An investigative report into the grounding of a Lake Erie ferry in 2012 revealed issues with the coordination of safety-critical activities in the port, the company’s safety management system and passenger emergency preparedness.
The Transportation Safety Board of Canada’s report on the grounding of the 200-foot Jiimaan near Ontario’s Kingsville Harbour also was critical of Transport Canada’s (TC) oversight of recent regulatory amendments related to passenger safety.
The passenger and car ferry was traveling from Pelee Island to Kingsville with 18 passengers and 16 crew aboard on Oct. 11, 2012. Because of silting in the charted channel into Kingsville Harbour, the crew intended to sail parallel to and east of the channel to avoid shallows, which were marked by a buoy.
Winds pushed the vessel off the intended course. It ran aground 420 feet from the harbor entrance. Evacuation was impossible due to high winds. The vessel was refloated the next day and escorted to Leamington, Ontario, where passengers disembarked. There were no injuries, no pollution and no damage to the vessel.
Jiimaan is owned by the Ministry of Transportation for Ontario and managed by the Owen Sound Transportation Co. (OSTC).
The TSB’s investigation found that “the company’s safety management system (SMS) did not include a risk assessment process. As such, the risks associated with deviating from the charted channel to avoid the obstruction were not adequately identified and mitigated.”
It also found that there was “a lack of coordination between the organizations involved in safety-related port activities, specifically with regards to communicating information about the buoy’s position and the extent of the channel obstruction due to silting with those responsible for maintaining charts and aids to navigation.”
TSB investigators identified deficiencies with passenger emergency preparedness. TC enacted new regulations in 2010 requiring vessels to have procedures in place to account for all passengers during an emergency and to conduct realistic emergency drills.
“The Jiimaan’s emergency procedures did not have the measures required by the new regulations,” the TSB wrote.
Previous TSB investigations have identified deficiencies and associated risks in the preparedness of the crew of Canadian passenger vessels to muster and account for passengers in an emergency situation. In response to TSB recommendations to address the issue, TC made regulations requiring that the muster list of a passenger vessel include tasks specific to passenger safety and that procedures be developed to carry out those tasks.
A documented muster list and evacuation procedure was kept on board Jiimaan and this was verified by TC during annual inspections, fulfilling the requirements for certification of the vessel. However, the documents in use on Jiimaan included none of the specific passenger safety-related duties or procedures required by the regulations, with the exception of “assembling the passengers at their designated muster stations.”
“Without effective TC oversight to ensure compliance with respect to passenger safety-related emergency procedures, there is a risk that these important initiatives will be ineffective in achieving their intended purpose,” the TSB wrote.
In its findings, the TSB noted that at the time of the occurrence, the Kingsville range was not usable due to silting in the channel approaches, requiring Jiimaan to proceed out of the marked channel to enter the harbor and east of the port-hand buoy marking the edge of the channel silting. In addition, the master allowed the vessel to pass farther east of the buoy than on previous voyages.
“Given the limited margin of error east of the buoy, this brought the vessel into shallower water and the vessel subsequently ran aground,” the TSB concluded.
The TSB suggested that each successful passage may have decreased the crew’s perception of the risk of the shoals.
“The absence of a risk assessment process within the company’s safety management system resulted in the risks, associated with deviating from the charted channel in response to the silting at the port of Kingsville, not being identified and mitigated,” the report found.
In its findings as to risk, the TSB said if safety-critical activities in ports are not coordinated among the entities involved, and safety-related information is not communicated to port users, the navigational safety of the port may be at risk.
The TSB stated that if audits do not effectively assess an organization’s capability to meet the safety objectives and functional requirements of SMS, as defined in the International Safety Management (ISM) Code, there is a risk that the benefits of SMS will not be realized.
The report pointed out that “without comprehensive and documented procedures and drills to muster and account for passengers, there is a risk that crewmembers will not be able to effectively carry out these duties.”
On Oct. 23, 2012, the TSB issued a Marine Safety Advisory (MSA) Letter to the Department of Fisheries and Oceans concerning the accuracy of the Canadian Hydrographic Services chart for the port of Kingsville.
In May 2013, the TSB issued an MSA to the OSTC concerning the implementation of procedures and associated drills on board OSTC vessels. A month later, TC advised its regional directors of programs to review waters surrounding public port facilities to ensure that water depths reflect what is represented on the navigational charts.
The OSTC has implemented plans and procedures to improve mustering and accounting for passengers on all OSTC-operated vessels. Fire and boat drills have been expanded to include a sweep and search of all vessel spaces as well as the water around the vessel.
The OSTC has also developed and implemented water level monitoring procedures. In March 2013, 28 OSTC employees participated in risk management and incident investigation training.
