The Transportation Safety Board released a report Tuesday examining what happened when the Japanese-owned bulk coal carrier Cape Apricot hit a conveyor belt at Westshore Terminals, south of Vancouver at Roberts Bank, in December 2012.
The collision caused extensive damage to the terminal, rendering one of its berths inoperable, and sent 30 tonnes of coal into the water. No one was injured.
The Cape Apricot was anchored near Victoria when it was cleared to berth at Westshore Terminals, the report said.
The ship picked up a local marine pilot — a requirement for large vessels navigating B.C. waters — before sailing to the Vancouver area. The ship arrived in the vicinity of Westshore Terminals shortly after midnight on Dec. 7 and approached the terminal with the assistance of two tug boats.
The vessel's course set it on a straight line toward the trestle on an angle that would have required a tight turn to avoid a collision, the report said.
However, by the time the marine pilot initiated the turn, it was too late, said the report. The ship collided with the trestle at a speed of 3.5 knots, or about 6.5 kilometres per hour.
The report said poor communication on the bridge meant neither the captain nor the pilot recognized the risk in time. They also hadn't discussed abort points — the points at which a manoeuvre can still be safely aborted.
"Without effective communication regarding their shared mental model during the approach, the master and the pilot did not identify the developing risk as the manoeuvre progressed and did not take timely corrective action," the report said.
The Pacific Pilotage Authority, a federal government agency, oversees the use of marine pilots on the West Coast. In the area where Westshore Terminals is located, the agency contracts the hiring of the pilots to B.C. Coast Pilots Ltd.
The safety board report also said inadequate safety planning increased the risk.
Neither the Pacific Pilotage Authority nor B.C. Coast Pilots has formal processes to assess risks or review accidents. The safety board considers such processes to be essential elements of a safety management system.
"Without a safety management system in place, pilotage organizations may not properly identify hazards and mitigate them, thereby placing vessels at risk," the report said.
The report notes the Pacific Pilotage Authority has since developed a protocol outlining what should happen following a collision.
A statement posted to the B.C. Coast Pilots website said the company was reviewing the report and would work with the Pacific Pilotage Authority to improve its policies and procedures.
"The (B.C. Coast Pilots) have one of the best marine pilotage safety records in the world," the statement said.
"With highly effective safety management practices that meet and/or exceed international and Canadian standards, the (B.C. Coast Pilots) has maintained a 99.98 per cent incident-free safety record for many years."