Marine Recommendations - 2004

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Reassessment of the Responses to Marine Safety Recommendation M04-01

Management of Safety by Operators of Passenger Vessels

Background

The Lady Duck was an amphibious vehicle based on the conversion of a Ford F-350 truck chassis and arranged to carry up to 12 passengers on combined road and water-borne tours in the National Capital Region and on the Ottawa River. The vehicle was developed and built by the owner and entered commercial service at the start of the tourist season in June 2001.

The Lady Duck started the amphibious tour at about 1500 on 23 July 2002, with the driver, 10 passengers and a tour guide on board. When the vehicle entered the water at the Hull Marina, the main bilge pumps were switched on to clear the hull of any shipped water. Because no water was seen to be discharging from the outlets, the emergency bilge pumps were also switched on. Water was then seen to be discharging intermittently from outlets on both sides of the vehicle. The vehicle was driven to the Ottawa side of the river to various points of interest. The river was calm, with waves caused by wakes from boats and other watercraft in the tour area. On occasion, the vehicle encountered waves that washed over the hood and up to the windshield.

Toward the end of the tour, while returning to the Hull Marina, the driver noticed that the front end of the vehicle was floating lower than normal and that water was being continuously discharged from both sides of the vehicle. The driver then ordered the four foremost passengers and the tour guide to move to the back of the vehicle to try to decrease the forward trim.

The forward trim continued to increase and, realizing that the safety of passengers was at risk, the driver instructed the tour guide to tell passengers to don personal flotation devices. The driver then broadcast a MAYDAY on VHF radio. The situation deteriorated rapidly as more floodwater accumulated in the forward end of the vehicle. The driver then called on the passengers to abandon the sinking vehicle. The driver, tour guide and six passengers managed to get free of the sinking vehicle. The remaining four passengers became trapped under the fabric awning and sank with the vehicle in 8 metres of water.

The Board concluded its investigation and released report M02C0030 on 03 June 2004.

Board Recommendation M04-01 (03 June 2004)

The picture that emerged from this investigation was one of an organization pursuing minimal compliance with regulations rather than one seeking to minimize risk through all available means. The organization did not demonstrate a commitment to operating safely in that it did not seek the advice of TC with respect to the condition of the vehicle and was reticent to follow recommendations that were not specifically required by regulation.

The Lady Duck was designed and built by its operator to conduct amphibious tours. Characteristics of the vehicle indicated a lack of awareness of marine standards of construction and maintenance, in that the vehicle was constructed with low freeboard, without watertight fittings at through-hull penetrations and with incorrectly installed bilge pumping arrangements.

The company's full-time mechanic in charge of vehicle maintenance had no formal training and held no formal certification.

Training provided by the company to enable drivers to make such decisions was minimal and informal. There was no formal training program offered to guides before conducting tours on any of their amphibious vehicles and there were no written company policies or procedures on what and how to train tour guides.

The effective management of safety requires operators to be able to identify the hazards associated with their operation, assess the risk arising from those hazards, and identify mitigation strategies to reduce the risks to the lowest possible level. However, as demonstrated in this occurrence, small passenger vessel operators may not be aware of the risks associated with the operation of their vessels or possess the competence to manage those risks.

Given the benefits associated in preventing accidents, and the need for a structured approach for operators to effectively manage the risks associated with their operation on an ongoing basis, the Board recommends that:

The Department of Transport take steps to ensure that small passenger vessel enterprises have a safety management system.
M04-01

Response to M04-01 (26 August 2004)

Transport Canada agrees with the intent of the recommendation. The Department is actively reviewing the feasibility of implementing safety management systems for operators of Canadian domestic (i.e. non-SOLAS Convention) vessels, including small passenger vessel operators. The review will assess the benefits and costs of marine safety management systems and examine the experience of other marine administrations (such as New Zealand and the U.K.) in their implementation of such systems.

The review is scheduled to be completed by mid-2005. If the results indicate that safety management systems are warranted and feasible for any given sector of the domestic marine industry, Transport Canada will, in consultation with industry, determine the best approach to effectively implement such regulatory requirements. In the meantime, Transport Canada continues to support the voluntary adoption of safety management systems by domestic operators.

