Marine Investigation Report M06W0052

2.0 Analysis

2.1 Overview

When the ferry reported to MCTS at 0002:34, it was approximately 1.3 nm away from the course-alteration point. Some 3.5 minutes later, having reached that point, the vessel then proceeded on its original course for approximately 14 minutes before striking Gil Island at 0021:20. This analysis will address the sequence of events in three stages: the missed course change, the passage toward Gil Island, and the striking sequence.

2.1.1 Missed Course Change

When undertaking routine tasks, it is possible for a distraction to cause a sequential step to be missed and for persons in such circumstances to believe that the missed step and those that follow have in fact been accomplished.69

In this instance, between the time the 4/O announced to MCTS that the vessel was approaching Sainty Point and the time the course change should have been made (3.5 minutes), the OOW's routine sequence of making a course change was interrupted by several events that were taking place simultaneously, including:

  • the 4/O and QM1 were engaged in a conversation of a personal nature;
  • the vessel was encountering a rapidly moving squall, causing reduced visibility; and
  • a visual alarm indicating a loss of target.

In dealing with the immediate requirement to identify the position of the lost target, combined with the effects of entering the squall, the 4/O was likely distracted at some point between logging the radio communication and carrying out the course change. As a result, he believed he had called for and verified the course alteration.

In addition, the ECS display was dimmed and the audible alarms had been deactivated, thereby negating any warning that may have been provided by the waypoint alarm. As a result of these combined factors, the vessel continued past Sainty Point and into Wright Sound without changing course.

2.1.2 Passage Toward Gil Island

Typically, the passage through Wright Sound from Sainty Point to the next course change at Point Cumming is about 27 minutes of travel across deep, open water with few hazards. Crews normally consider that part of the voyage to be less difficult, particularly compared with the upcoming, more complex legs of the Inside Passage. It was in anticipation of transiting Wright Sound that the 2/O took a lunch break, leaving the 4/O and QM1 alone on the bridge.

Having entered the less difficult portion of the voyage through Wright Sound and believing he had made the course alteration at Sainty Point, the 4/O did not monitor the vessel's progress and failed to determine that the vessel was on an improper course.

The setup of the navigational equipment hampered effective monitoring, including:

  • The brightness on the ECS monitor had been turned down such that the display could not be read.
  • The ECS cross-track alarm, which would have alerted the crew to any substantial deviation, was turned off.
  • The navigation-danger alarm on the ECS, which could have indicated the close proximity of Gil Island, was unavailable because a raster chart was loaded.
  • Alarms available with other electronic navigational equipment (for example, radars) were not set up or enabled.

As well, a number of basic principles of safe navigation70 were not observed by the bridge team:

  • verifying the course after Sainty Point;
  • reducing speed when the vessel encountered an area of reduced visibility;
  • calling the senior OOW or the master to the bridge when visibility became reduced and the radar target (Lone Star) was lost;
  • maintaining an effective lookout;
  • posting a dedicated lookout during a time of restricted visibility;
  • communicating with the target vessel;
  • locating and identifying the navigational lights at Point Cumming, Cape Farewell, and Sainty Point;
  • monitoring the vessel's progress visually, via radar and with the ECS;
  • frequent plotting to determine the vessel's position; and
  • maintaining appropriate bridge team composition.

Many of these practices would have assisted in keeping the vessel on course or provided the cues necessary to determine that the vessel was not on course.

The TSB examined a number of plausible scenarios. In the absence of objective data, such as from a VDR, the investigation was unable to explain why the 4/O and QM1 did not follow basic watchkeeping practices so as to keep the vessel on course - nor why the 4/O failed to detect the vessel's improper course for up to 14 minutes.

The TSB rejects the suggestion that QM1 was alone on the bridge in the time leading up to the grounding. The preponderance of evidence leads to the conclusion that the 4/O and QM1 were both on the bridge throughout this period.

2.1.3 Striking Sequence

When an individual's mental model of a situation differs from the actual, there is a period where contradictory information is rejected, followed by one where it is recognized that the mental model is incorrect and the individual or crew will need to work to reconcile the new information to form a more accurate picture. It is often only when very salient contradictory information is presented that they can realign their mental model.71

It is not known exactly when the 4/O began to be aware that the vessel was off course. However, approximately one minute before the striking, something prompted the 4/O to approach the window, and to move between there and the radar before subsequently ordering a course alteration to 109º, which would bring the vessel to a course for Point Cumming. As QM1 stood up and moved to alter course, both crew members saw trees ahead. The 4/O, now at the aft steering station, then gave the order to switch to hand-steering. This order was not complied with because QM1 was unfamiliar with the switch at the forward station.

Analysis of the DGPS data recorded by the ECS data logs indicates that, during the final 30 seconds before the striking, the vessel's straight-line course changed by about six degrees to port. It could not be determined whether this course change resulted from the action of the QM1 at the autopilot or if the 4/O made the switch to manual steering and applied moderate helm. Interaction forces between the hull and the steep sides of the island may also have influenced the vessel's motion in those final seconds. Regardless, there is no indication that aggressive evasive action was taken, and indeed any action taken by the crew was too little too late to prevent the vessel from striking Gil Island.

2.2 Familiarity with the Steering System

The procedure used by the B watch to change from autopilot to hand-steering (wheel) required QM1 to move from the forward to the aft station and stand by the wheel while the 4/O operated the switch at the forward station. A similar procedure was followed when switching from hand-steering to autopilot. This was the limit of QM1's experience with the steering changeover. In this instance, when the 4/O went to the aft steering station and ordered QM1 to switch to hand-steering at the forward station, QM1 was unfamiliar with the switch at that station and was unable to comply.

Unfamiliarity with an essential piece of equipment increases the risk to the vessel, its passengers, and crew.

2.3 On Board Navigational Practices and Safety

As shipboard personnel move from vessel to vessel, and as the BC Ferries crewing arrangements allow regular and casual crews to move between watches, consistency in route-wide fleet operations and adherence to the basic, accepted principles of navigation safety are essential to ensure safe ferry operation throughout the fleet.

On board the Queen of the North, the working environment on the bridge was less than formal, and accepted principles of navigation safety were not consistently or rigorously applied. As such, unsafe navigation practices persisted that, in this occurrence, contributed to the loss of situational awareness by the bridge team.

2.3.1 Bridge Watch Composition

A review of the bridge watchkeeping practices on board the Queen of the North identified the following areas of concern:

  • Full consideration was not given to the maintenance of an adequate bridge complement at critical locations and times, and in poor weather conditions.
  • Notwithstanding that two officers were assigned to each 12-hour shift, it was not unusual to have only one officer on the bridge - even during major course alterations, and, occasionally, during periods of adverse weather and visibility.
  • The selection and composition of the bridge watch did not take into full consideration the experience of the bridge team. For instance, the C/O and 3/O stood the 0600 to 1800 watch (during predominantly daylight hours), while the 2/O and 4/O stood the 1800 to 0600 watch (during hours of darkness).
  • The officers took their breaks such that the 2/O was on watch with an experienced QM, leaving the more junior 4/O on watch with a less experienced and uncertified QM during hours of darkness.
  • QM1, who did not hold an appropriate certificate, was allowed to stand watch without being supervised by an appropriately certified person (other than the OOW).
  • A third person was not called to the bridge when the vessel encountered restricted visibility around the time that the course alteration at Sainty Point should have been made.

