Marine Investigation Report M06W0052
1.0 Factual Information
1.1 Particulars of the Vessel
|"QUEEN OF THE NORTH"|
|Port of Registry||Victoria, B.C.1|
|Type||Passenger and vehicle ferry|
|Built||1969, Bremerhaven, Germany|
|Propulsion||Two MAN V-16 diesel engines, totalling 11 631 kW and driving two controllable-pitch propellers|
|Cargo||Passengers and vehicles|
|Passengers||On board: 59 Maximum: 650|
|Crew||On board: 42 (including 2 being trained) Maximum: 50|
|Vehicles||On board: 22 Maximum (nominal): 157|
|Owner/Manager(s)||British Columbia Ferry Services Inc. (BC Ferries),3 Victoria, B.C.|
Description of the Vessel
The passenger roll-on/roll-off (ro-ro) vehicle ferry Queen of the North, originally named the Stena Danica, was built in Germany in 1969. In 1974, it was purchased by the Government of British Columbia, and its registry was transferred to Canada. The vessel was then renamed the Queen of Surrey and put into service between Nanaimo, British Columbia, andHorseshoe Bay, British Columbia, on home trade voyages, Class III. In 1980, the vessel underwent a modification for the northern British Columbia ferry routes and was renamed the Queen of the North.
The vessel was built of steel and had eight decks, including a double bottom, as follows (see Figure 1):
- Deck 8 Ventilation Deck
- Deck 7 Boat Deck
- Deck 6 Promenade Deck
- Deck 5 Saloon Deck
- Deck 4 Platform Deck
- Deck 3 Main Car Deck
- Deck 2 Tween Deck
- Deck 1 Double Bottom
The hull below the main car deck was subdivided by 11 main transverse watertight bulkheads, with 11 sliding watertight doors providing access to the main compartments. The engine rooms were located amidships. Deck 2 (Tween Deck) contained crew accommodation spaces.
There were two car decks: the main car deck and the platform deck - Decks 3 and 4, respectively. Vehicles had access to Deck 3 by way of the stern or the bow doors and ramps. Deck 3 was arranged for three lanes of cars on the port side and two lanes on the starboard side. The engine casing was mounted slightly off the centreline. Two sets of transverse flood-control doors were fitted on this deck. Deck 4 was divided into five sections port and starboard, with three hoistable platforms on each side.
Deck 5 (Saloon Deck) contained passenger common areas such as the cafeteria and the bar, and also the galley and purser's office. Deck 6 (Promenade Deck) contained a passenger accommodation space aft, a port midship lounge, and an enclosed reserved passenger seating area, as well as a lounge and a passenger seating area forward. Deck 7 (Boat Deck) contained another passenger accommodation space aft, the officers' accommodation space amidships, and the wheelhouse at the forward end.
Figure 1. General arrangement
1.2 History of the Voyage
The vessel was crewed by a live-aboard crew with two two-week watches, A and B. The A watch had brought the vessel out of its recent four-month refit in Richmond, British Columbia, and handed over to the B watch on 15 March 2006. At 1700 Pacific standard time4 on 21 March 2006, the Queen of the North arrived from Skidegate, British Columbia, at the BC Ferries terminal at Prince Rupert, British Columbia. After unloading passengers and vehicles, the crew prepared the vessel for departure to Port Hardy, British Columbia.
The crew commenced loading vehicles and embarking passengers and, at 2000, the Queen of the North departed for Port Hardy with a crew of 42 and 59 passengers. Scheduled arrival time was 1330 the following day, March 22.
The bridge team on departure comprised the master, the second officer (2/O), the quartermaster5 (QM1), and an additional QM. The additional QM was on the bridge to support QM1, who had requested assistance due to unfamiliarity with the steering system. The fourth officer (4/O) joined them after completing his vessel-departure duties. QM1 was hand-steering the ferry from the aft steering station in the wheelhouse,6 while the ferry was on "standby"7 and proceeding in a southerly direction. QM1's duties included being a lookout, but not while steering the vessel. As it neared Ridley Island, the vessel was taken off standby but remained on hand steering.
At about 2050, QM1 was relieved by QM2 and at approximately 2100 the master handed the con of the ferry to the 2/O and wrote out his night orders. The 2/O was also instructed to call the master if there was traffic at Stella Creek.8 The master then retired to his cabin. The weather was clear with good visibility and light winds.
Between 2200 and 2350, QM3 and QM4 rotated watches as did the 2/O and 4/O. The 2/O had the conduct of the vessel. At some point during this period, the 4/O went below to the crew's mess to eat lunch. QM1 returned to relieve QM2 at approximately 2345 and took over the helm at 2350. The vessel was on autopilot, with steering controls at the forward steering station. The ferry was on a course of about 139º true (T) through Grenville Channel, maintaining a speed made good of about 17.5 knots with engines under bridge control (see Appendix A for the vessel's track).
Before midnight, when the 4/O returned to the bridge, the 2/O informed him that there was no reported traffic9 but that there was a southbound vessel ahead. This vessel, later identified as the fishing vessel Lone Star, was about 4.4 nautical miles (nm) fine on the port bow, southbound, at a speed of 5.9 knots. The 4/O - now the officer of the watch (OOW) - was also informed that the wind was gusting to 30 knots on the ferry's starboard bow. The 2/O then retrieved a laptop computer from his cabin to play music and, after leaving it on the bridge, proceeded on his break. A personal conversation ensued between the 4/O and QM1, who were now alone on the bridge. At 2359, a course adjustment of 4º to port was made to keep the vessel on track.
The 4/O used the electronic chart system (ECS)10 to determine his estimated time of arrival at the next calling-in point and then used a dimmer knob to turn down the brightness on the ECS monitor to prevent the screen's light from interfering with the visual lookout. At 0002:34, approximately 1.3 nm in advance of a planned course alteration to 118º T, the 4/O reported the ferry approaching Sainty Point11 to Prince Rupert Traffic.12 The call took about 40 seconds and music could be heard on the bridge at this time. The 4/O subsequently logged his communication then resumed a personal conversation with QM1.
At about this time, the Queen of the North encountered a squall of heavy winds, rain, and reduced visibility. The Lone Star, meanwhile, having already passed Sainty Point and now rounding Waterman Point, proceeded east to seek shelter from the weather behind Promise Island. At 0005, the Lone Star was 2.8 nm away and bearing 22º on the port bow. It was then no longer visible on the radar screen, and the target-lost alarm was displayed and acknowledged. No attempt was made to communicate with the vessel.
At 0007, the vessel, without making the required course alteration, proceeded past Sainty Point and into Wright Sound. At a speed of 17.5 knots, the next course-alteration point on the planned route would have been 27 minutes ahead, off Point Cumming light.
As the vessel proceeded in Wright Sound, the 4/O and QM1 sat in their chairs next to the radar and forward steering station, respectively, and conversed intermittently for the next 12 minutes while music was being played in the background. Shortly after the Lone Star had rounded Waterman Point and proceeded north toward Brodie Point, the squall passed and visibility improved.
At about 0020, with the vessel now 13 minutes past the planned course-alteration point at Sainty Point, the 4/O moved between the bridge's front window and the radar, and subsequently ordered a course change to 109º, which QM1 queried and he reaffirmed. As QM1 stood to make the change, she looked up and saw trees off the starboard bow. The 4/O also saw trees and moved to the aft steering station. As he did so, he ordered QM1 to switch from autopilot to hand-steering. QM1, however, was unfamiliar with the operation of the switch at the forward steering station and did not know how to comply.