Board Assessment to the Response to M04-01 (20 December 2004)

In their reply, TC agrees with the intent of the recommendation. A study to evaluate the feasibility of implementing a safety management system for the domestic fleet was completed in May of 2002. The study found that there is no clear indication that safety management has improved maritime safety although there was some evidence that safety management in other environments has delivered benefit [The study included a survey but there were no responses from the Canadian Shipowners Association, the Canadian Ferry Operators Association and the Canadian Passenger Vessel Association. There were only six responses from tour and other passenger vessels.]. The study recommended that consideration of the New Zealand two-tier approach in which a safety management system (SMS) be applied to all commercial vessels carrying more than 12 passengers or above 15 gross tons. For smaller passenger and cargo vessels, a Safe Operating Plan (SOP) programme should be implemented. An SOP is a scaled-down version of an SMS aimed at providing a practical and affordable set of safety requirements for small commercial vessels. Individual operators draw up an SOP which includes a written record of the vessel=s maintenance and safe operating procedures. It also details the conditions under which a vessel operates and the conditions for carrying passengers.

The department is reviewing the feasibility of implementing safety management systems for operators of Canadian domestic vessels, including small passenger vessel operators. The review of that study is scheduled to be completed by mid-2005. If the results indicate that safety management systems are warranted and feasible, TC will, in consultation with industry, determine the best approach to effectively implement regulatory requirements for such systems. TC continues to support the voluntary adoption of safety management systems by domestic operators.

Since TC intends to consult with industry to determine how best to implement safety management systems, should the results of the review warrant their implementation, the response is considered Satisfactory Intent.

Board Reassessment of the Response to M04-01 (07 December 2005)

Although the review by TC of the study on domestic safety management systems was completed in August 2005, no update of TC's further action has been received by TSB. If the study recommendations are fully implemented, the risks associated with small passenger vessel operations will be substantially reduced. This review has been completed and a report, entitled Analysis of Options for Safety Management Systems in the Canadian Domestic Shipping Industry, was submitted to the TC Marine Safety Executive Committee in September 2005 for consideration. TC intends to review all essential information, including that which may come from an anticipated coroner's investigation, and consult with stakeholders prior to implementing any additional safety requirements.

The response is considered Satisfactory Intent.

Response to M04-01 (November 2006)

TC's update, dated November 2006, indicated that the report on the feasibility of implementing safety management system (SMS) for small vessel operators, even a relatively simple safety management system can represent a significant operational and cost burden. The justification for applying SMS across the entire domestic passenger vessels would have to be reviewed. However the report suggested that if a suitable industry sector be identified, a pilot project on the implementation of a safety management system approach could be commenced.
Transport Canada Marine Safety will consult with the small passenger vessel industry for their feedback.

The booklet for Small Commercial Vessels Safety Guide (TP 14070) contains elements of SMS such as a self-inspection checklist and routine maintenance schedule. And also provides information regarding applicable regulations.

Board Reassessment of the Response to M04-01 (November 2006)

The report on the feasibility of implementing a SMS for small vessel operators found that even a relatively simple safety management system can represent a significant operational and cost burden. However, the report suggested that if a suitable industry sector be identified, a pilot project on the implementation of a safety management system approach could be commenced.
Transport Canada Marine Safety intends to consult with the small passenger vessel industry for their feedback.

Therefore, the assessment remains at Satisfactory Intent.

Response to M04-01 (June 2008)

TC's update, dated June 2008, indicated that TC conducted a study of safety management systems (SMS) with regards to the domestic fleet, including holding consultations with industry. Following on this study, TC continues to review the application of SMS to small vessels and will consider its application in the future where appropriate.

The booklet for Small Commercial Vessel Safety Guide (TP 14070) contains elements of SMS such as a self-inspection checklist and routine maintenance schedule. And also provides information regarding applicable regulations. Revisions to the Small Commercial Vessel Safety Guide will expand upon the SMS concept and both promote and explain the concept.

Board Reassessment of the Response to M04-01 (September 2008)

TC's update, dated June 2008, indicates that it continues to review the application of SMS to small vessels and will consider its application in the future where appropriate and that the to-be-revised Commercial Vessel Safety Guide (TP 14070) will used to promote SMS, indicates support for the voluntary adoption of safety management systems by domestic operators.