2.3.2 Crewing Regulations-Interpretation

At the time of the occurrence, the minimum composition of the deck or bridge watch on the Queen of the North was defined by sections 39 through 41 of the Crewing Regulations of the Canada Shipping Act. In 2007, these regulations were superseded by the Marine Personnel Regulations, issued under the authority of the Canada Shipping Act, 2001, with sections 213 through 216 specifically applicable.

The language of the Crewing Regulations has led to differing interpretations. Nonetheless, a plain language reading leads to the conclusion that the minimum bridge watch required by the Crewing Regulations in the context of the Queen of the North at the time of the occurrence was intended to be as follows:

  • a qualified person in charge of the watch (the OOW); and
  • an additional person who holds one of an efficient deckhand certificate, an able seaman certificate, or a bridge watchman certificate.

Whenever the use of the automatic steering system was not appropriate - for example, when prompt helm action might be required due to encountering situations such as restricted visibility - then a second additional person was required. Under these circumstances, only one of either the additional person or the second additional person must hold one of the aforementioned certificates. The other does not, provided that he or she is assigned to the deck watch as a rating under training for the purpose of obtaining a certificate.

Therefore, regardless of whether the Queen of the North was in restricted visibility, the uncertified QM should have been supervised by either the second of the two officers on the bridge or, in the absence of the second of the two officers, by a qualified QM.

The TSB is of the opinion that the absence of a third (and appropriately certified) person on the bridge at the time of the missed course change, and through to the time of the striking, reduced the defences in place, thereby increasing the possibility that the error would go undetected.

2.4 Watertight Doors

The subdivision of passenger vessel hulls into watertight compartments is a fundamental principle of design intended to improve survivability should a vessel sustain damage below the waterline. While it is generally accepted that the operations of the ship may require doorways to be fitted in some of these bulkheads, these doors must be of special watertight construction and must remain closed in order to realize the benefits of the watertight subdivisions. On the Queen of the North, at the time of the occurrence, as per regular practice, several watertight doors were open.

As a result of the striking, at least three main compartments were damaged below the waterline, and flooding progressed rapidly and extensively. Although it was reported that the watertight doors were closed shortly after the striking - and this was relayed to Prince Rupert Traffic approximately 16 minutes later - one door remained blocked open by debris.

The full extent of damage, and therefore the potential to control the flooding, could not be determined with accuracy. By not ensuring that the integrity of subdivision measures, such as watertight bulkheads and doors, was maintained at all times while the vessel was in operation, the potential to slow down or stem the progressive flooding of the vessel was not realized. Any delay in ensuring that all watertight doors are closed can contribute to progressive flooding into compartments other than those initially damaged.

2.5 Navigation Equipment Alarm Features

Analysis of the information obtained from the recovered ECS indicates that the system was functioning within its set parameters. However, the lack of policies and procedures to manage the configuration of the system meant that important safety features (alarms) that could have alerted the crew had been either deactivated or silenced. Additionally, the display had been dimmed in response to the overly bright monitor and raster charts. As such, the possibility of receiving a visual warning was also negated. Furthermore, alarm features available with other electronic navigation equipment were not set up or enabled.

The navigation equipment, therefore, was not set up to take full advantage of the available safety features and, as a result, the warnings that could have been provided with respect to the developing dangerous situation were not provided.

2.6 Voyage Data Recorders

The purpose of a VDR/S-VDR is to create and maintain a secure, retrievable record of information indicating the position, movement, physical status, and command and control of a vessel for the period covering the most recent 12 hours of operation.72 Objective data - voice data in particular - are invaluable to investigators and operators in seeking to understand the sequence of events and identify operational problems and human factors.

The presence of a VDR/S-VDR on board provides a unique, cost-effective opportunity to accurately record for future analysis information pertaining to a vessel and crew's performance, including understanding and adherence to procedures. As a result, VDR/S-VDR data provide an effective source of information for auditing of ISM Code compliance between scheduled audits. VDR/S-VDR data may also be used proactively within an ongoing program of incident analysis with a goal of constant safety improvement and a reduction of accidents on board vessels.

Accident investigation agencies benefit from more efficient, timely, and accurate collection, assimilation, and analysis of information with corresponding benefits of a shortened investigation process and more timely communication of safety deficiencies and accident reports to stakeholders and the public. In this instance, the lack of a VDR/S-VDR on board the Queen of the North prolonged the investigation by several months while a dive was planned and executed to recover the on-board ECS system. Although the recovery was successful, the data retrieved were limited in comparison to those that would have been provided by a VDR/S-VDR - in particular audio recording of bridge conversations.

Despite the significant safety benefits to the company, investigators, and the travelling public, there is no current requirement for VDR or S-VDRs on non-SOLAS vessels - depriving accident investigators of a fundamental source of information and the domestic industry of a proven and valuable tool to continually enhance and improve performance and safety.

Furthermore, the limited availability of objective data, combined with contradictory witness statements, resulted in a protracted investigation and the use of investigation techniques that would have been unnecessary had a VDR/S-VDR been installed and recovered.

2.7 Liferafts

When a vessel sinks rapidly, it is critical that lifesaving equipment be deployed, either by the crew, or automatically as the vessel submerges. This is particularly important when a vessel may not be expected to stay afloat for long after sustaining extensive damage from collision, grounding, or capsizing.

Such was the case on 28 September 1994 when the Estonian-registered passenger ro-ro ferry Estonia suffered a bow door failure while en route in the Baltic Sea, capsized, and sank within 35 minutes with the loss of 852 passengers and crew. The vessel carried inflatable liferafts, equipped with hydrostatic release mechanisms. While the rapid sinking prevented the orderly deployment of lifesaving equipment and abandonment of the ship by passengers and crew, once the vessel sank, the liferafts deployed automatically and were available for some survivors in the water.

As the Queen of the North sank, the liferafts that had not been launched by the crew did not automatically deploy, nor were they required to do so. Although large domestic passenger vessels built in or imported into Canada after 1996 are required to have inflatable liferafts equipped with float-free devices, existing passenger vessels are not required to be so equipped. As a consequence, passengers and crew travelling on older vessels may not be afforded an equivalent level of safety in comparison to newer vessels operating on the same route with similar risks, and may therefore be placed at risk in the event of the vessel sinking rapidly.

2.8 Damage Stability and Regulatory Concerns

Passenger ferries play a significant role in the Canadian transportation network. In 2006, over 44 million passengers and 16 million vehicles travelled by ship in Canada.73 BC Ferries alone carries more passengers each year than the combined ferries of the four nations operating on the English Channel.74

In all, 113 passenger vessels above 500 gross tons are operating in Canada. About 50 of these vessels carry more than 400 persons. Although most of them operate in domestic rather than international trade, there is an equal (if not greater) risk of damage due to collisions and groundings.

As noted earlier, the Queen of the North was operating domestically as a one-compartment vessel, and at the time of the occurrence, was not required to meet the damage stability requirements of the 1990 SOLAS Convention. International standards require that a similar vessel engaged on international voyages must meet the 1990 SOLAS Convention standards in October 1998 for one-compartment subdivision, and in October 2008, for two-compartment subdivision, or else would have to reduce the number of persons carried to less than 400.

According to the compliance schedule of the amended TP 10943, the Queen of the North would have had to meet the damage stability requirements equivalent to those of the 1990 SOLAS Convention not later than the first periodical survey (that is, annual survey) after October 2010 for one-compartment subdivision, and after October 2013 for two-compartment subdivision, or else would have had to reduce the number of persons carried to less than 400. However, the Hull Construction Regulations have not yet been amended to make TP 10943 mandatory.

