Investigators identify crew communication failure in B.C. ferry crash

A B.C. Ferries boat crashed into its berth in 2011 due to a misunderstanding between the master and chief engineer while they coped with a fuel-injector problem, investigators concluded.

Queen of Coquitlam landed hard at the Departure Bay terminal in Nanaimo on Nov. 18, 2011, because of “incomplete communications” between the engine room and bridge, the Transportation Safety Board of Canada (TSB) said in a report.

The accident damaged the ferry’s port bow and the fender’s articulated pad. There were no casualties or pollution.

The 457-foot Queen of Coquitlam is powered by two MaK diesel engines, with a total of 8,848 hp, driving two controllable-pitch propellers with one at each end of the vessel.

During the passage from the Horseshoe Bay terminal on the mainland to the Departure Bay terminal on Vancouver Island, one of the vessel’s two main engines had to be shut down because of a leaking fuel injector.

While work on this engine was being completed, the bow propeller was locked out in the engine room, making it unavailable to the vessel’s master and leaving the stern propeller as the only operational propeller. As Queen of Coquitlam approached Departure Bay, incomplete communications between the engine room and the bridge led to a misunderstanding as to the availability of engines and propellers for docking, the investigators said.

With only one propeller available, the master was unable to slow or control the vessel adequately. This resulted in the vessel striking the port-side fender.

The communications between the engine room and bridge addressed the status of the main engine. It did not include information as to which clutches were locked out or the fact that Mode 2 (both propellers under power) was not available, the report said.

As the vessel entered Departure Bay, it became apparent to the bridge crew that Mode 2 had not engaged. Upon calling down to the engine room to find out why it was not engaging, the master was told by the chief engineer that it was not available.

The TSB said that incomplete communications between the master and the chief engineer led to a lack of understanding regarding the status of Mode 2 and its availability for docking.

The master had previously made a landing with only stern propulsion and continued with the docking procedure. With only the stern propeller to maneuver with, the bank cushion effect caused the vessel to move to port toward the port-side fender.

The master was not able to counteract these forces, which were compounded by the vessel’s speed as it approached the berth. Consequently, Queen of Coquitlam struck the port-side fender. Under normal circumstances, with both engines and propellers operational, the master would have had sufficient control to compensate for these forces.

“By not attempting to engage Mode 2 at the distance from the berth specified in the vessel-specific manual, the master had a reduced amount of time to assess the situation and take corrective action,” the investigators wrote.

B.C. Ferries conducted its own investigation and reached similar findings, spokeswoman Deborah Marshall said in an e-mail.

“We concluded procedural errors and miscommunication caused the incident,” Marshall wrote.

The TSB issued a Marine Safety Information Letter in April 2012 advising of the safety issues identified in the investigations into the berth strikings of both Coastal Inspiration in December 2011 and Queen of Coquitlam.

In May, B.C. Ferries responded by stating that it had implemented new standard operating procedures for speed reduction. For example, as the vessel proceeds, it must now pass through pre-determined “gates” that will be standardized for each route and will provide safety checks as the vessel approaches the conclusion of the voyage.

By Professional Mariner Staff