The investigation was unable to ascertain whether QM1 initiated the ordered course change using the autopilot, or if steering was switched to hand-steering by the 4/O, or both. However, data from the ECS indicate that at 0020:50 the vessel's course over ground (COG) began to alter to port, subsequently striking Gil Island at 0021:20 in position 53º19.2' N, 129º14.3' W.
QM1 left the bridge to get the master. The ferry continued to travel forward for a short time, but at a reducing speed as it struck along the island, and then drifted off in a northerly direction.
There is no information to suggest that, up to the time of the striking, navigational equipment or machinery malfunctioned during the voyage.
In late April 2007, BC Ferries forwarded new information to the TSB that suggested that QM1 may have been alone at the time of the grounding.
The TSB thoroughly investigated this new information and the suggestion that QM1 was alone on the bridge at the time of the accident. This included conducting additional interviews, taking into account conflicting statements, and undertaking extensive analysis.
1.2.1 Events Following Striking
After the ferry struck the island, the 2/O, who was in the officers' lounge, ran to the bridge. At the end of the hallway, he passed QM1. On the starboard radar display, the 2/O saw land. He moved the engine throttle controls from full ahead to full astern, but the vessel did not respond. The master entered the bridge after the general alarm had been sounded. He turned on the deck lights. Shortly thereafter, he ordered the watertight doors to be closed. It was reported that the familiarizing chief officer13 closed the doors.
Between 0023 and 0027, the vessel's latitude and longitude were incorrectly communicated to Prince Rupert Traffic on three occasions. The Queen of the North reported that there were 101 persons on board. Meanwhile:
- Water ingress into the hull was immediate, rapid, and extensive.
- As the bilge pumps could not keep up with the ingress of water through the breached hull, the engineers of the watch closed the watertight door at frame 74 between the main engine room and the auxiliary engine room using the local control handle. They then informed the bridge that the engine rooms were being evacuated. The watertight door at frame 55 between the main engine room and the workshop was obstructed by debris, and, as there was flooding on both sides, the crew did not close it. The crew did not have the time to fully ascertain the extent of damage to the hull before evacuating.
- The chief officer (C/O), who was off duty and sleeping in his cabin, woke up, proceeded to the bridge, and phoned the engine room, but the call went unanswered. He informed the master and, taking a radio with him, proceeded to check the engine room. He descended to Deck 4 midships in the area of frame 100, and noted that the main car deck (Deck 3) was awash. He also noted the ferry had a small list to starboard and was trimmed by the stern.
- The 2/O and 4/O proceeded to the main foredeck, and both anchors were let go. The 2/O then went below through Decks 5, 4, and 3 calling out, looking for people, and assessing the flooding.
- The Prince Rupert BC Ferries marine superintendent, who was on board, informed BC Ferries management of the striking.
At 0026, the Queen of the North advised Prince Rupert Traffic that the vessel was aground and required immediate assistance. At 0027, Prince Rupert Coast Guard Radio broadcast a Mayday Relay on very high frequency (VHF) radiotelephone channel 16, indicating that the Queen of the North was aground, listing severely, and taking on water just south of Sainty Point in Grenville Channel.
At 0038, Prince Rupert Traffic was informed that the watertight doors were being closed. At 0140, following abandonment, the ferry sank by the stern in 430 m of water in position 53º19.9' N, 129º14.7' W. After the stern struck the bottom, the ferry came to rest on its keel. The hull was buried in silt to a depth of about 9 m.
1.3 Abandonment Phase
1.3.1 Passenger Muster
After the ferry struck the island, water was rapidly accumulating in the crew accommodation spaces on Deck 2. In some cases, water was waist deep by the time crew members evacuated. An announcement was made over the public address system that passengers and crew were to go to the upper-deck boat and liferaft stations.14 Some crew members attended with lifejackets, but not all donned the reflective crew identification vests as required by BC Ferries Fleet Regulations.
Some passengers, many having taken their lifejackets from their state rooms, went to Deck 8, but most proceeded directly to Deck 7. A few passengers experienced difficulties doing so,15 and there were reports of baggage being displaced in the cabins. One crew member on Deck 2 was briefly trapped in her cabin when a locker fell and blocked the door. She freed herself, by which time some four feet of water had accumulated inside the cabin. Once passengers reached Deck 7, passengers and crew shared clothing with those who were not warmly dressed, and crew members ensured that everyone wore lifejackets. No head count was made while the crew prepared the survival craft for boarding.
1.3.2 Clearing of Cabins and Passenger Spaces
Just after the striking, some crew members knocked on other crew members' doors and began clearing crew cabins on Deck 2. The second steward from the night shift reported to the purser's office on Deck 5 and laid out gear for catering staff to clear passenger and crew cabins.16
As crew members proceeded to muster stations, all passenger cabins except those on the starboard side of Deck 7 were eventually cleared.17 Clearing was not carried out according to procedures in BC Ferries Fleet Regulations: chalk marks were not placed on doors, and not all rooms were physically searched. Not all cabins were cleared by those assigned to that particular muster duty: some crew members were delayed by water ingress; others had already cleared the areas; and there was some confusion about whether to follow the public announcement (directing people to proceed directly to the upper-deck boat and liferaft stations) versus following the procedure of clearing all passenger areas.
On Deck 6, the lounges were cleared. It is not known if the washrooms on this deck were cleared. On Deck 5, the cafeteria and bar were locked and inaccessible to passengers. It is not known if other public areas on Deck 5, such as washrooms, were cleared.
Deck 3 was observed to be flooding and was not cleared.
Once mustered on Deck 7, passengers were directed to stay clear, and the crew prepared to launch the survival craft. A few blankets were brought to the muster station, yet although the lifeboats were equipped with space blankets, these were not used. As the port lifeboat was made ready and passengers embarked, a rigid-hull inflatable rescue boat was launched with two crew members. Three liferafts were rigged, slewed out, inflated, bowsed in, loaded with passengers, and davit launched. The roof of one liferaft did not fully inflate, but this did not impede the abandonment.
Passengers and crew used three liferafts, one lifeboat, and one rescue boat during their abandonment. At 0053, the master and remaining crew members abandoned ship using an additional lifeboat, this one on the starboard side.
1.3.4 Abandonment Concerns
Regarding the process of abandonment, as well as mustering and clearing of cabins, the investigation revealed the following:
- Awareness of Emergency: Although most passengers had been asleep, the majority were alerted by the noise and motion of the striking. Roughly half of them-mostly those on Deck 6, as well as some crew on Deck 5 - reported that they did not hear the public announcement or the general alarm. Nearly all had left their staterooms before crew members arrived to begin clearing cabins.
- Communication with Passengers/Crowd Control: This proved difficult. For instance:
- Some passengers who had sought information from the purser's office were directed to Deck 7; crew members there were busy clearing away the survival craft, and the passengers were sent back down, below-decks.
- Instructions to passengers were passed by word of mouth, some crew were not easily identifiable, and some passengers could not differentiate between port and starboard when told to move to the port side of Deck 7.
- Although some crew members and passengers recognized the need to restrict passenger movements, as demonstrated by the spontaneous response of blocking off several exits to the outer decks of Deck 7, this procedure had not been included in the formalized vessel-specific evacuation plan.18
- Counts: Difficulties were encountered when making accurate passenger counts. These were attempted at various stages of abandonment, often yielding differing numbers. For instance:
- As passengers boarded each survival craft, a count was carried out to prevent overcrowding, and these counts were relayed to the master but were not recorded. One person designated to perform this count was reportedly distracted by a passenger with young children, and only later returned to complete the count.
- After abandoning the vessel, the master detailed one person in each lifeboat and liferaft to do a head count, but this was hampered by insufficient flashlights, no means of recording the counts, and no practised method of carrying out counts. The master requested several recounts as the totals were not consistent.