In this instance, given the extensive breach of watertight integrity, the additional damage stability requirement would not have ensured the survivability of the vessel. Nonetheless, under the current Canadian regulatory regime, older passenger vessels operating in Canada are not held to the same level of damage stability protection as those plying internationally or to new/substantially renovated vessels operating in Canada, potentially placing the passengers at risk.

2.9 Accounting for Passengers and Crew

The clearing of passenger and crew cabins during an emergency does not, by itself, ensure full accounting for all passengers and crew - this would assume that all persons always remain in their cabins. In this occurrence, the port passenger cabins on Deck 7, where the cabin to which the two missing passengers were assigned was located, were reportedly cleared.

In an emergency, as time is of the essence, any delay in determining if passengers or crew are missing has the potential to place lives at risk. It is therefore essential that measures be put into place to account for everyone during an emergency. At the very least, this requires that an accurate head count be performed once the complement has been mustered.

Although head counts of those boarding the survival craft were made, in at least one case, the crew member performing the count was distracted and the count was not accurate. There were no roll calls before proceeding with abandonment, nor were head counts made while the crew prepared and cleared away the survival craft. This lack of an accurate head count of passengers and crew before abandoning the vessel precluded a focused search for missing persons at that time.

2.9.1 Passenger Manifest

There was confusion when attempts were made to reconcile information on the manifest with that obtained after the abandonment. This was the result of insufficient and inaccurate information obtained from the way BC Ferries generated passenger manifests.

In an emergency where abandoning ship is the only recourse, accurate passenger information is vital to both the abandonment and SAR operations. A detailed passenger and crew information system can identify missing people, their infirmities (if any), and where they may be on board the vessel.

The International Maritime Organization (IMO) has established requirements for a minimum amount of passenger information to be collected,75 and these requirements apply to all Convention passenger vessels constructed on or after 01 July 1998. The benefits of such a system were demonstrated in 2000 when, during a fire aboard the passenger vessel Nieuw Amsterdam, a roll call successfully helped the crew identify and find two missing passengers.76

In 1993, the TSB issued a recommendation regarding passenger information,77 and in 1999, TC published guidelines regarding passenger counts on ferries.78 In a 2003 occurrence involving the ferry Joseph and Clara Smallwood,79 the TSB again highlighted the need for accurate passenger information on board vessels so that roll-call methodology can be used to identify, account for, and locate missing passengers.

While it is recognized that the scope of passenger information collected may necessarily vary depending on the type of operation,80 the adoption of a mandatory requirement for collecting passenger information would help ensure that crews have the information they need during an emergency.

2.10 Emergency Preparedness

The combination of freely moving passengers in an unfamiliar environment for relatively short periods of passage time poses unique challenges for ferry operators in the management of emergencies, particularly with respect to passenger safety. Given the significance of preparation for abandonment and the identified shortcomings in this occurrence, this section focuses on the issues of on-board planning, procedures and crew's familiarity with them, and crew performance.

2.10.1 Planning

In an emergency situation, decisions are often made in a stressful environment involving heavy task loads, and where errors may result in significant consequences. Without a sufficiently detailed plan in place, difficult decisions are inevitably made based on an individual's past experience and his or her current understanding of the present risk. Given the risks associated with decision making in emergency situations, contingency planning is therefore the cornerstone of emergency preparedness, providing the necessary framework for evaluating risk and considering risk-mitigation options. Ship evacuation is one such contingency plan.

BC Ferries was in the process of developing evacuation plans/procedures for its vessels; a detailed plan for the Queen of the North, however, had not been completed. Documentation available to the crew did not provide sufficient detailed information about passenger-control duties during abandonment.

2.10.2 Training

It is imperative that crew members have adequate training so as to respond to emergency situations and carry out assigned emergency duties. On vessels where large numbers of passengers may be aboard, those responsible for passenger safety require knowledge of crowd-management techniques as well as a basic understanding of crisis management and human behaviour in emergencies. There are several places in which BC Ferries documents its guidelines for crowd control. However, given the criticality of this issue for passenger safety, specific training is required in addition to the provision of written information. Only one crew member, who was assigned passenger-control duties, had received this training.81

The TSB, concerned by the lack of knowledge and skills for effectively managing passengers during emergencies, has previously issued two Marine Safety Advisories82 and has also recommended to TC that officers and crew members who are responsible for passenger safety receive formal training in crowd control and relevant emergency procedures (M93-07).83

A more recent investigation84 determined that the current TC requirements for crew training in crowd management, crisis management, and human behaviour in emergencies were not adequate to ensure that crew on all passenger vessels who are responsible for passenger safety are provided with adequate training in these areas.

At that time, TC indicated that proposed Marine Personnel Regulations85 would mandate training in passenger safety management for officers and crew members with responsibilities for passenger safety. The TSB, however, noted that the new requirements would not include training for crew of smaller vessels (500 gross tons or less) or for vessels engaged on voyages in sheltered waters, regardless of size. The TSB reiterated in a safety concern86 that persons aboard such vessels will continue to be at risk.

2.10.3 Exercises and Drills

In addition to formal training, regular drills are essential to prepare crews for potential emergency situations - increasing confidence and efficiency should such situations arise. Drills also help evaluate preparedness and address identified shortcomings. On large passenger vessels, it is critical that emergency drills simulate the challenges of managing large numbers of people.

Although conducted regularly as required, drills on the Queen of the North were considered mundane and typically involved mustering the fire party, mustering crew members at embarkation stations, and launching a lifeboat. The abandonment process was included in both the boat and fire drills, and no separate exercises were conducted for abandonment even during annual regulatory safety certificate endorsement. Additionally, there is no requirement for separate drills involving the mustering and control of passengers.

Moreover, the boat and fire drills did not effectively simulate mustering and/or control of passenger movement and so did not provide an opportunity to assess the adequacy of procedures or of crew skill levels. These exercises did not fully address the challenges associated with managing large numbers of people (for instance, no means were provided to record head counts). Additionally, as the vessel did not have a completed evacuation plan, the master and the crew had to rely on their own experience to set up the drills, without the benefit or guidance of official advance planning.

The lack of a completed evacuation plan/procedure, in addition to inadequate passenger safety training/drills, left some crew members ill-prepared to handle some aspects of the abandonment, thereby placing passengers at risk.

2.10.4 Evacuation Procedures

In this occurrence, the crew was able to evacuate 57 of 59 passengers in the 30 minutes between the time of the striking and the time senior crew members entered the last survival craft, including both the mustering and clearing away duties. However, with this crewing level, the vessel was certified to carry up to 474 passengers. Given the short timeframe available for the preparatory phase of abandonment, the presence of 474 passengers would have posed additional challenges, compounding the difficulties experienced in the mustering, accounting, and abandonment phases.

In a rapidly developing emergency situation and in the absence of a comprehensive evacuation plan on board, masters have to rely on experience and their perception of the emergency to make decisions and deal with the situation. Given that such experience is rare and given that people respond to emergencies in different ways, a comprehensive evacuation plan is paramount to better prepare the crew for emergencies in the interest of passenger, crew, and vessel safety. Such an approach would positively influence the outcome of evacuation and further passenger safety.

