Inspections failed to identify problems in small ferry

The Transportation Safety Board of Canada (TSB) has concluded that federal inspectors failed to identify a host of serious problems which contributed to the sinking of True North II, a casualty that cost the lives of two seventh-graders returning from a school camping trip in June 2000 (PM #51).

On the morning of June 16, True North II picked up 19 passengers, including 13 schoolchildren, from an island in Fathom Five National Marine Park. After the 35-foot passenger vessel set out from the island onto Lake Huron’s Georgian Bay, it encountered 30-knot winds and 5-foot waves that broke over the bow.

One wave stove in the bridge front door and window. As water accumulated on the deck, it downflooded into the main compartment through several non-watertight hatches.

Within 15 minutes of leaving the dock, True North II sank by the stern. The sinking was so rapid that the master did not have time to distribute lifejackets, and the passengers did not know where they were stowed.

The passengers and the captain found themselves in the 50° F (10° C) water clinging to two rigid floats that had floated free. The vessel’s inflatable liferaft, stowed on the roof of the cabin, did not deploy automatically and the master was unable to free it before the vessel sank.

Eighteen people clinging to the floats were fortunate that the sinking occurred approximately 200 yards upwind from the island. The wind and waves pushed them to shore. But when they arrived and took a head count, they discovered two children were missing. Their bodies were subsequently found on the lake bottom near True North II.

Issuing the report on May 11, TSB Chairman, Beno”t Bouchard observed that federal safety inspectors failed to identify numerous problems despite annual inspections of the vessel. “Were these problems identified during safety inspections? No, but the vessel had been inspected by Transport Canada Marine Safety every year since it was converted to a passenger vessel in 1972,” Bouchard said. “One, the safety of the vessel was not challenged. And two, the status quo should always be challenged in order to safely operate every vessel, especially those carrying passengers.”

The TSB report identified numerous problems that the inspections did not turn up:

The vessel was required to have two crew members, but the captain had operated it alone for years. As a result, no other crew member was available “to guide or render assistance to the passengers, during and after the abandonment,” the report said.

The vessel was not watertight because of modifications made over the years to the former fishing vessel. There were three hatches flush with the deck that lacked gaskets or other means to make them watertight. A wooden casing covering the engine access left open a space in the deck that allowed water to flow below.

The scuppers draining the fore deck were inadequate, and two of the four freeing ports designed to drain the main deck had been welded shut. The combination of poor deck drainage and leaky hatches permitted “the shipped water to be retained on deck and quickly downflood the underdeck compartment,” the report said. “As a result the vessel lost reserve buoyancy and sank rapidly by the stern.”

Lifejackets were not readily available. Their location on the boat was not clearly marked. Stored in the wooden casing covering the engine access, the lifejackets were wrapped in opaque plastic bags. Following the sinking, passengers told investigators that none of them knew where the lifejackets were kept.

The inflatable liferaft on the roof of the cabin was secured by a latch that needed to be released manually, even though federal regulations require that such rafts be designed to float free without human intervention in the event of a sinking. “The liferaft sank with the vessel because it was neither placed in deep chocks without lashings nor fitted with a hydrostatic release unit,” the report said.

The Ship Inspection Certificate gave the master authority to decide whether to sail in less than ideal conditions, discretionary authority he should not have had. The original restriction issued by the Board of Steamship Inspection prohibited the vessel from sailing in anything but good weather, without mentioning any discretion granted to the captain. The inspection certificate improperly added “at master’s discretion” to the phrase limiting operations to “fine clear weather only.”

On the day of the sinking, a small craft warning and thunderstorm advisory were in effect. The report also noted that the passengers on True North II did not receive a pre-departure safety briefing to acquaint them with the location and use of the lifejackets.

Such briefings were not required of vessels like the True North II, even though the TSB had issued a recommendation in 1996 to Transport Canada that briefings be required on small sightseeing boats. Transport Canada encouraged such vessels to conduct safety briefings but did not require them.

The TSB report concluded that the federal vessel inspection program was not adequate. “This investigation has found procedural, performance and management deficiencies associated with the safety inspection regime of the safety inspection program.”

The TSB urged the agency to move beyond a “rule-book approach” to enforcement by developing a system that “would enable managers and safety inspectors to identify and address all unsafe practices and conditions.” It called for several specific actions involving operators of small passenger vessels, including requirements for safety briefings before departure, self-deploying liferafts and communication devices such as EPIRBs (emergency position-indicating radio beacons) to issue calls for help.

“We call on the regulator, the Department of Transport, to expedite the review of the deficiencies in the inspection and certification process,” Bouchard said.

While the TSB does not assign blame in its reports, it was clearly concerned by the failure of inspectors to detect problems as obvious as the leaky hatch covers. “It’s perfectly obvious they are not watertight,” said Lancelot Bedlington, a senior investigator and naval architect with the TSB. “Why weren’t they caught? You’ll have to ask Transport Canada.”

Following the issuance of the TSB report, Transport Canada did take a number of actions regarding safety on small passenger vessels. It has begun reviewing inspection reports and certification records of small passenger vessels to identify problems in crew size, life-saving equipment and watertight integrity.

The agency has also proposed regulations to require pre-voyage safety briefings for passengers of small vessels. And it has issued Ship Safety Bulletins regarding voyage planning and stowage of liferafts designed to float free.

However, a Transport Canada spokeswoman declined to answer questions about how the inspection system could have missed so many problems on True North II. She also declined to say whether the issues raised by the TSB are indicative of more pervasive problems with the inspection program that go beyond True North II.

“We’re not in a position to answer because of pending litigation and the coroner’s inquest,” said Marie-Jose Dubois, a public affairs official with Transport Canada in Ottawa.

Fixing the inspection system will require “a change of philosophy, mentality” at Transport Canada, according to Paul van den Berg, a senior investigator and safety analyst at the TSB. “I’ll be interested in seeing their response.”

By Professional Mariner Staff