1.4 Search and Rescue Operation
At 0026, the Joint Rescue Coordination Centre in Victoria (JRCC Victoria) was informed by MCTS Prince Rupert that the Queen of the North had reported running aground and required assistance, setting in motion search and rescue (SAR) operations.
Immediately after the 0027 Mayday Relay broadcast, the Lone Star, about 5 nm from the scene, informed MCTS Prince Rupert that it would provide assistance. Residents of Hartley Bay, British Columbia, which is six miles away, heard the Mayday Relay at home and quickly responded, organizing several small craft to provide assistance. These included the April Augusta, Miss Yolanda, Mad Max, Miss Ardell, and Crystal Jean. The cultural centre in Hartley Bay made preparations to receive survivors.
The Canadian Coast Guard ship (CCGS) Sir Wilfrid Laurier, which was at anchor 17 nm to the south and would later be tasked as the on-scene coordinator (OSC), informed MCTS Prince Rupert that it would be underway shortly and was sending its fast-rescue craft, Laurier 1.
JRCC Victoria tasked a number of resources, including two SAR aircraft and four Canadian Coast Guard (CCG) vessels.
At 0113, the April Augusta arrived and was instructed by the 2/O to make a sweep around the Queen of the North using a high-powered light, but no one was seen on board or in the water. The 2/O, with the master's permission, took the fast-rescue boat, with two deckhands, and circled the vessel looking for people. The interior of the vessel was visible through the windows. The outer decks were still lighted. The rescue boat remained on station as the vessel sank, and afterward conducted a surface search. Other vessels arrived, including the CCGS W.E. Ricker, and began to transfer some survivors to bring them to Hartley Bay. Arrangements were made to have the survivors met at the Hartley Bay dock for a head count and to take their names. The chief steward was detailed by the master to take charge of persons going ashore. Some survivors displayed signs of mild hypothermia by the time they reached Hartley Bay.
When the ferry sank, many of the lifejackets floated free from their stowage lockers. The inflatable liferafts did not float free or auto-inflate, nor were these features required by regulation. The ferry's float-free emergency position-indicating radio beacons (EPIRBs) began transmitting automatically shortly after the vessel sank. These signals were received by the Canadian Mission Control Centre (CMCC) at Trenton, Ontario. At 0151, CMCC informed JRCC Victoria of the signals.
At 0144, the Lone Star arrived on scene and, after loading 17 survivors, took them to Hartley Bay.
At 0154, the C/O of the Queen of the North informed the CCGS Sir Wilfrid Laurier, using a hand-held VHF radio, that they were not confident that all persons had been accounted for. Throughout the remainder of the rescue operation, the number of survivors reported recovered fluctuated and, given this variance in passenger counts, the search was continued.19
At 0156, the Laurier 1 arrived on scene. At 0220, the CCGS Sir Wilfrid Laurier arrived on scene.
At the request of BC Ferries, the remaining survivors in Hartley Bay were put aboard the CCGS Sir Wilfrid Laurier and taken to Prince Rupert. With that vessel's departure, the CCGS W.E. Ricker took over as OSC.
Canadian Forces aircraft searched a radius of 5 nm from the debris field. Barrier searches20 were established at 1.5 nm and 5 nm from the accident site to search for anyone who did not make it into survival craft. At 1415 on March 22, the search was placed on reduced status, and officially concluded at 1856 on March 23.
Two persons were unaccounted for, and the matter was handed over to the Royal Canadian Mounted Police as a missing-persons case. The TSB investigation could not determine where on board the vessel the two missing persons may have been at the time of the striking.
1.5 Injuries to Persons
Two passengers, who boarded the ferry at Prince Rupert, have been declared dead.
Although there were no other serious injuries, some people received first-aid treatment, and 11 people were airlifted to Prince Rupert. Of those airlifted, 3 were crew members who suffered minor injuries; 4 others were passengers, and 4 were other crew members who required medical attention due to stress.
1.6 Damage to the Vessel
When the vessel struck the island, the starboard-side hull plating was ruptured along the keel at the forward end and also in way of at least two other main watertight compartments: the main engine room, and one crew accommodation area aft on Deck 2, including the workshop below. Although a more detailed assessment was not possible due to the limited information available from crew members and the disposition of the vessel in the silt, it is known that at least three main compartments experienced initial flooding.
Once the vessel sank, it struck the bottom stern-first. This created buckling at various places along the side shell, which was later observed during the post-occurrence underwater survey. The vessel came to rest upright on the bottom, deep in sediment. The bridge was covered in silt and several bridge front windows were missing. The engine controls were in the full-astern position. Various overhead panels, fittings, and furniture had been dislodged. The ECS computer was intact. There was also a release of pollutants.
1.7 Geographical, Weather, and Current Information
The Inside Passage between Prince Rupert and Port Hardy is largely sheltered from southwesterly to northwesterly winds and from offshore sea states. Wright Sound is located at the south end of Grenville Channel, which leads north to Prince Rupert. The sound is deep throughout and leading into it are various channels and passages, the sides of which are mountainous. The south side of the sound is bordered by Gil Island, a 27 km, tree-covered island with a summit of 844 m. The seabed along the last 300 m of the vessel's track shoals from a depth of 70 m to approximately 5 m at the point of striking.
The following aids to navigation are located in the immediate area (see Appendix A):
|Location of Light||Characteristics||Range|
|Sainty Point||Flashing white; once every 4 seconds||4 miles|
|Cape Farewell, southern tip of Promise Island||Flashing white; three times every 12 seconds||7 miles|
|Point Cumming, southeast of Gribbell Island||Flashing white; once every 6 seconds||5 miles|
There is no weather-observation station near the occurrence area. Heavy rain and windspeeds as high as 40 knots were reported as a cold front moved through from the southeast. An Environment Canada analysis of the meteorology suggests that winds changed dramatically with the passage of the cold front. The wind shifted and rose from moderate northeasterly to gale force southeasterly just as the Queen of the North was approaching Sainty Point. This was consistent with the conditions experienced on board the vessel at that time. Air temperature was approximately 7ºC. Tidal streams in the sound are one knot or less. Low tide occurred at 2332, and moonrise was at 0339.
At the time of the striking, it was reported that there was little or no wind or rain, the seas were relatively calm, and the visibility was good.
1.8 Vessel Certification
The Queen of the North held a Transport Canada (TC) Ship Inspection Certificate (SIC 16), issued at Vancouver, British Columbia, on 02 March 2006 and valid until 01 March 2007. The vessel was certified for its intended operations. Attached to the SIC 16 was a Ship Inspection Notice (SI 7) citing 13 deficiencies. The following deficiencies with respect to lifesaving equipment and plans were noted:
- The lifesaving equipment plan had not been approved by TC.21
- There was no evacuation plan.
- No general alarm bells were fitted on the exterior of Decks 7 and 8, which were accessible to passengers.
- Tween Deck, alleyways, and rescue routes were not clearly marked with differential low-level markings visible under low-lighting conditions.
A proposal to correct deficiencies 1 and 2 was required to be submitted to TC within 60 days of issuing the SIC 16. Deficiencies 3 and 4 were required to be rectified by 01 April and 30 November 2006, respectively. The deficiencies noted in the SI 7 attached to the SIC 16 were not considered by TC to be of a nature that would render the vessel unsuitable for its intended operation.
1.9 Watertight Doors
The vessel's hull below the main car deck was subdivided by 11 main transverse watertight bulkheads. A total of 11 sliding watertight doors were fitted in the bulkheads at frames 32, 44, 55, 74, and 95 on Deck 1, which contained engine spaces and tanks, and at frames 20, 32, 44, 110, 125, and 138 on Deck 2, which contained crew accommodation spaces.