Current TC regulations require that every passenger ship have procedures for the safe evacuation of the complement within 30 minutes after the abandon-ship signal is given.87 Although this requirement has been in force since 1996, TC has not established guidelines for operators to develop such procedures, nor has TC established criteria for the inspectors to evaluate/accept these procedures. Furthermore, no criteria are applied to the earlier (preparatory) phase of evacuation - muster and clear away88 - which on a large passenger vessel is a critical element of the abandonment process.

Although TC reviews a new vessel's capability to abandon when initially certified, the focus is on the hardware - that is, quantity and location of equipment provided for this purpose. Likewise, while TC inspectors regularly review fire and boat drills, the main focus is placed on the operation of abandonment devices and survival craft. As such, performance of the wide range of actions necessary to manage passengers during abandonment and the corresponding number of crew required to do so successfully are not practically assessed.

TC does not currently provide operators of passenger vessels with guidance on how to prepare evacuation procedures, nor are performance measures stipulated for the mustering and clear-away phases of evacuation. Consequently, there is no means to objectively test the overall adequacy of an evacuation plan.

2.10.5 Passenger Vessel Abandonment and Technology

The evacuation of passenger vessels poses unique challenges, in which passengers and crew have to respond cooperatively for safe, effective, and rapid abandonment under trying circumstances. This creates communication and behavioural challenges, requiring crews to be efficient in the preparatory phase of carrying out an orderly abandonment.

It is well recognized that a ship's survivability - and therefore the time available - is a key factor in passenger vessel evacuation. The IMO's approach to large passenger vessel safety has, as a guiding principle, the premise that more emphasis should be placed on the prevention of a casualty from occurring, and that future passenger vessels should be designed for improved survivability so that, in the event of a casualty, persons can stay safely on board as the ship proceeds to port. In other words, evacuation should be avoided if at all possible.

However, the need for vessel evacuation can never be fully avoided. Furthermore, the need to muster passengers to safe areas of the ship will be necessary in a variety of emergency situations. The benefits of effective crew training and drills in accomplishing these tasks are well recognized and addressed by the regulatory regime.

While the benefits of technology to assist in preparing the vessel for abandonment have been recognized, they have yet to be fully realized/implemented.89 As a result, there are relatively few practical applications of research and technology on board that directly affect the preparatory phase of the evacuation process such as clearing the ship, accounting for passengers, controlling and guiding the movement of passengers, and communicating with passengers. Until technology is introduced into the preparation for abandonment phase, this stage will continue to be a weak link in the abandonment process - to the detriment of passenger and crew safety.

2.11 Crew Training and Familiarization

2.11.1 Familiarization with New Equipment

In replacing the aft steering-mode selector switch, the functionality of the overall steering selector system was altered. This change created a usability problem for the crew. Although the shift (A watch) that took the vessel out of refit was made familiar with this change in functionality, the subsequent shift (B watch) was not fully briefed. Furthermore, instead of following the procedures developed by the previous shift, the new shift determined its own preferred method of operation. As personnel can move between shifts, the lack of standardized procedures may lead to confusion, thus compromising safety.

As BC Ferries did not make a thorough risk/training needs analysis following changes made to the vessel's steering-mode selector switch, some crew members were not fully aware of how to operate this equipment once the ferry returned to operation following refit. This had the potential to compromise the safety of passengers, crew, vessel, and the environment.

2.11.2 Familiarization and Clearance for Assigned Duties

BC Ferries employees are encouraged to move from department to department when positions become available. The contractual agreement between BC Ferries and the employees' union requires the company to fill vacant positions based on the seniority of the candidate as long as any basic qualifications, such as certification, are fulfilled. 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. An employee on a leave of absence (except in very limited circumstances) or approved for non-availability of more than 30 days will have his or her service seniority adjusted for the period of time he or she is away. The contract therefore creates a situation where employees, particularly casual employees, may experience prolonged absences from their positions, and only require re-familiarization and clearance if that absence is more than one year long.

By establishing a benchmark of one year's absence before requiring re-familiarization, the system does not take into consideration an individual's ability to retain skills and information over long periods, nor does it consider that some individuals may not be comfortable speaking up if they feel they need additional training. The risk is that some employees, although maintaining clearance in accordance with the one-year rule, may not be fully competent to perform the duties expected of them.

2.11.3 Training and Continued Proficiency

It is important that personnel skills be upgraded to keep pace with technological and operational changes. In this instance, the 4/O had received no formal ECS training and had not - despite advances in radar technology - had SEN refresher training, neither was this required by regulations.

Furthermore, the 4/O had been issued a certificate of competency as a watchkeeper that had been endorsed by the STCW Convention. The STCW Convention, Section A-VIII/2, states that the "officer in charge of the navigational watch shall have a full knowledge of the location and operation of all safety and navigational equipment on board the ship."

In the absence of regulatory or industry-wide standards for ensuring that officers have received up-to-date training appropriate to the equipment they use, some mariners may lack the skills required to operate modern bridge equipment - jeopardizing the safety of the passengers, crew, vessel, and the environment.

2.12 Quality of Safety Management System Audits and Reviews

An effective SMS enables ship operators to anticipate and address safety shortcomings/deficiencies with the objective of improving on-board safety and reducing risk. SMS audits and management reviews are carried out to verify that a company's SMS not only meets these objectives, but that it is being effectively implemented. It provides for safe operating practices, and assures that safeguards against all identified risks have been established. Operators must ensure that the quality of audits and management reviews is such that performance measurement is accurate. Accordingly, operators must also have proper procedures and records to show that the auditing and reviews carried out were adequate.

A review of available audit records dating from 1998, in addition to the quarterly management reviews, revealed that several key non-conformities90 relating to the Queen of the North had not been identified by internal or external audits. These included:

  • deck officers not being provided with appropriate training to operate the electronic navigation equipment;
  • BC Ferries certification requirements not being complied with (the certification requirements for several deck officer positions under BC Ferries employment policy exceeded those of TC. There were cases where, although an officer met the minimum TC certification requirement, the higher BC Ferries requirement was not being met);
  • deckhands, who were expected to perform the duties of a quartermaster, not always being qualified in accordance with the BC Ferries Fleet Regulations;
  • watertight doors being left open in contravention of Canadian regulations and a TC Board of Steamship Inspection decision;
  • no vessel-specific contingency plan or procedures being in place for responding to the various potential emergency situations associated with an evacuation;
  • a less than formal working environment on the bridge; and
  • an inconsistent application of accepted principles of navigation safety.

Additionally, senior management was advised in an August 2004 quarterly management review that there was an increase in the number of crew members assigned to vessels without being fully trained or cleared as required by the Fleet Regulations. The report indicated that part of that increase may have been attributed to the introduction of a new human resource management system while maintaining the previous system. The Operations Safety Log indicated instances where there was no documentary information of crew members having valid certificates/tests. However, there were no subsequent audit records relating to the Queen of the North identifying that deckhands continued to act as members of the deck watch (bridge team) without appropriate training or certification.

Taken together, this is an indication that the quality of these internal and external SMS audits was less than thorough.

Although internal audit records noted those instances where a non-conformity or an observation91 was raised, there was no recorded information to identify those activities that were audited and found to be in accordance with requirements. Moreover, the audit plans were only retained for four to five months. This lack of audit history precluded internal auditors from effectively planning future audits, based on past results.

