Backgrounder

Investigation findings from TSB investigation M18C0225 – August 2018 grounding of passenger vessel Akademik Ioffe near the Astronomical Society Islands, Nunavut

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the grounding of the Akademik Ioffe in Nunavut in 2018, several factors led to the accident. The seven findings below detail the causes and contributing factors that led to this occurrence. Additionally, during the course of the investigation, the TSB also made 12 findings as to risk and 13 findings that could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.

Findings as to causes and contributing factors

These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

1. Due to the prevailing environmental conditions at the Hecla and Fury Islands, the Akademik Ioffe deviated from its original voyage plan toward Lord Mayor Bay, west of the Astronomical Society Islands.
2. In his assessment of the new voyage plan, the master relied on a Canadian chart but was not aware that the chart contained outdated and partial bathymetric data despite the chart indicating such.
3. In preparing a new voyage plan based on the Canadian chart and Russian sailing directions, the master concluded that the shallowest water depth the vessel might encounter was 50 m. Consequently, the master did not implement any additional precautions.
4. While transiting the narrows, the officer of the watch was multitasking, the helmsman was busy steering the vessel, and no other crew were tasked with monitoring the echo sounders and keeping lookout. As a consequence, they did not notice the under-keel water depth steadily decrease.
5. The under-keel low water depth aural and visual alarms for both echo sounders were turned off.
6. By the time the officer of the watch noticed the decreasing water depth on the echo sounder display, it was too late for the bridge team to take evasive action, and the vessel, which had been travelling at 7.6 knots, ran aground on an uncharted rocky shoal.
7. The master attempted to free the vessel from the rocky shoal using the vessel’s propulsion, which aggravated damage to the hull.

Findings as to risk

These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.

1. If a vessel’s crew conducts passage planning and assessment based on incomplete and unreliable navigational data without taking mitigating measures, there is an increased risk to the safety of the vessel and its complement.
2. If bridge navigation equipment is not optimally operated and automatic safety features such as alarms are turned off, there is a risk that a bridge team will miss critical information, especially in situations where the prevailing navigating conditions create a high workload for bridge team members.
3. If the bridge team composition is inadequate during periods of high workload, such as when transiting confined waters, there is a risk that critical navigational parameters, such as the under-keel water depth, will not be properly monitored, compromising vessel safety.
4. If passengers are not familiarized with shipboard lifesaving appliances upon their embarkation and before the vessel proceeds to sea, there is a risk they will not be able to respond appropriately to an emergency situation, should the need arise early in the voyage.
5. If passenger safety briefings and familiarizations are planned and delivered by uncertified staff rather than qualified crew members, there is risk that lapses in this critical familiarization will occur and impede passenger readiness in an emergency.
6. If critical safety tools such as emergency procedures and decision support systems are not optimized for use by the crew in an emergency or simultaneous emergencies, there is a risk that their response will be uncoordinated.
7. If proper post-occurrence contingency actions are not taken in an emergency situation, there is a risk of adverse consequences affecting the seaworthiness of the vessel or the safety of its passengers and crew.
8. If passengers are not given concise information and clear instructions during a shipboard emergency, there is a risk that passengers will become confused and react in an uncoordinated manner, delaying an orderly evacuation and compromising their safety.
9. If the coastal waters surrounding the Canadian Arctic Archipelago are not surveyed to modern international hydrographic standards and the existing government-issued navigation charts are based on incomplete bathymetric data, there is a risk that mariners will not have adequate information to safely navigate in these waters.
10. Until the coastal waters surrounding the Canadian Arctic Archipelago are adequately charted, and if alternate mitigation measures are not put in place, there is a persistent risk that vessels will make unforeseen contact with the sea bottom.
11. If the mandate of a vessel traffic coordinating and controlling organization does not include warning vessels to use extreme caution as they sail into poorly surveyed waters, there is a risk that crews will miss critical warnings from the official navigational publications, compromising the safety of their vessels and complements.
12. Given the increasing volume of vessel traffic in the Canadian Arctic, if search and rescue resources are not able to provide assistance to a marine occurrence in a timely manner, there is an increased risk of adverse consequences to vessels, their complements, and the environment.

Other findings

These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.

1. The master of the Akademik Ioffe did not wait for a Canadian Coast Guard vessel to arrive before evacuating the vessel. Although not enough lifesaving appliances were available on the Akademik Sergey Vavilov for the combined complements of both vessels, the Joint Rescue Coordination Centre and Transport Canada agreed to the evacuation plan.
2. At 0912, the Akademik Sergey Vavilov departed the occurrence site for Kugaaruk with the passengers from the Akademik Ioffe on board, after having been granted an exemption from Transport Canada to sail with 100 persons more than the vessel’s lifesaving equipment capacity.
3. The 4 certified bridge watch officers on board the Akademik Ioffe had completed and signed the P.P. Shirshov Institute of Oceanology of Russian Academy of Sciences’ familiarization checklist for shipboard bridge equipment. The equipment familiarization checklist on board the Akademik Ioffe included the use of the echo sounders but did not include the electronic chart display and information systems.
4. An Arctic Pollution Prevention Certificate was issued to the vessel, although it was not required. The certificate stated that the vessel was carrying the most recent editions of the Canadian Sailing Directions, the Canadian Notices to Mariners, and the Ice Navigation in Canadian Waters, despite the fact that the most recent editions of these publications were not on board the vessel at the time the certificate was issued.
5. The Akademik Ioffe initiated its expedition cruise from a Canadian location (Kugaaruk, Nunavut) not listed in the letter of compliance for its coasting trade licence.
6. The minimum and maximum operating draughts prescribed in the Arctic Pollution Prevention Certificate differed from those stated on the vessel’s Polar Ship Certificate.
7. The Akademik Ioffe’s shipboard post-grounding checklist required the master to attempt refloating the vessel after mustering the entire complement, but before carrying out a damage assessment that included the integrity of the hull and its appendages.
8. It is within Transport Canada’s mandate to assess a vessel’s ice navigation capabilities against existing ice conditions. The Northern Canada Vessel Traffic Services serves as a communication intermediary between the vessel and Transport Canada for the information exchange; Northern Canada Vessel Traffic Services does not have the mandate, expertise, or regulatory authority to assess the safety of a vessel’s intended passage for hazards.
9. Although they were included in the Akademik Ioffe’s safety management system, procedures for responding to a grounding or flooding or for evacuating the crew, expedition staff, and passengers were not included in the decision support system.
10. Contrary to the International Convention for the Safety of Life at Sea, 1974 requirements, the lifeboat mustering and ship safety briefing were carried out more than 12 hours after the vessel’s departure to sea from its anchorage off Kugaaruk.
11. The investigation determined that the passenger safety checklist had not been updated to reflect the 2015 amendment to the International Convention for the Safety of Life at Sea, 1974, which requires specific tasks to be conducted prior to or immediately upon vessel departure.
12. The first Port State Control inspection, conducted by Transport Canada in Louisbourg, Nova Scotia, did not identify any of the 12 deficiencies noted during the post-occurrence Port State Control inspection 37 days later while the Akademik Ioffe was at anchorage off the Astronomical Society Islands.
13. Although some passenger vessels carry forward-looking sonar systems to mitigate the risks associated with navigating in poorly surveyed waters and areas where navigation charts are unreliable, these systems are not mandatory under the International Convention for the Safety of Life at Sea, 1974, flag state, or coastal state requirements, for vessels operating in polar waters.