These doors were power-operated and could be closed by a master lever on the bridge. They could also be operated from the emergency station on the platform deck or locally at the doors themselves. The arrangement was such that, with the master lever in the "closed" position, a locally opened door would automatically close. Conversely, if the master lever was open, doors opened locally would remain open.
Canadian regulations require that the master and persons in charge of the navigation and engine-room watches ensure that all watertight doors are kept closed during navigation except when necessarily opened for the working of the ship.22
In 1981, after a BC Ferries crew member was crushed to death by a watertight door, BC Ferries deemed it potentially unsafe to allow anyone, particularly untrained passengers,23 to routinely operate the watertight doors in the passenger accommodation areas. The company then made a request to TC for an interpretation of the regulations that would allow watertight doors on the Queen of the North and the Queen of Prince Rupert24 to be left open except in emergencies or when the master or officer in charge deemed it prudent to close them.
TC subsequently indicated that the doors' status should be an operational decision, taking into consideration factors including operation, design, layout, weather, sea conditions, environment, and traffic. BC Ferries interpreted this to mean that the vessels could operate with watertight doors open. This has been the case since 1981, a fact of which TC was aware.
In 1995, a safety audit by British Columbia's auditor general25 questioned this practice, and that August, at the auditor general's request, BC Ferries sought confirmation of its interpretation of the regulations - requesting that the Board of Steamship Inspection rule on the matter.26 TC's regional office stated that it agreed with the BC Ferries interpretation, and it did not request a Board of Steamship Inspection ruling as it believed that the situation had been previously reviewed. When contacted by the auditor general, however, TC could find no record of the Board of Steamship Inspection having addressed this issue.
The auditor general therefore made an official recommendation that BC Ferries again request a Board of Steamship Inspection ruling on the practice, which the company did in May 1996. To support its position, in August 1996, BC Ferries issued a modified version of the practice to masters of vessels on the northern run, copying it to TC. The new risk-based practice allowed watertight doors within the accommodation and engine spaces to be left in the open position at the master's discretion.
On 05 September 1996, the Board of Steamship Inspection ruled that the Queen of the North and the Queen of Prince Rupert must comply with the regulatory requirements.27 The Board of Steamship Inspection also pointed out that the margin line28 would quickly become submerged should flooding occur while any watertight doors were open. As the Hull Construction Regulations are ambiguous as to when the doors may be kept open, the Board of Steamship Inspection also considered the requirements of Regulation 15, Chapter II-1, of the International Convention for the Safety of Life at Sea (SOLAS Convention) when considering BC Ferries' request. Vessel masters were further instructed to take all precautions to ensure the safe transit of passengers and crew through the watertight doors.
Although no correspondence was found in TC's file showing that action was taken to advise BC Ferries in writing of the Board of Steamship Inspection's decision, BC Ferries was in possession of a copy of the document.29 However, the practice of operating with some watertight doors left open has persisted.
When the Queen of the North struck Gil Island, the master lever on the bridge was in the "open" position and at least two watertight doors were open - those in the forward and aft bulkheads of the main engine room.
1.10 Navigation Equipment
Navigation equipment in the wheelhouse included three radars,30 ECS,31 a differential global positioning system (DGPS), and an automatic identification system (AIS). Also within the wheelhouse were paper charts, the controls for the watertight doors, the fire alarm panel, fire door indicator panel, ventilation shut-down panel, and the general alarm/public address system.
Visibility forward of the beam was not significantly hindered by the design of the bridge or the layout of its equipment (see Figure 2).
Figure 2. Layout of the bridge (not to scale)
1.10.1 Dive Operations and Data Recovery
Extensive dive operations, using a remote operating vehicle (ROV), were carried out by the TSB on the Queen of the North from 15 to 17 June 2006. The following equipment was recovered:
- ECS/Transas computer
- Sperry GPS/AIS receiver
- Northstar DGPS
- digital selective call (DSC) VHF radio
1.10.2 Navigation Equipment Alarm Features
ECS is a navigation information system that electronically displays vessel position and relevant nautical chart data.32 It provides chart information with real-time vessel position and navigation information. It also provides alerts and prompts for track monitoring, planned course alterations, and other navigation and safety features, including continuous data recording for later analysis. These include waypoint alarms, which sound once a desired waypoint is reached and a course alteration is required, and cross-track error (XTE) alarms, which are activated when the vessel leaves the course line's set parameters. When vector charts are used, a navigation-danger alarm may be set up that establishes a radius of navigation danger centered on the ship's position. The area delineated within this circle is then constantly checked for any dangers pre-determined by the user.
Alarm features are also available with other navigational aids, namely:
- DGPS: cross-track feature alarm
- Radar: cross-track feature alarm (when used with loaded routes)
- Autopilot: off-course feature alarm
Alarms may be tailored to reduce distractions on the bridge by configuring them to alert only in situations where they would normally be expected to provide useful information.
1.10.3 Electronic Chart System Setup on the
Unlike the electronic chart display and information systems (ECDIS) - for which monitors must meet strict international standards for factors such as brightness, contrast, and colour - the purchaser of an ECS system may use any monitor.
On the Queen of the North, some bridge officers on both shifts found the ECS display overly bright during the night watch. This problem is exacerbated when the system is displaying raster charts,33 because land is shown as yellow-orange in colour and water is shown in white, regardless of whether the ECS is in day or night display mode.34 As a result, raster charts are inherently brighter than vector charts when the system is in night mode.
To alleviate this, the crew in a previous season had placed a screen over the monitor. A rotary dimmer was later installed to let bridge officers dim the screen beyond the standard setup brightness option for the monitor, even if night-setting palettes had already been selected. Some officers had developed the practice of dimming the screen, using this dimmer, and brightening it only when they wanted to check their position.
At the time of the occurrence, the ECS was displaying a raster chart, and the display had been dimmed by the 4/O. In addition, the investigation revealed the following points regarding the setup of the ECS on board the vessel:
- The chart portfolio for the areas being navigated by the Queen of the North was mostly in raster format.
- The navigation-danger alarm was unavailable while the raster chart was loaded.
- The cross-track alarm had been manually deactivated around the time of the refit.
- The software was configured such that all alarm sounds were deactivated. As a result, active alarms would provide visual warning only.
To defend against the ad hoc modification of parameters, such as alarm settings, the system was provided with a password. However, this password was well known and easily accessible to any who wanted it. Furthermore, BC Ferries had no policies or procedures in place to define the desired configuration of the ECS safety features. This effectively left the system setup at the discretion of each operator.
The waypoint, cross-track, and navigation-danger alarm features available with the other electronic navigation equipment had not been set up or enabled.
1.10.4 Electronic Chart System Recorded Data
The ECS data log files for the occurrence were successfully retrieved. They contained a record of the electronic information originally obtained from both external sensing devices and screen presentations. The data log was updated every minute with date, time, latitude, longitude, heading, course over ground, and speed over ground. Latitude and longitude were recorded every 10 seconds (see Appendix B). No system malfunction was recorded by the ECS.
During a voyage, an ECS also maintains a recorded log of some, but not all, actions undertaken, be they undertaken automatically by the ECS or manually by an operator. The ECS logbook indicated that four charts were loaded by the ECS system while the 4/O was on the bridge. The chart displayed while transiting Grenville Channel was a vector chart; the chart displayed for Wright Sound was a raster chart. The last recorded operator action was a scale change/set scale of 1:10 000 at 2302:04.