Previous TSB investigations have also identified shortcomings with the BC Ferries SMS. In the investigation into the 2002 malfunction of the automatic steering control system on board the ferry Bowen Queen,92 the TSB found that the SMS of BC Ferries vessels did not require repairs to all critical equipment to be documented. In the investigation into the 2003 engine-room fire on board the ferry Queen of Surrey,93 the TSB found that shortcomings in the monitoring, tracking, and correcting of safety deficiencies indicated inadequacies in the performance of the vessel's SMS.

In 1996, BC Ferries employed four full-time auditors to conduct SMS audits throughout the fleet, as well as in its shore offices and terminals. In the fiscal year ending 31 March 2006, there were only two full-time auditors and, when required, contractors were hired. While additional auditing resources may have been required to verify initial compliance and effectiveness of the SMS, the thoroughness of subsequent audits - so as to ensure continued compliance and effectiveness - is equally important. As per BC Ferries Fleet Regulations, Section 12.1, all 35 vessels94 and the approximately 150 sites were to be internally audited annually. During the 2005-2006 fiscal year, BC Ferries conducted 257 audits, of which 56 were conducted on board vessels, with 694 requests issued for corrective action. During the previous fiscal year, there were 243 audits, of which 92 were conducted on board vessels, with 449 requests issued for corrective action. While recognizing that it is difficult to objectively evaluate the effect of the audit team's workload upon the thoroughness of their past audits, it nonetheless cannot be ruled out as a contributing factor to the failure of the audits to identify significant non-conformities.

The continuity and thoroughness of safety audits, both internal and external, and thus the effectiveness of the measurement of the safety performance of the organization have been ineffective in identifying safety deficiencies on board BC Ferries vessels. Conditions contributing to this situation include the lack of audit history records and the heavy workload demand upon the audit team.

2.13 Alcohol and Drug Use on Board Vessels

Any impairment of employees who perform safety-critical tasks in the transportation industry is a risk to safety - whether due to impairment while on duty, or during off-duty periods if required to carry out emergency functions. Senior crew and management play an important role in ensuring that crew members conduct their duties in a safe and efficient manner and that their performance is not impaired by alcohol and drugs. However, on board the Queen of the North, some crew members regularly smoked cannabis between shifts, and not all senior crew members consistently took action to ensure that the company's no-tolerance policy was strictly adhered to.

Effective action to address the use of alcohol and drugs by employees usually involves a combination of measures including clear policies, an employee assistance program, education, reporting systems, enhanced supervision, and methods to detect impairment and the associated risks to safety. Some of these measures were in place at BC Ferries. For example, through enhanced supervision and enforcement of BC Ferries zero-tolerance policy with respect to alcohol and drugs, 5 terminations, 10 suspensions, and 8 letters of reprimand have been issued since 2004.

Given the documented effects on performance, the use of alcohol and drugs by crews of vessels presents an undue risk to the safety of passengers and the environment. Actions taken by BC Ferries regarding this issue were not adequate to ensure that this risk was addressed.

3.0 Conclusions

3.1 Findings as to Causes and Contributing Factors

  1. The fourth officer (4/O) did not order the required course change at the Sainty Point waypoint.
  2. Various distractions likely contributed to the 4/O's failure to order the course change. Furthermore, believing that the course change had been made, the next course change was not expected for approximately 27 minutes.
  3. For the 14 minutes after the missed course change, the 4/O did not adhere to sound watchkeeping practices and failed to detect the vessel's improper course.
  4. When the 4/O became aware that the vessel was off course, the action taken was too little too late to prevent the vessel from striking Gil Island.
  5. The navigation equipment was not set up to take full advantage of the available safety features and was therefore ineffective in providing a warning of the developing dangerous situation.
  6. The composition of the bridge watch lacked an appropriately certified third person. This reduced the defences and made it more likely that the missed course change would go undetected.
  7. The working environment on the bridge of the Queen of the North was less than formal, and the accepted principles of navigation safety were not consistently or rigorously applied. Unsafe navigation practices persisted which, in this occurrence, contributed to the loss of situational awareness by the bridge team.
  8. No accurate head count of passengers and crew was taken before abandoning the vessel, thus precluding a focused search for missing persons at that time.

3.2 Findings as to Risk

  1. In an emergency where abandoning ship is the only recourse, accurate passenger information is vital to both the abandonment and search and rescue (SAR) operations. In the absence of a mandatory requirement for collecting passenger information, the ability for ships' crews and SAR authorities to verify that all passengers are accounted for is compromised.
  2. As a result of the practice of operating with some watertight doors open, the potential to slow down or stem the progressive flooding was not realized, thereby placing the vessel, its passengers, and crew at undue risk.
  3. The lack of a completed evacuation plan/procedure, in addition to inadequate passenger safety training and drills, left some crew members of the Queen of the North under-prepared to handle the abandonment, thereby placing passengers at risk.
  4. The overall adequacy of passenger vessel evacuation procedures is not fully assessed by Transport Canada, neither at the time of initial certification nor throughout the life of the vessel, increasing the risk to passengers in the event of an emergency.
  5. British Columbia Ferry Services Inc. (BC Ferries) crew members were not fully familiarized with new safety-critical equipment installed during refit, and the company's training/familiarization program does not take into consideration an individual's ability to retain skills over a long period of time. As such, BC Ferries does not ensure that all employees are fully competent to perform the duties expected of them, thereby placing the vessel, its passengers, and crew at risk.
  6. In the absence of regulatory or industry-wide standards for ensuring that officers have received up-to-date training appropriate to the equipment they use, some mariners may lack the skills required to operate modern bridge equipment - jeopardizing the safety of the vessel, passengers, or the environment.
  7. Internal and external International Safety Management Code (ISM Code) safety audits have been ineffective in identifying significant safety deficiencies on board BC Ferries vessels. This indicates that measurement of the organization's safety performance has been inadequate, undermining the objectives of the safety management system.
  8. Canadian regulations regarding the stowage of inflatable liferafts and damage stability of passenger vessels apply lower standards to older vessels even though these are exposed to similar risks. As such, passengers on older vessels are not afforded an equivalent level of safety in the event damage to the hull is sustained below the waterline.
  9. The lack of a requirement for voyage data recorders (VDRs) or simplified VDRs (S-VDRs) on non-Convention vessels deprives the domestic maritime industry of a proven and valuable tool that can improve safety.
  10. Action taken by BC Ferries was not adequate to fully address the risk to safety of the public and the environment posed by crews whose performance had been impaired by the use of alcohol and drugs.

3.3 Other Findings

  1. The rapid response of the residents of Hartley Bay assisted in early recovery of survivors.
  2. The application of research and technology to the preparatory phase of the ship evacuation process has yet to be fully realized in the passenger vessel industry.
  3. Both the 4/O and the quartermaster (QM1) remained on the bridge when the second officer (2/O) took his break.
  4. The change from sleeping during the night to sleeping during the day, together with the restless sleep, likely increased the risk of QM1 being fatigued.
  5. The lack of a VDR/S-VDR installed on board the vessel resulted in a more complex and protracted investigation.
  6. Although the two missing persons had been allocated a cabin on the aft port side of Deck 7, the investigation could not determine where on board the vessel they were at the time of the striking.

4.0 Safety Action

4.1 Action Taken

4.1.1 BC Ferries Passenger Manifest

Following the sinking of the Queen of the North, British Columbia Ferry Services Inc. (BC Ferries) updated the passenger reservation system for its northern fleet to create a manifest containing all passengers' names. At the terminal, all passengers are issued a boarding number, which is collected upon boarding, tallied, and then cross-checked against the names on the manifest maintained ashore.

