Final Report Issued on Queen of the North Sinking

By 250 News

The Transportation Safety Board of Canada (TSB) has released its final report  into the sinking of the BC Ferries Queen of the North, which occurred on March 22, 2006 at Gil Island, Wright Sound, British Columbia.

"Essentially, the system failed that night. Sound watchkeeping practices were not followed and the bridge watch lacked a third certified person," said Wendy Tadros, Chair of the TSB. "The recommendations we are making today go beyond the cause of this sinking to ensure that Canadians will always reach port safely. Passengers are the focus of our first two recommendations. In an emergency, all passengers must be accounted for and evacuated to safety. Our third recommendation calls for voyage data recorders on all of Canada’s large vessels," she added.

At 08:00 p.m. on March 21, 2006, the passenger and vehicle ferry Queen of the North departed Prince Rupert,  for Port Hardy. On board were 59 passengers and 42 crew members. After entering Wright Sound from Grenville Channel, the vessel struck the northeast side of Gil Island at 12:21 a.m. on March 22.

 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.

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.

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.

The vessel sustained extensive damage to its hull, lost its propulsion, and drifted for 1 hour and 17 minutes before it sank in 430 m of water. Passengers and crew abandoned the vessel before it sank. Two passengers were unaccounted for after the abandonment and have since been declared dead.To read the full report,  click  here.

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