The Transportation Safety Board of Canada (TSB) has determined that informal crew practices and insufficient supervision were contributing factors in a training accident on a BC Ferries vessel. Two Spirit of Vancouver Island crewmembers fell overboard while launching a rescue boat during the drill in August 2018, injuring one of the mariners.
“We conducted a detailed investigation and risk assessment into this incident,” said Deborah Marshall, BC Ferries’ executive director of public affairs. “The inquiry identified multiple causal factors. Equipment configuration, modifications, quality assurance, procedural changes, communication and supervisory oversight all played a role.”
The incident occurred on Aug. 31, 2018, at the Swartz Bay Ferry Terminal in North Saanich, British Columbia. In June 2018, another of the ferry’s rescue boats fell 50 feet when a bent spring-loaded safety latch caused the vessel to slip off a hook during a davit repair. The boat’s hull sustained minor damage and the fuel tank cracked, spilling about 26 gallons of gasoline. Two months earlier, a rescue boat on another company ferry also fell during a drill, injuring two crewmembers.
The company has made several changes to prevent similar incidents in the future, including creating new supervisory offices, updating policies and procedures, and checking crew proficiency.
“As a marine transportation company that is accountable for the safety and security of our customers and our employees, safety is our highest value,” Marshall said.
Spirit of Vancouver Island is a 522-foot, 22,000-ton vehicle and passenger ferry. Built in 1993 by Victoria-based Integrated Ferry Constructors, it has eight decks and can carry 2,059 passengers, 41 crew and 470 vehicles. It has four 16-foot rigid-hull inflatable rescue boats cradled with davits for launching. Rescue boat No. 1 is used for marshaling and towing life rafts deployed during a vessel evacuation, and for man-overboard rescues.
In 2016, BC Ferries replaced two of the rescue boats on Spirit of Vancouver Island with a new model that includes high-profile, self-righting equipment at the stern. The company did not replace the rescue station davits and cradles. According to the TSB report, neither the ferry company nor the boat installer conducted a risk assessment on incorporating the new vessels with the original equipment. Checklists for operational procedures also were not updated.
The changes resulted in the brake release line being out of adjustment, causing it to sag. Some crewmembers began leaving the release line bag on deck while the rescue boat was launched after the line tangled on the boat’s propeller during an earlier drill.
“This practice deviated from the standard order issued in BC Ferries’ senior master directive,” the TSB said in its report on the August 2018 incident. “According to the directive, the brake release line bags for rescue boat stations No. 1 and No. 2 should have been deployed (dropped in the water and allowed to float freely) while each boat was launched.”
The TSB said this “informal practice” allowed the line to snag while the rescue boat rotated out from the davit, creating tension that released the brake and dropped the boat without warning. The boat hit the edge of the deck and tipped, dropping the coxswain almost 50 feet into the water. He sustained minor injuries. A second crewmember who grabbed the bow painter line as the boat dropped also fell, but he was not injured.
The TSB also cited “insufficient supervision” as a contributing cause, as the chief officer’s “high workload and simultaneous tasks at multiple locations” kept him from overseeing the drill.
“Significant efforts have been underway to rectify any identified hazards and to ensure the safety of our employees during our many marine rescue operations,” Marshall said. As a temporary measure, crewmembers will not occupy rescue boats while they are being raised or lowered during training drills, and instead will board them from the water.
Marshall also said that BC Ferries has developed a “patent-pending, first-of-its-kind system” to protect crewmembers from sudden falls during rescue boat operations, but she declined to say more about it until it is deployed across the fleet.