4.1.2 Guidelines for Passenger Manifest

In August 2006, the TSB sent Marine Safety Advisory (MSA) 09/06 to Transport Canada (TC) concerning the adequacy of current guidelines for creating passenger manifests to ensure that sufficient information is available about passengers travelling on Canadian ferries.

In response, TC indicated that it will review current guidelines for creating passenger manifests with an eye to ensuring that sufficient information is available about the numbers, identity, and (as necessary) possible locations of all passengers travelling on Canadian ferries. TC has contacted the Canadian Ferry Operators Association and the Canadian Passenger Vessel Association, providing them with a copy of the MSA so as to solicit their comments.

On 02 August 2007, TC issued Ship Safety Bulletin (SSB) 06/2007, recommending that owners and masters have readily available information on all persons on board that will be of assistance during emergency situations and search and rescue (SAR) operations. The recommendation was made in anticipation of TC adopting the International Convention for the Safety of Life at Sea (SOLAS Convention) with regard to information on passengers95 with the following additional details:

  1. All persons on board all passenger ships shall be counted prior to departure. The number shall be recorded and shall be readily available to the master.
  2. Details of persons who have declared a need for special care or assistance in emergency situations shall be recorded and communicated to the master prior to departure.
  3. In addition, the names and gender of all persons on board, distinguishing between adults, children, and infants, shall be recorded for search and rescue purposes:

    • on Unlimited Voyages (formerly Foreign Voyages) or Near Coastal Voyages Class I (formerly Home Trade Voyages Class I or II);
    • on voyages longer than 12 hours;
    • on overnight voyages or voyages on which there is at least one assigned berth.
  4. The information required by paragraphs 1, 2, and 3 shall be kept ashore and made readily available to the master and to search and rescue services when needed.

4.1.3 Crew Familiarization of Equipment

In May 2006, the TSB sent MSA 07/06 to BC Ferries indicating that not all bridge team members were sufficiently familiar with on-board equipment, controls, and their functions.

In response, BC Ferries indicated that it has implemented additional procedures to ensure that bridge officers and quartermasters are familiarized with new equipment. Furthermore, BC Ferries has contracted a review of bridge and engine-room procedures, and an evaluation of its practices.

4.1.4 Passenger Safety Management Training

In response to the Board's Safety Concern dealing with passenger safety management training,96 TC indicated that it will adopt Regulations V/2 and V/3 of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended in 1995 (STCW Convention), which address training in crowd management, for Canadian non-Convention passenger vessels. With the coming into force of the Marine Personnel Regulations in 2007, passenger safety management training is required by 07 November 2011 for crews on domestic roll-on/roll-off (ro-ro) ferries over 500 gross tons that are tasked with any of the following:

  • assisting passengers in emergency situations;
  • providing service to passengers; and
  • assisting embarking and disembarking passengers.

4.1.5 BC Ferries Divisional Inquiry

BC Ferries conducted an internal Divisional Inquiry to determine the cause and circumstance of the occurrence, and to make safety recommendations that could be applied, if necessary, to the BC Ferries fleet to educate and to prevent the recurrence of a similar occurrence. A Divisional Inquiry panel, which included representatives from both management and the union, was convened. The inquiry concluded that the deck watch of the Queen of the North failed to maintain a proper lookout, failed to make the required or any course changes at Sainty Point, and that the vessel proceeded straight on an incorrect course for four nautical miles over 14 minutes until striking Gil Island. The inquiry also made 31 recommendations regarding equipment, bridge team, procedures, and evacuation. As of December 2007, BC Ferries stated that it had addressed 21 of the recommendations, and that the remaining recommendations would be acted upon.

Subsequent to the release of the report of the Divisional Inquiry, new information was provided to BC Ferries, and the panel was reconvened. Two BC Ferries employees provided sworn statements that they had heard QM1 (quartermaster) say, in the context of the striking, that she was alone. It is noted that, although the Divisional Inquiry panel found the statements to be credible, there was one dissenting opinion. Also, further analysis by BC Ferries found that the impact marks on the shoreline of Gil Island were consistent with a straight-line extension of a track line from Grenville Channel to the impact marks. As a result, BC Ferries issued an addendum to its Divisional Inquiry, though the original findings were unchanged.

4.1.6 Review of Operational Safety at BC Ferries

On 22 January 2007, BC Ferries released an independent review that it had commissioned on its safety policies, procedures, and practices.97 The safety review concluded that, overall, BC Ferries is operating a safe coastal ferry transportation system. The review also made 41 recommendations on issues such as safety management system and audits, crewing and training in operational safety, bridge resource management, crowd management and control, the familiarization process, and emergency drills. In response, BC Ferries states that it is committed to working with the BC Ferry & Marine Workers' Union (BCFMWU) to implement all of these, 16 of which have been addressed to date.

To this end, BC Ferries and the BCFMWU have initiated a new safety program, SailSafe, which allows employees to suggest improvements and highlight safety concerns. A 41-member team met in January 2008 to evaluate documented concerns and create a plan of action.

4.1.7 Cannabis Use in the BC Ferries Northern Fleet

In November 2006, Come Sail With Us booklets were developed and presented to all union employees. These booklets included BC Ferries policy on alcohol and drugs.

In March 2007, the Terminal Operations Supervisory Skills Training Program was commenced. This included information on supervisors' responsibilities, as well as information on recognizing substance abuse and appropriate actions to take.

In October 2007, the TSB issued a Board Safety Concern to BC Ferries regarding the use of cannabis by some crew members on the Queen of the North. The Safety Concern states that, given the documented effects on performance and the risk to passengers and the environment, the TSB considers the use of cannabis by crews of vessels to be an unsafe condition - one that could lead to a serious accident. The Safety Concern further states that BC Ferries should determine whether cannabis is in use by crews of other vessels or whether it was isolated to the Queen of the North, and that this determination should include a review of the effectiveness of the company's policy on alcohol and drugs. The TSB requested that BC Ferries address the issue without delay and report back on measures taken to ensure that the public and the environment are not placed at risk by crews whose performance has been impaired.

In October 2007, BC Ferries issued a memorandum to all staff emphasizing the no-tolerance policy and, as of 12 December 2007, a total of 104 BC Ferries northern route employees had attended information sessions regarding substance abuse.

Employers in the transportation industry have developed programs for the management of alcohol and drug misuse, in compliance with the Canadian Human Rights Act and the Canadian Human Rights Commission Policy on Alcohol and Drug Testing.98,99

In February 2008, BC Ferries advised the TSB of its new Policy and Commitment to Employee Wellness and Substance Abuse. This wide-ranging policy includes the requirement that employees report any behaviour or conduct that is contrary to this policy to either a supervisor with whom an employee is comfortable making disclosure, or confidentially via a Web site, e-mail, or telephone call. It also includes provision for mandatory testing for alcohol, drugs, and medications where "reasonable cause" exists.

The policy states "Employees in Safety Sensitive Positions shall not consume any mood altering substance(s) within 8 hours of reporting to work." The TSB Safety Concern states, however, that the impairment due to a single dose of cannabis may last 24 hours.

On balance, the TSB believes that the effective implementation of this new policy will substantially reduce or eliminate the safety deficiency highlighted in its Safety Concern.

