The ship master and "an observing captain" entered the pilothouse of the Roger Blough seven minutes before she ran aground on May 27, 2016.
One moment they were getting coffee and confirming delivery of ship's provisions, respectively, and the next the lake freighter was grinding to a halt on the bedrock floor of Lake Superior - puncturing steel in multiple places and flooding her forward ballast tanks to the waterline less than 30 feet above the well-charted bottom of Whitefish Bay.
Those details and more were part of the National Transportation Safety Board's marine accident brief, the "Grounding of Freighter Roger Blough," released in July.
The report pinned responsibility for the grounding on the bridge's seasoned mariners, including a second mate in control of the ship who both failed to heed a verbal command from the ship's master to slow down, and "failed to use all navigational resources to determine the ship's position as it approached shallow water near Gros Cap Reefs."
Stalled in the southeasternmost part of the lake, the Blough was considered a "marine casualty." No one was hurt or pollution reported, but the damage to the ship was significant - $4.5 million worth to the Blough's hull and interior cargo system of tunnels, belts and pulleys. Freeing the Blough required a two-day lightering of her taconite iron ore cargo onto a pair of fleet mates, the Arthur M. Anderson and Philip R. Clarke. Afterward, the Blough was shepherded to a shipyard in Sturgeon Bay, Wis., to be out of commission for about two months of repairs.
Among further conclusions, the NTSB report, while acknowledging the master and observing captain "were in the wheelhouse," noted that ship leadership went against company policy by not having a second officer "actively engaged in safe navigation of the vessel."
Canadian National Railway owns the Blough as part of its Great Lakes Fleet of ships, which are operated by Key Lakes Inc., based in Duluth. Both parties declined to comment on personnel actions taken in the wake of the NTSB conclusions, said CN spokesman Patrick Waldron. The NTSB report noted the master has sailed the lakes for 28 years and the second mate for 17.
According to the NTSB report, Key Lakes did use the Blough example as the topic of the company's most recent annual fleet seminar training, studying lessons learned from the grounding while also providing refresher training on "no-go" areas.
Before the grounding at just past noon, the Blough had emerged from fog into a clearing day and was attempting to maneuver past a powerless dead-ship, the Tim S. Dool, being towed by the Anglian Lady. In a radio conversation with the Anglian Lady, the Blough's second mate agreed to take the high left of the Birch Point Course as both headed out of Lake Superior toward the Soo Locks. Anglian Lady would stay right and low in the channel. At 14.5 mph, the Blough was traveling between 8-9 mph faster than the towing operation.
"(The second mate) did not slow the ship's speed prior to entering the channel, in accordance with the master's verbal instructions," the NTSB report said.
The Blough never made the pass - getting hung up on the channel's outer edges and skidding to a long stop that pulled into view the Gros Cap Reef Light 240 yards away. The light is a midlake protrusion that marks the start of the St. Marys River.
The results of a separate U.S. Coast Guard investigation into the grounding have yet to be released. While the federal agencies overlapped with one another to investigate the grounding, both issue their own reports and independent findings on the incident, said the Coast Guard's lead investigator, Lt. Daniel Every of Coast Guard Sector Sault Ste. Marie.
Interestingly, there will be a discrepancy in the two findings.
The NTSB concluded of two Coast Guard watchstanders located at the Sector Sault Ste. Marie Command Center that "had the watchstanders effectively monitored the vessel's track, they likely would have identified that the Roger Blough was operating at the edge of the channel and approaching the shallow water near Gros Cap Reefs."
But the watchstanders were not aware of Blough's danger until after the crew reported running aground, the NTSB report said.
Vessel Traffic Service watchstanders monitor water levels and the transit of about 23 freighters per day through the 77 nautical miles of river between lakes Superior and Huron, said a Coast Guard fact sheet. Watchstanders have any number of tools at their disposal and the authority to "monitor, inform, recommend and direct" vessel traffic, said the NTSB report.
The Coast Guard report will dispute criticism of the watchstanders.
"Although the Coast Guard agrees with many of the findings in the (NTSB) report, our investigation, while not available to the public yet, determined that the St. Marys River Vessel Traffic Service (VTS) was operating in substantial compliance with Coast Guard policies," Every told the News Tribune. "Of note, the NTSB report did not include any safety recommendations. Therefore, the Coast Guard does not plan to make any changes to the operation of St. Marys River VTS at this time."
In the end, there will be no new precedent-setting safety recommendations as a result of either report.
"We intend to circulate information on the Great Lakes to raise awareness of a few issues that would be best practices for some companies and some mariners to utilize," Every said, describing the extent of upcoming Coast Guard findings.
One of best practices now adopted within the Great Lakes Fleet, according to the NTSB report: a reduction of standing verbal orders in favor of written ones.
Also, the Great Lakes Fleet added data recorders on two vessels with plans to outfit the whole nine-vessel fleet. The recorders maintain sequential records of data related to equipment, command and control and, said the NTSB report, can "capture bridge audio from certain areas in the pilothouse and on the bridge wings."