Appendix B presents the vessel's track as recorded by the ECS for the final minutes of the voyage.
1.11 Voyage Data Recorders
Various modes of transportation have used data recorders to assist investigators and provide owners and operators with a means to continually improve operations. Although the aviation industry has enjoyed the benefits of flight data recorders for 50 years and cockpit voice recorders for 43 years, experience with voyage data recorders (VDRs) in the maritime industry is relatively new.
In addition to bridge audio, a VDR is capable of recording such items as time, vessel heading and speed, gyrocompass, alarms, VHF radiotelephone communications, radar, echo sounder, status of hull openings, windspeed and direction, and rudder/engine orders and responses.
Passenger vessels built on or after 01 July 2002 are required to carry a VDR when engaged on international voyages. In 2006, cargo vessels on international voyages became subject to the requirement for a VDR or, alternately, a simplified VDR (S-VDR).35 Although such S-VDRs do not store the same level of detailed data, they nonetheless record at a minimum:
- date and time (GPS)
- latitude and longitude (GPS)
- speed (speed log)
- heading (gyrocompass)
- bridge and VHF audio
- main radar (substitute AIS if radar is impossible to record)
Moreover, should a vessel sink, such units containing the stored data may, in some instances, float free.
In Canada, VDRs or S-VDRs are not mandatory for passenger vessels on domestic voyages such as the Queen of the North.
In this instance, an exploratory dive was conducted by BC Ferries shortly after the occurrence by a manned submersible capable of recovering a fixed VDR capsule, should the vessel have been so equipped.
1.12 Steering-Mode Selector Switch
The Queen of the North was in refit from January 2006 until 02 March 2006. Its steering system was modified, and the following items were modernized:
- the steering wheel at the aft steering station
- the steering-mode selector switch at the aft station
The new steering-mode selector switch, albeit a newer model, was for all intents and purposes physically the same as the original switch. However, the logic and the manner in which the steering system functioned were altered with the installation of the new steering-mode selector switch.
In situations where a replaced system is physically similar to the original system, but where changes have been made to the underlying logic of the system, usability issues may emerge. As a result of negative transfer,36 significant training can be required to overcome the automatic response associated with the original system logic. This can be particularly important in times of stress, where the original automatic response is evoked because of the physical similarity between the original system and the new system.
Throughout the refit, the C/O of the A watch had remained with the vessel. When the new steering-mode selector switch was installed, a procedure was developed for its use. The procedure and information on the functional characteristics of the new steering-mode selector switch were posted on a laminated sheet immediately aft of the steering wheel at the aft steering station. All deck crew of the A watch were familiarized with the operation of the new switch. The posted procedure did not highlight the fact that the rear steering station was no longer the "primary" station.
At the time of the handover, the C/O of the A watch informed the C/O of the B watch of the replaced switch and advised him of the instructions posted behind the aft steering station. Not all crew (including QM1) of the B watch were familiar with the changes in operation, nor with the rationale for the new system and procedure. The B watch's unfamiliarity with the changes in steering system functionality following the installation of the new steering-mode selector switch was demonstrated by the fact that, subsequent to the accident, various B watch deck crew provided investigators with four different explanations as to the interaction between the forward and aft steering station switches and which specific functions were available at various switch settings.
Following the change in watches, a number of crew members of the B watch challenged the new operational procedure. The master, in discussion with the crew and after testing the steering-mode selector switches en route, decided to use the steering selector system differently than the previous watch, and in a manner analogous to the original system. The B watch wanted the forward wheel to be active when the QM was at the forward station, and it was not active in the A watch system.
In developing their procedures, both the A watch and the B watch were attempting to maintain elements of the operation of the original steering system. However, the procedures for the original system and the procedures used by the A and B watches differed.
|A Watch||B Watch|
|Original Procedure||QM moves the switch at the aft station from FWD to AFT|
|Procedure After Change||Aft station switch pre-set to AFT
OOW moves the switch at the forward station from AUTO to WHEEL
|Aft station switch pre-set to FWD
QM moves the switch at the aft station from FWD to AFT
OOW moves the switch at the forward station from AUTO to WHEEL
Table 1. Procedural differences for switching from autopilot to aft steering station
In the original system and the B watch system, the QM would normally only be required to operate the steering-mode selector switch at the aft steering station.
1.13 Lifesaving Equipment
The vessel's lifesaving equipment included a pair of 57-person motorized lifeboats suspended under gravity davits fitted port and starboard on Deck 7, as well as 30 25-person davit-launched "valise"-type inflatable liferafts stowed port and starboard on Deck 7. The liferafts were launched by four sets of single-arm davits also located on Deck 7, two on the port side and two on the starboard side. There were also 21 lifebuoys, 3 VHF radios for survival craft, 96 children's lifejackets, and 955 adult lifejackets. A six-person motorized rescue boat, capable of being launched by a single davit arm, was carried forward on the port side of Deck 7.
The vessel's inflatable liferafts were not equipped with automatic release devices or arranged to float free in the event of sinking, nor were they required to be. Under Part I of the Lifesaving Equipment Regulations, non-Convention vessels that were registered in Canada or whose keel was laid before 28 April 199637 are not required to have float-free liferafts.
1.14 Damage Stability
1.14.1 Damage Stability and Subdivision Concepts
"Damage stability" is a vessel's ability to remain afloat without capsizing during and after flooding, depending on the degree of subdivision. "Subdivision" refers to the partitioning of a vessel's internal volume below the bulkhead deck (in this case Deck 3) into main watertight compartments by bulkheads-thereby limiting water ingress (flooding) following hull damage.
The degree of subdivision makes a significant difference in a vessel's survivability. A one-compartment subdivision means a vessel will survive (that is, will remain afloat without capsizing) if one main compartment is flooded. (Note: This implies that the watertight bulkheads remain intact.) A two-compartment subdivision means a vessel will survive if any two adjacent main compartments are flooded.38
1.14.2 International Standards
The standards on subdivision and stability for vessels engaged on international voyages are set out in the SOLAS Convention.39
The 1960 SOLAS Convention had minimal damage stability requirements. In 1990, major amendments for new passenger vessels enhanced safety by defining standards of residual damage stability (see Appendix C).
In 1992 and 1995, the damage stability requirements of the 1990 SOLAS Convention were extended to existing ro-ro passenger vessels, albeit in accordance with a phase-in schedule. Also in 1995, special requirements were introduced for ro-ro passenger vessels carrying 400 persons or more. These were applicable to all new Convention vessels, with a phase-in schedule applied for existing Convention vessels. In order to phase out those that had been built to a one-compartment subdivision standard, a vessel's damage stability was required to meet the 1990 SOLAS Convention to a two-compartment standard.40
Other similar requirements were adopted in the SOLAS Convention for new non-ro-ro passenger vessels built after 01 July 2002.
1.14.3 Canadian Standards
The standards on subdivision and damage stability for Canadian vessels engaged on domestic voyages are mainly set out in the Hull Construction Regulations, which are based on the 1960 SOLAS Convention.
In 1989, TC began to examine how the new 1990 SOLAS Convention's international damage stability standards could serve as a basis for TC's ongoing review of Canadian regulations and standards for passenger vessels.
In April 1990, recognizing that Canadian regulations for passenger vessels operating on international voyages did not incorporate the latest international standards, TC adopted new ones to enhance safety.41 In June 1991, similar standards were adopted, with the same intent, for passenger vessels operating domestically.42 Both standards were based on the 1990 SOLAS Convention, but their residual damage stability requirements were applicable only to new vessels.