4.1.8 Location of Crew Accommodation

Subsequent to the occurrence, BC Ferries required that the crew of the Queen of Prince Rupert be placed in accommodations above the waterline.

4.1.9 Installation of Voyage Data Recorders

Subsequent to the occurrence, BC Ferries voluntarily installed simplified voyage data recorders (S-VDRs) on 14 vessels and stated that it expects the remaining 18 vessels to be similarly equipped by mid-2008.

As part of the Canada Shipping Act, 2001 regulatory reform project, TC commissioned a study to conduct a cost-benefit analysis of potential regulatory requirements for voyage data recorders (VDRs)/S-VDRs for Canadian non-Convention vessels. The study is expected to be completed in the spring of 2008.

4.1.10 Inflatable Liferafts

On 02 August 2007, TC issued SSB 07/2007 entitled Inflatable Liferafts and Rescue Platforms, Storage and Proper Access. This document urged owners and operators to stow liferafts in such a manner as to float free automatically if the vessel sinks. This SSB also urged owners/operators that, even if liferafts are carried voluntarily, these should float free.

4.1.11 Audit Plans

BC Ferries audit plans are now retained for 12 months, or until the next audit plan is prepared and the previous audit plan is used in preparation of the new audit plan.

4.1.12 Bridge Watch Composition

On 13 February 2008, the TSB sent MSA 03/08 to TC regarding the interpretation of the Marine Personnel Regulations. In this MSA, the TSB suggested that TC may wish to carry out a review of the existing minimum deck watch requirements with a view to simplifying the language so as to enhance understanding, compliance, and overall safety.

4.2 Action Required

Passenger ferries play a significant role in the Canadian transportation network. In 2006, over 44 million passengers and 16 million vehicles travelled by ship in Canada.100 In all, 113 passenger vessels above 500 gross tons operate in Canada, and some 50 of these vessels carry more than 400 persons.

Most Canadian ferries operate wholly in domestic trade where, taking into account route characteristics and traffic levels, there is an equal (if not greater) risk of damage due to collisions and groundings than there is internationally. Domestic ferries nonetheless operate under a different regulatory regime, which in many instances is less stringent.

International shipping is subject, through flag-state enabling legislation, to international norms negotiated within the International Maritime Organization (IMO) and set out in the relevant conventions, including the SOLAS Convention. Domestic shipping is not subject to these conventions, and the flag state has the option of regulating industry separately or adopting the international conventions to cover domestic shipping - with or without modification to suit perceived local circumstances. Vessels subject to the IMO conventions are frequently referred to as Convention vessels; those that are not are referred to as non-Convention vessels.

Much of the cross-border traffic handled by sea between Canada and the United States is carried by vessels that also trade domestically within their respective countries. Although vessels of one country may traverse the other country's waters during the course of a domestic voyage, it is accepted practice that such vessels are not required to meet the conventions applicable to ships engaged in international trade; rather, they must meet the requirements of their own flag state.

The TSB is of the opinion that all large passenger vessels should adhere to the same safety standards, regardless of domestic or international operation, and that, in general, the rules set out in the various conventions should apply to all large passenger vessels operating in Canada. A number of the recommendations and safety concerns that follow should be considered in the context of this basic principle.

4.2.1 Accounting for Passengers

The accounting for passengers includes collecting information concerning passenger numbers and identities, maintaining that information in a form readily accessible on the vessel and ashore, ensuring that all passengers are accounted for during an abandonment, and effective use of the information in any subsequent SAR operation.

During and following the abandonment of the Queen of the North, those responsible for ensuring that all passengers had been accounted for had difficulties establishing the total count, reconciling that count against the recorded information, and identifying those who were missing.

In MSA 09/06 issued 10 August 2006, the TSB advised TC that it may wish to review the adequacy of guidelines for creating passenger manifests, so as to ensure that sufficient information is available about the number, identity, and, as necessary, the possible location of all passengers on board Canadian ferries.

On 02 August 2007, TC issued SSB 06/2007, recommending that owners and masters have readily available information on all persons on board that will be of assistance during emergency situations and SAR operations.

In addition, BC Ferries implemented a new procedure for establishing passenger manifests on the northern routes to ensure that the passengers on board the vessels are accurately reflected in the passenger manifest maintained ashore.

The TSB recognizes the safety value of TC's and BC Ferries' actions to enhance the information collected and recorded for the purpose of accounting for passengers. However, the scope of the safety action does not include near coastal voyages, Class II, and so covers less than one-third of Canadian ferry passenger journeys. For instance, BC Ferries' action does not extend to its southern routes and, although there are logistical and business barriers to collecting this information in the busy period preceding the loading of a large passenger vessel, the risk to safety remains.

Further, the scope of the action is limited to collecting and documenting passenger information and does not extend to the other critical aspects of accounting for passengers - counting and locating passengers aboard the vessel, and subsequently carrying out SAR operations. Although the Canadian Coast Guard has developed draft procedures and tools for accounting for rescued passengers,101 these have not yet been implemented. Other aspects of accounting for passengers, such as the means to efficiently and accurately perform counts of large numbers of passengers before abandonment, have not been identified. It is important that an integrated set of tools and procedures be developed to support the accounting for passengers by all groups involved in the management of their safety, from embarkation to arrival and throughout all activities undertaken during an emergency.

The Board believes that a tailored approach is required, not just for each operator or route but for each individual vessel - one that addresses both the potential risks of a particular voyage and the most appropriate means of addressing them.

The Board, therefore, recommends that:

The Department of Transport, in conjunction with the Canadian Ferry Operators Association and the Canadian Coast Guard, develop, through a risk-based approach, a framework that ferry operators can use to develop effective passenger accounting for each vessel and route.


Assessment/Reassessment Rating: Fully Satisfactory

4.2.2 Preparation Before Abandoning a Vessel

During abandonment, it is essential that all passengers be accounted for and that they board survival craft in an organized, efficient manner. Crew members must therefore be familiar with mustering and crowd-control procedures, as well as passenger-counting methods and measures to reconcile any discrepancies in those counts.

A number of other distinct challenges must also be addressed, including:

  • High passenger-to-crew ratios
  • Dealing with passengers in several different languages
  • Passengers requiring assistance (for example, hearing, sight, mobility)
  • Congestion
  • Identifying and locating missing passengers

Following a May 2003 occurrence involving the ro-ro passenger ferry Joseph and Clara Smallwood (Marine Investigation Report M03N0050), a TSB investigation revealed a number of safety deficiencies related to emergency duties performance and training. A performance analysis indicated that crew members did not possess the knowledge or skills to adequately perform their emergency duties, and the TSB subsequently expressed its concern about the adequacy of passenger safety management training. Although crew members in that occurrence met regulatory requirements, additional training in crowd management, crisis management, and human behaviour would have better prepared them to respond. They had not received such training, nor had such on-board drills been conducted.

Canadian regulations require passenger vessels to have a procedure for safe evacuation of the complement within 30 minutes of an abandon-ship signal. There is no requirement to carry out a drill involving crowd-control duties before evacuation. Although some ferry operators have voluntarily conducted full-scale abandonment exercises, these do not involve crowd control.102

Under the new Marine Personnel Regulations, which came into force on 01 July 2007, crew members assigned to assist passengers in an emergency must have a passenger safety management certificate or endorsement.103 However, due to the number of employees that some ship owners will be required to train, domestic passenger vessels have been granted a phase-in period, which will end 07 November 2011.