The effective management of safety requires operators to be able to identify the hazards associated with their operation, assess the risk arising from those hazards, and identify mitigation strategies to reduce the risks to the lowest possible level. SMS represents a systematic process for managing safety risks and has been widely embraced.

While voluntary application of safety measures can be achieved if their adoption is encouraged and promoted, all small passenger vessel operators may elect not to participate and, therefore, unknowingly continue to put at risk the safety of their crews and passengers. Until such time that efforts to promote the use of SMS has become the norm for the small passenger vessel industry, or that it is required, the safety deficiency identified by the recommendation will not be substantially reduced or eliminated.

The response is therefore considered Satisfactory in Part.

Response to M04-01 (December 2009)

TC's update, dated December 2009, indicated that TC is in the process of consulting with industry to develop a safety management system (SMS) tailored to the needs of the Canadian domestic fleet, which is comprised primarily of smaller vessels.

A 2-year pilot project commenced early in 2009 to test the functionality of what has become known as a Domestic Safety Management System (DSM). The goal of introducing a DSM is to:

• enhance the safety culture on board Canadian vessels;
• entrench this safety culture throughout the Canadian maritime industry;
• improve safety and environmental performance;
• improve operational reliability;
• improve industry safety credentials;
• increase industry productivity.

As of January 2010, TC is in the final stages of developing a Domestic Safety Management manual and other tools that will assist Canadian operators in implementing a SMS. These will be available to all operators in the near future as part of an information and outreach campaign that will seek to inform operators on how SMS will strengthen stewardship over safety and environmental protection in their operations.

Board Reassessment of the Response to M04-01 (May 2010)

The proposed Domestic Safety Management (DSM) system for the Canadian domestic fleet is a voluntary system based on the International Safety Management (ISM) Code. The objectives of DSM are to encourage domestic operators to develop a safety management system as a tool to enhance safety and assist operators in complying with the modernized Canada Shipping Act,  2001, specifically section 106 (l)(b), which requires operators to develop procedures to ensure the safety of their vessels and to deal with emergencies.

While voluntary application of safety measures can be achieved if their adoption is encouraged and promoted, not all small passenger vessel operators will elect to participate and, therefore, unknowingly continue to put at risk the safety of their crews and passengers. Until such time that efforts to promote the use of DMS has become the norm for the small passenger vessel industry, or that it is required, the safety deficiency identified by the recommendation will not be substantially reduced or eliminated.

At the April 2010 meeting of the Canadian Marine Advisory Council, a Domestic Vessel Regulatory Oversight Working Group, co-chaired by TC and an industry representative, was formed that will explore how to implement by regulation a safety management system for the domestic fleet.

The response is therefore considered as Satisfactory Intent.

Response to M04-01 (December 2010)

TC's update of December 2010 reiterated that, under the Canada Shipping Act, 2001, safety is the responsibility of the authorized representative/owner. TC indicated that its role is to provide tools and guidance to help authorized representatives meet their regulatory requirements and to develop regulations that efficiently and effectively promote safety.

TC has begun consultations to develop Safety Management Regulations. A three-tier approach is being proposed for safety management of domestic vessels based on their size, type and/or number of passengers. TC has undertaken a pilot project, in collaboration with the Council of Marine Carriers, to test safety management system implementation in the Canadian domestic fleet. Results from this pilot project will be used to aid in the adoption of safety management throughout the Canadian domestic fleet. Tier 2 of this program covers vessels over 15 gross tons (GT)  and/or with 12 or more passengers and would require a Domestic Safety Management (DSM) system to be put in place. Tier 3 of this program is for vessels under 15 GT and carrying less than 12 passengers to have on-board guidelines for operational safety.

Board Reassessment of the Response to M04-01 (March 2011)

If fully implemented, the proposed actions will enable operators to identify the hazards associated with their operation, assess the risk arising from those hazards, and identify mitigation strategies to reduce the risks to the lowest possible level. As such, risk will be substantially reduced or eliminated. 

Therefore, the assessment of the response remains as Satisfactory Intent.

Next TSB Action (March 2012)

TSB Marine Branch staff will monitor the proposed actions.

The deficiency file is assigned an Active status.