Owing to resistance from the industry, TC, in consultation with the Canadian Ferry Operators Association (CFOA), decided not to apply the damage stability provisions of the document Ship Safety Passenger Ship Operations and Damaged Stability Standards (Non-Convention Ships) (TP 10943) to existing Canadian vessels (that is, those built before 1991).43
Full compliance with TP 10943, however, is mandatory for those existing vessels entering into Canadian operation since 1991, although there are phase-in dates for compliance similar to the SOLAS Convention.44
TC has amended TP 10943 based on risk assessment and on risk factors such as area of operation, number of people on board, age of the vessel.45 These amendments came into force on 01 October 2007 and apply damage stability requirements based on the SOLAS Convention to all domestic vessels (new or existing) of more than 15 gross tons or those carrying more than 12 passengers.46 There is a compliance schedule for existing vessels. The compliance schedule of TP 10943 differs from that in the SOLAS Convention, in that the former allows a longer phase-in time for existing vessels. Where an existing vessel is not compliant with these standards, a risk-based methodology might also be used to demonstrate an equivalent level of safety on a route-specific basis.
1.14.4 Damage Stability of the Vessel
The Queen of the North was originally built in 1969 to the 1960 SOLAS Convention, for short international voyages, as a two-compartment subdivision vessel with a draught of 4.75 m.
An inclining experiment was first carried out on the vessel in 1969, and then again after modifications in 1980 - at which point, due to its greater deadweight, increased operating draught, and reduced reserve buoyancy, it was reclassified as a one-compartment vessel with a draught of 5.25 m. More modifications were made in 1999, the vessel was re-inclined, and an intact/damage stability booklet based on this was approved in 2001.47
In the 2001 approval, the vessel's damage stability was assessed against the requirements of the Hull Construction Regulations, Schedule II, as a one-compartment subdivision vessel.
Although it was not required because the Queen of the North was a non-Convention vessel and thus operated under differing regulations, the 2001 approval also had the vessel's damage stability assessed as a one-compartment subdivision vessel against the 1990 SOLAS Convention criteria. The vessel was found compliant.
1.15 Relationship Between the Fourth Officer and the QuartermasterInformation provided to the investigation indicated that the 4/O and QM1 had a recurrent relationship that was brought to an end two weeks before the accident.
Both the 4/O and QM1 joined the vessel on March 15. Following an absence due to illness, QM1 returned to work on March 20, when the vessel was docked at Prince Rupert. On the evening of March 21, QM1 and the 4/O met and conversed in the crew's mess while other crew members were present. At approximately 2345, QM1 went on to the bridge for her turn at the helm. Minutes later, the 4/O replaced the 2/O as OOW. This was their first shift alone on watch together since the end of the relationship.
1.16 Crew Work/Rest History
During the 72-hour period preceding the occurrence, the 4/O maintained a regular sleep/wake pattern and only worked night shifts. Although working night shifts is known to influence circadian rhythms and increase fatigue, this likely had a small effect on the 4/O because he was somewhat adjusted to working at night and sleeping during the day, having joined the vessel seven days earlier.
Having joined the vessel on March 15, QM1 went home on sick leave on March 17. During her illness, she slept mostly at night. Having awoken at 0600 on March 20, she rejoined the vessel at approximately 1800 and immediately began working a 12-hour night shift. She experienced restless sleep during the day before the occurrence. The change from sleeping during the night to sleeping during the day, together with the restless sleep, increased the risk of QM1 being fatigued.48
1.17 Personnel Certification and Experience
The senior master started his sea career in 1962. Although not on board at the time of the occurrence, he was responsible for overall safe operation of the Queen of the North. He served on Royal Canadian Navy vessels and tug boats, before joining BC Ferries as a deckhand. After obtaining a master's certificate in 1975, he worked as a relief master on various ferries. In 1999, he was appointed as senior master on the Queen of the North.
The master's previous experience included eight years with the CCG, three of them in command of SAR vessels. He joined BC Ferries as a deckhand in 1987. Since 1990, he has worked as a master and C/O on both the Queen of Prince Rupert and the Queen of the North. He was appointed an exempt master in February 2006.49
The 2/O's regular position is a deckhand, and he has served in that capacity for about 25 years. He obtained his watchkeeping mate, ship certificate in 1997 and has been relieving as third officer (3/O) and 4/O since 1998. He obtained his first mate, intermediate voyage certificate in 2001 and has since substituted as a 2/O.
Before joining BC Ferries as a deckhand in 1990, the 4/O worked on board fishing vessels; he acquired his fishing master, Class III certificate of competency in 1981. The 4/O's regular position with BC Ferries is as a deckhand. He obtained his watchkeeping mate certificate and Simulated Electronic Navigation (SEN-I) training in 1995. He was cleared to work as an officer in 1995, and has been relieving as 3/O and 4/O on both North Coast run vessels since 1998. In 2002, he was issued a certificate of competency to serve in the capacity of an officer in charge of a navigational watch for near coastal voyages, which was endorsed pursuant to the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended in 1995 (STCW Convention). During 2004 and 2005, he worked as a deck officer for a total of 67 and 119 days, respectively, and worked 126 days of 169 days in the previous 12 months (from March 2005 to March 2006) as a deck officer.
QM1 was issued a Marine Emergency Duties (MED) certificate in January 2005. She was familiarized and cleared to work as a deckhand on board the Queen of Prince Rupert and the Queen of the North in March and April 2005 respectively, as per BC Ferries standards and clearance protocol. The period of May to October 2005 was spent working on board the Queen of Prince Rupert and performing all the general duties as well as the steering and lookout duties of a deckhand. Having sailed with the crew of the Queen of Prince Rupert for the trip into refit on 03 March 2006, QM1 was then called on 15 March 2006 to work on the Queen of the North.
QM1 was one of three quartermasters50 who did not possess a bridge watchman certificate and who could therefore not be included as part of the minimum deck watch required by the Crewing Regulations without supervision by another appropriately certified person.51
1.18 BC Ferries Employment Policies
Provisions within the contractual agreement between BC Ferries and the BC Ferry & Marine Workers' Union (BCFMWU) create a situation where all non-exempt52 new employees, whether ratings (unlicensed) or officers (licensed), are hired as casual employees. Employment opportunities may be found at the terminal, or on board vessels in the following departments: catering, deck (as deckhands, deck officers), and engine (as engine-room ratings, engineers).
As BC Ferries encourages casual employees to work within different job classifications, employees may, if there is a need and the employee is found suitable, request to be familiarized in a different job classification than that for which they were hired. An employee hired in the terminal may be familiarized in the catering department, in the deck department, or in the engine room (and vice versa). This policy is intended to allow both the employer and the employee an opportunity to maximize employment (employee utilization) during slow months. Once cleared, an employee can move between classifications as and when there is a demand for work.
A new employee begins to accrue service seniority from the first day of work, and thereafter continues to accrue seniority regardless of whether the employee works in a calendar year. Employees on leave of absence (except in very limited circumstances) or approved for non-availability of more than 30 days will have their service seniority adjusted for the period of time they are away.
Job vacancies are filled according to seniority from the appropriate seniority list: unlicensed or licensed classifications. The employee with the most seniority fills the vacancy, provided he or she meets all the job posting qualifications. In the case of licensed employees, they must also hold the appropriate TC-issued certificate of competency.
When employees are unavailable to work a shift due to leave, illness, etc., casual or regular employees are substituted, starting with the most senior qualified employee available.
The contractual agreement specifies seniority as the sole qualifying factor for awarding permanent jobs (that is, regular status, as opposed to casual) within the various classifications. Under this system, it is possible for a regular employee to compete for, and win, a job ahead of a casual employee who may have extensive job-specific knowledge/experience in a certain classification.