Although passenger safety management courses based on the provisions of the STCW Code are offered, these involve, for the most part, classroom instruction only. As this alone is not enough, regular exercises and drills need to be conducted so that crews are confident and prepared to carry out their emergency duties.

On the Queen of the North, boat and fire drills were to be conducted at intervals of not more that two weeks.104 These were limited to crew members mustering at their designated emergency stations, followed by the deployment and operation of lifeboats. The drills did not include the full range of skills necessary to muster and control large numbers of passengers.

In this occurrence, crew members on the Queen of the North evacuated 57 of 59 passengers in the 30 minutes between the striking and the time senior crew members entered the last survival craft. With such a crewing level, however, the vessel was certified to carry up to 474 passengers - a significantly larger number that, given the short timeframe available for the preparatory phase of abandonment, would have compounded the mustering, accounting, and abandonment difficulties identified in this occurrence. Crew training and experience is therefore paramount for passenger safety on vessels, especially where there are high passenger-to-crew ratios.

When crews are faced with an actual emergency, the response of those who have received training and practice is more automatic and requires less interpretation and decision making. Failure to reinforce this training with practice and evaluation reduces the benefit of the original training. Given the risks associated with improperly coordinated preparations for evacuating large number of passengers, the Board therefore recommends that:

The Department of Transport establish criteria, including the requirement for realistic exercises, against which operators of passenger vessels can evaluate the preparedness of their crews to effectively manage passengers during an emergency.


Assessment/Reassessment Rating: Fully Satisfactory

4.2.3 Carriage of Voyage Data Recorders

The Queen of the North was not equipped with a VDR or S-VDR, as this was not a requirement for passenger vessels engaged on domestic voyages.

Although the electronic chart system (ECS) provided some information concerning the vessel's movements before the striking, unlike a VDR, it was incapable of recording bridge voice data. Information gathered about the activities of the bridge team was in conflict with information derived from the ECS. The lack of a VDR resulted in a more complex and protracted investigation.

The purpose of a VDR is to create and maintain a secure, retrievable record of information indicating the position, movement, physical status, and command and control of a vessel. Objective data - voice data in particular - are invaluable to investigators and operators seeking to understand the sequence of events leading up to an accident.

Although the aviation industry has enjoyed the benefits of flight data recorders for 50 years and cockpit voice recorders for 43 years, the maritime industry's experience with VDRs is in its infancy - though the proven benefits from their carriage are already evident. These include the proactive analysis of information stored in VDRs for constant improvement within a company safety management system, and benefits to accident investigators in the form of early and objective identification and communication of safety deficiencies.

It should be noted that, under the Canadian Transportation Accident Investigation and Safety Board Act, "on-board recordings" are privileged information.105

In the Coast Guard and Maritime Transportation Act of 2006, Congress directed the United States Coast Guard to conduct a study of the carriage of VDRs by passenger vessels carrying more than 399 passengers. The vessels that this study involves are ferries of at least 100 gross tons, providing transportation only between places that are not more than 300 miles apart, and carrying more than 399 passengers.

Despite the significant safety benefits to operators, accident investigators, and hence the travelling public, there is no requirement for the carriage of VDRs on non-Convention vessels, thereby depriving the industry of a proven and valuable tool for improving safety.

The Board, therefore, recommends that:

The Department of Transport extend the requirement for the carriage of voyage data recorders/simplified voyage data recorders to large passenger vessels over 500 gross tonnage and all other commercial vessels on an equivalent basis to those trading internationally.


Assessment/Reassessment Rating: Satisfactory Intent

4.3 Safety Concerns

4.3.1 Watertight Doors

The role of watertight doors is to maintain the integrity of the watertight bulkheads and the benefits of watertight subdivision.

The Hull Construction Regulations require that all watertight doors be kept closed during navigation except when necessarily opened for the working of the ship. As currently written, these regulations leave room for interpretation with regard to the terms "necessary" and "working of the ship." The SOLAS Convention, however, provides clear and specific instruction as to when these watertight doors may be opened.

On the Queen of the North at the time of the occurrence, as per regular practice for over 25 years, several watertight doors were open.

Over the last 30 years, the sinking of at least five vessels in Canada has been attributed to watertight doors being left open. TC has subsequently issued three SSBs, reinforcing the importance of keeping these doors closed.106 The TSB has also issued a recommendation promoting awareness of this issue's serious consequences.107 The practice, however, persists, and this has been addressed by MSA 02/08.

The Board is therefore concerned that some Canadian operators continue to operate their vessels with watertight doors open, thereby placing vessels, passengers, crews, and the environment at undue risk.

4.3.2 Damage Stability

The damage stability requirements applicable for Canadian domestic vessels are mainly set out in the Hull Construction Regulations. Recognizing that the present Canadian regulations for passenger vessels do not incorporate the latest international requirements, TC has adopted the amended TP 10943. Although it is TC's intent to apply these standards in advance of updating the Hull Construction Regulations, these regulations are still in force, and their provisions are less stringent.

The revision of the Hull Construction Regulations is part of phase 2 of the Canada Shipping Act, 2001 regulatory reform project. Information provided by TC indicates that it is too early in the reform process to adequately predict the timelines for publication of the new regulations in the Canada Gazette. The proposed amendments to these regulations are expected to be presented for consultation with the stakeholders in 2009 and 2010.

The TSB recognizes TC's effort since 1990 to enhance damage stability requirements and improve the survivability of passenger vessels by adopting the amended standards. However, until the Hull Construction Regulations make the application of the amended TP 10943 mandatory to all passenger vessels operating in Canada, the Board is concerned that passengers and crews on older vessels will not be afforded an equivalent level of safety compared to those plying internationally. Moreover, because the new standards have a longer phase-in time than the SOLAS Convention, the same concern applies to existing vessels until such time as they meet the standards.

4.3.3 Auditing Voluntary Adopted Safety Management Systems

The objectives of the International Safety Management Code (ISM Code) are to prevent human injury, loss of life, and damage to the environment. Although most vessel operators in Canada are not required to comply, several have done so voluntarily.

The goal of a safety management system (SMS) is to permit participants to detect and prevent unsafe practices and conditions before an accident occurs rather than having others identify safety shortcomings afterward. It is therefore important that, when any non-conformity is reported, appropriate corrective action be taken in a timely manner.

In this occurrence, internal and external audits failed to identify a number of shortcomings. It was also reported that external audits did not always apply the same standards regarding compliance. Major non-conformities, for example, which would have otherwise been cited, may not have been issued because the ISM Code had been adopted voluntarily. Therefore, less emphasis may have been placed on taking corrective action - effectively defeating the objectives of both the ISM Code and an effective SMS.

In Canada, TC has delegated five classification societies108 to perform ISM Code audits on Convention vessels. TC also monitors, via audits, the activities of these classification societies. However, TC's monitoring, auditing, and overview is for mandatory systems only: TC does not monitor the application of the ISM Code where it has been voluntarily adopted.

The Board is concerned that this lack of consistent application compromises the objectives of the ISM Code. Moreover, the Board believes that, with the large numbers of passengers that may be carried at any one time on a passenger vessel, quality audits are essential in being able to identify deficiencies requiring corrective action. The Board, therefore, will monitor the situation.

This report concludes the Transportation Safety Board's investigation into this occurrence. Consequently, the Board authorized the release of this report on 30 January 2008.

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