptable level, electronic circuit (defruiter)interference received on a radar display from adjacent radars.

kn

knot(s): nautical mile(s) per hour

kW

kilowatt(s)

log entry,

An entry into the ship's official records.

log,

logged

Loran C

electronic positioning system

m

metre(s)

M

nautical mile(s)

magnetron

Main transmitting valve of a radar equipment.

manoeuvring

A diagram illustrating the turning circles of a vessel to port and diagram starboard at different speeds.

Mayday

international distress signal

Mayday Relay

A Mayday issued by a third party on behalf of the vessel(s) involved in the distress.

MED

Marine Emergency Duties, an approved course of instruction on shipboard emergency procedures.

MOB

Man Overboard Boat, rescue boat

MSI

Marine Safety Information Letter

N

north

navaids

navigational aids

NE

north-east

Notship

Notice to Shipping, navigational advice to ships.

NW

north-west

ODAS

Ocean Data Acquisition System

on-scene

Usually a vessel or aircraft designated by RCC to control a local search.

ON

Ocean Navigator

Ont.

Ontario

OOW

officer of the watch

Power Squadron

A yachting association.

radar plotting

Plotting the targets observed on a radar screen, normally to plan the best collision avoidance action.

reflection plotter

A device fitted over the top of a radar display to assist manual plotting of targets.

RCC

Rescue Coordination Centre

ROV

remotely operated vehicle, usually carrying a video recording device. R/T-radiotelephone

SAR

search and rescue

SE

south-east

sea clutter

Signal return from waves, rain, etc. displayed on a radar screen.

security call

A radiotelephone call advising others of matters affecting the safety of navigation.

SEN

Simulated Electronic Navigation

SHP

shaft horsepower

SI

International System (of units)

single-chine hull

A design of vessel construction utilising a single line of intersection between the sides and the bottom of a flat or V-bottom hull.

SMS

Safety Management System

SSB

single side band, a type of radio transmitter/receiver.

SW

south-west

T

true (bearing or course)

tote

A cubic open box, about 1.2 m square, of durable plastic to hold the catch.

trawl doors

A pair of heavy boards, one attached on each side of the mouth of a trawl net, to keep it open when it is dragged through the water.

TC

Transport Canada

TSB

Transportation Safety Board of Canada

US

United States

USCG

United States Coast Guard

UTC

Coordinated Universal Time

VBE

call sign for CGRS Sarnia

VHF

very high frequency

VTS

Vessel Traffic Services

W

west

WSW

west-south-west

°

degree(s)

′

minute(s)

″

second(s)

2/O

second officer

3/O

third officer

4/O

fourth officer