The same process applies for licensed employees. Under the terms of the collective bargaining contract, service seniority is the qualifying factor for a regular/casual employee to acquire his/her first licensed regular job. Although an arbitration awarded the company the option of promoting employees based on the suitability of the candidate as determined by interview and the employee's personnel file, this "suitability" criterion was not uniformly applied, with preference still being given to seniority to avoid grievance conflicts.
1.18.1 Familiarization and Clearance Procedures
According to BC Ferries Fleet Regulations, all masters, officers, and crew members must first be assessed before being afforded the opportunity to familiarize, after which they must be familiarized with safety procedures and equipment before being assigned a position on board a vessel. They must also be instructed in the safe operating procedures for any equipment to be used in the course of assigned duties, after which - and before taking up duty - they must be cleared by BC Ferries to sail. The familiarization process is carried out under the guidance of an employee's supervisor, who subsequently authorizes the clearance to work.
Clearance procedures may vary by department with respect to vessel type, position, and duration to maintain the clearance. For example, in order to maintain clearances, the Fleet Regulations indicate that:
- deckhands substituting in deck officer positions must serve in the higher position for 10 days on an operational vessel in each six-month period,
- deckhands must work a minimum of one day a year in order to maintain clearance on a given class of vessel.
1.19 BC Ferries Crew Training
According to the Crewing Regulations, a ship's owner is responsible for ensuring that written instructions are set out and followed so as to ensure that the ship's complement is properly familiarized. The master must also ensure that the ship's complement is trained in and carries out the policies and procedures.53
Consistent with the International Safety Management Code (ISM Code), "the corporation must employ suitably qualified people on board and in the office. Employees must receive written instructions on how to carry out their duties. Training must be delivered if and when necessary"54 to meet job-specific requirements. In keeping with this statement, BC Ferries has a documented system to provide and record employee training.
The senior master for each route and the master of each vessel are responsible for ensuring that crew members are appropriately qualified for duty.
Although BC Ferries offers training in areas including bridge resource management (BRM), ECS, and passenger control, this training was not consistently provided in all regions. None of the deck officers on board the vessel at the time of the occurrence had received formal ECS training.
1.20 Bridge Watch Procedures and Practices
The conduct of a vessel by watchkeeping personnel is governed by the International Regulations for Preventing Collisions at Sea (Collision Regulations) and Parts 2, 3, and 3-1 of Section A-VIII/2 of the STCW Convention.
The Collision Regulations address the need for vessels to maintain a proper lookout at all times, by all available means, as well as maintaining a safe speed appropriate to the prevailing circumstances. The STCW Convention also addresses the maintenance of a proper lookout and provides guidance on watch composition, performing a navigational watch, the effective use of all navigational equipment at the disposal of the OOW, and ensuring that the vessel follows the planned course.
While entering Wright Sound, the Queen of the North experienced conditions of restricted visibility that required a third person on the bridge in addition to the OOW and the QM. In this case, as QM1 was not certified, when the 2/O left the bridge, another person, who was certified, was required to be assigned to the watch.55
1.21 Navigation Practices on the
The vessel was operated on a "12 hour on, 12 hour off" shift pattern, with the 0600 to 1800 shift assigned to the C/O and 3/O, and the 1800 to 0600 shift to the 2/O and 4/O, respectively. Four deckhands were assigned to each shift, and each took an hourly turn as lookout/helmsperson in the wheelhouse, with the remainder of each shift spent on routine deckhand duties elsewhere.
As the ferry had been on a regular run, a routine had evolved for the watches. After the master handed over the conduct of the vessel to the OOW, it was not unusual for one officer to leave the bridge. The two officers would relieve each other throughout the watch. They would both be on the bridge when the vessel was in an area where it was required to be on standby. Otherwise, no specific criterion was used to determine when the senior of the two would be on the bridge, and no measures were in place to ensure adherence to the minimum deck watch requirements of the Crewing Regulations. The officer not on the bridge would carry a hand-held VHF radio.
The passage across Wright Sound from Sainty Point to Nelly Point was not considered to be an area requiring standby. It features relatively open water with few hazards, and consists of an approximate 27-minute period which crews frequently view as an opportunity to take a meal break - particularly given the upcoming intense period of navigation.
The radars and the ECS were the main equipment used to navigate the vessel. The company maintained a route-specific manual, which contained information for each route on which vessels operated. For the Queen of the North, routing information was entered into the ECS. It was not routine practice to plot positions on the chart while the vessel was on a regular run.
1.22 Responsibilities of the Senior Master and Master
As described in BC Ferries Fleet Regulations, the senior master is "accountable for the safe, efficient and economical operation of a vessel for the purpose of transporting passengers and vehicles in accordance with all regulatory requirements." Besides serving as and assuming all authorities and responsibilities as master, the duties and responsibilities may be described as follows:
- responsible for coordinating and administering a comprehensive vessel safety program with emphasis on training and standardization;
- liaise with other masters on the same route or class of vessel toward establishing the composition of vessel staffing to allow leave to be taken without compromising the cohesiveness of bridge teams;
- participate in the appointment and promotional process for licensed and unlicensed personnel;
- initiate and maintain operational standing order and directives after consultation with the vessel's other masters; and
- responsible for the delivery and crewing of the vessel to and from refit, including monitoring the progress of the deck department refit items.
The responsibilities outlined in the job position profile, the effective date of which was 01 June 2005, also included:
- responsibility for overall management of the vessel and its employees;
- managing and leading the shipboard management team;
- establishing and maintaining a professional work environment by, among other things, implementing employee training programs in all phases of vessel operations, ensuring crew members are familiar with policies and procedures, regularly conducting emergency drills in passenger safety and control, and ensuring compliance with internal and external regulations and legislation.
In addition to having the overall responsibility for the safety of the vessel, the master's responsibilities included:
- ensuring safe practices in vessel operations and that employee work practices meet workplace health and safety standards;
- regularly conducting emergency drills in passenger safety and control;
- implementing employee training programs in all phases of vessel operation, ensuring crew members are familiar with policies and procedures;
- monitoring and ensuring compliance with internal and external regulations and legislation;
- ensuring timely and effective communication among employees across watches and departments; and
- ensuring that all written policies and procedures are kept current and that route performance records for the vessel's operation are in accordance with regulatory, certification, and audit requirements.
1.23 Passenger and Traffic Manifests
Before the vessel departed Prince Rupert, BC Ferries had a record of the number of passengers on board the Queen of the North, but not all their names. When a customer made a reservation, they needed only to provide one name and the number of people travelling. This reservation name might not match the passenger's name; it could be a company name, or it could be the name of a relative whose details are already within the reservation system.
Information from the reservation system was used to generate a passenger manifest containing reservation name or group name, the number of vehicle passengers, the number of foot passengers, and the number/type of vehicles aboard the vessel. This manifest was provided by the terminal agents to the ferry before sailing.
The traffic manifest was provided to the 4/O for loading purposes. This was different from the passenger manifest, and contained the number of vehicles but not the number of vehicle passengers. No head count was taken of the passengers as they boarded.
There is no mandatory requirement for domestic ferries to collect passenger information. In 1999, following TSB investigations and international passenger ferry accidents, TC recommended that all persons on board passenger ferries should be counted and that details of persons who have declared a need for special care or assistance in emergency situations should be recorded and communicated to the master before departure.56
1.24 Safety Management System
Although not required, BC Ferries had voluntarily elected to develop a Safety Management System (SMS) for its fleet to meet ISM Code requirements. The purpose of the ISM Code is to provide an international standard for the safe management and operation of ships, to prevent injury or loss of life, and to prevent pollution.
BC Ferries was issued an initial Document of Compliance for shore-side aspects of the SMS on 24 September 1997. The Queen of the North was first issued a Safety Management Certificate on 18 August 1999. At the time of the occurrence, the ferry held a Safety Management Certificate issued by Lloyd's Register on 27 July 2004. The certificate, which was valid until 17 August 2009, was subject to an external intermediate verification57 of the vessel's SMS between the second and third anniversaries-sometime between July 2006 and July 2007 - to ensure compliance with the ISM Code. The Document of Compliance may be cancelled upon an external auditor issuing major non-compliance notices. However, it was reported that, because BC Ferries had voluntarily adopted the ISM Code, notices that would have been warranted might not be issued by the external auditor.
Internal audits were carried out annually on board the Queen of the North. Typically, an internal audit was performed by a team of two auditors (three for vessels with a catering department); it addressed each of the first 13 sections of the ISM Code, and took up to 12 hours to complete. The audit also considered applicable regulatory requirements as well as corporate policy and procedures, as per Section 12.01 of the BC Ferries Fleet Regulations. The scope of each audit did not necessarily address all of the elements within a section of the ISM Code. Rather, the scope for each audit was based on a number of factors including previous audit reports and corrective action requests.
An audit schedule covering all of the sites (for example, terminals, offices, vessels) was drawn up for the calendar year. Internal audit plans were prepared in advance. When the site was a vessel, each of the vessel's departments - deck, engineering and, if provided, passenger services - would be audited, and it was not uncommon for the audits of these departments to be conducted individually at different times of the year and while the vessel was underway. Vessels were informed in advance when the audit would be conducted. At the opening meeting on the day of the audit, the methods for conducting the audit were explained to the vessel's senior officers.
These internal audits were originally carried out using a checklist, but this was found ineffective - it limited the flexibility of the audit, and knowledge about the items on the checklist became so widespread as to make it ineffective.
Internal audits are now carried out by conducting interviews with shipboard personnel and by walking throughout the vessel and making observations, in addition to random sampling and the routine verification of specific items. The most recent audit before the occurrence was carried out by BC Ferries on 12 August 2005. It was reported that audit plans identifying those elements of the 13 sections of the ISM Code to be examined and the questions to be asked were developed in advance of conducting annual internal audits on board the Queen of the North. However, upon the completion of the audit, these plans were retained only for four to five months. At the time of the occurrence, the audit plan for the 2005 internal audit had been discarded.
In accordance with the ISM Code, BC Ferries established quarterly management reviews to evaluate and review its SMS. Any findings of an SMS audit, including trends and issues of concern, are presented at these management reviews.
When BC Ferries first developed its SMS, four full-time auditors were employed to conduct audits throughout the fleet, shore offices, and terminals. In the fiscal year ending 31 March 2006, two full-time auditors and, when required, contractors, conducted 257 SMS audits, of which 56 were conducted on board BC Ferries ferries. During the previous fiscal year ending 31 March 2005, 243 audits were conducted, of which 92 were conducted on board BC Ferries ferries, with 449 requests issued for corrective action.
In addition to the audits, BC Ferries Fleet Regulations required that a complete review of the shipboard SMS and the vessel-specific manual be undertaken annually, under the direction of the senior master. This was done, and no shortcomings were recorded. Furthermore, an agenda item for the monthly shipboard management meetings included a review of the SMS.
1.24.1 Emergency Preparedness
In order to comply with the ISM Code, BC Ferries established procedures for identifying and responding to emergency situations. The Emergency Management and Response Manual outlined corporate strategy for emergency management, as well as policies for organizing and activating its response. Vessel-specific manuals contained the procedures for on-site responses to vessel emergencies and emergency procedures checklists were developed.58 Furthermore, the BC Ferries Fleet Regulations required that contingency plans be developed for all identified potential emergency situations - including abandoning ship - and that a schedule of drills and exercises be established for each plan.59 At the time of the occurrence, the Queen of the North had abandon-ship procedures in the vessel-specific manual, but these did not address the various situations that may be associated with an evacuation. Such situations include identifying and locating missing passengers, and directing passengers from assembly stations to embarkation stations.
Pursuant to the Canada Shipping Act, Section 111 of the Life Saving Equipment Regulations requires every passenger vessel to have an evacuation plan that provides for the complement to be safely evacuated from the vessel within 30 minutes of the abandon-ship signal. BC Ferries had sought clarification from TC with regard to what was required to satisfy the requirement, but without success. An amendment to Section 111 was published in the Canada Gazette, Part II, Volume 140, No. 22, on 01 November 006, which clarified the requirement to have an evacuation procedure rather than a diagrammatic plan.
In January 2004, a BC Ferries team prepared an internal, draft version of an evacuation analysis for the Queen of the North, taking into consideration calculations to determine if the lifesaving equipment on board could be launched, and the vessel evacuated within 30 minutes - not including the time to muster. The stated purpose of the analysis was to assist the master in formulating the muster list functions and evacuation plan for the vessel. One of the recommendations included in the draft analysis was the development of a comprehensive evacuation plan.
BC Ferries was in the process of developing evacuation plans for its vessels. Although it has been a regulatory requirement since 1996, it was not until TC inspected the Queen of the North in early March 2006 that the requirement to have an evacuation plan/procedure was singled out. An SI 7 notice was issued to that effect on 02 March 2006.
1.25 Cannabis Use on the
It was determined that some crew members in safety-critical positions were casual users of cannabis and that they had previously smoked the drug aboard the vessel and while in port. There is no information to suggest that the 4/O or QM1 were under the influence of alcohol or illegal drugs at the time of the occurrence. Toxicological tests were not performed.
BC Ferries has a no-tolerance policy with respect to alcohol and drugs aboard ship. For live-aboard vessels, such as the Queen of the North, crew members are not permitted to consume nor have in their possession alcohol or any other mood-altering substance, which would render them unfit for duty. This prohibition is considered to include all hours on or off duty/watch, from the time an employee joins the ship until release for rest days.60 In addition to the policy, an employee assistance program is available to provide counselling and assist BC Ferries employees with alcohol and drug dependencies.
BC Ferries provides information concerning the alcohol and drug policy to crew through several information packages as well as when members first join a vessel. BC Ferries also educates staff about alcohol and drug use. In addition, line managers and supervisors are provided with guidance on substance misuse and prevention and how to deal with problems related to alcohol and drug use. The BC Ferries employee assistance program offers confidential counselling for alcohol and drug abuse. However, the TSB investigation revealed that Queen of the North crew members who were regularly using cannabis showed insufficient awareness of its impact on fitness for duty.
BC Ferries also has a Voluntary Individual Safety Observation Reporting System (VISORS) for employees to report directly on operational safety issues or concerns. However, there is a reluctance to report safety concerns as employees are required to sign their name on the form.61 Furthermore, the investigation revealed that not all senior crew members aboard the Queen of the North consistently took action to ensure the company's no-tolerance policy was strictly adhered to.
1.25.1 Effects of Cannabis on Performance
A large number of studies have shown that cannabis use can lead to significant impairment of a wide range of human performance characteristics.62,63 Although these studies have mainly focused on car driver and aviation pilot performance, the types of impairment are also clearly important to the variety of tasks required for the safe operation of vessels.
For example, cannabis use can impair psychomotor performance, memory, attention, and coordination.64 Cannabis use has also been shown to affect the ability to quickly react to complex or unexpected scenarios.65
The impairment due to a single dose of cannabis is greatest during the initial high,66 after which the impairment reduces, but can last 24 hours. Although cannabis users are commonly aware of the initial period of impairment, they are not normally aware of the longer-term effects.67,68
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