The operator of British Columbia’s provincial ferries has agreed to add warning alarms and use stronger mooring systems after one of its vessels pulled away from a dock while vehicles were being loaded.
A pickup truck plunged into the water after MV Quinsam unexpectedly moved away from the ramp in the Jan. 9 incident at Nanaimo Harbor. A deck hand was able to warn the pickup’s driver to exit the vehicle and jump to safety in the nick of time.
No one was injured, and no other vehicles were lost.
An inquiry by the operator, BC Ferries, concluded that human error on the bridge — possibly due to distraction by telephone chatter — likely caused the premature movement away from the dock. Verbal and visual check procedures may not have been followed, the report said.
Earlier, Canada’s Transportation Safety Board said the accident happened because at least two of the ferry’s four right-angle drive (RAD) units weren’t thrusting in the proper direction.
“It was a malfunction in the steering system,” said Raymond Mathew, a TSB senior marine investigator. “The master was in the wheelhouse. He took steps to hold the vessel into the dock, but it happened very fast.”
The incident at 1900 involved the 25-year-old roll-on/roll-off Quinsam, which is 284 feet long and accommodates as many as 407 passengers and crew and 70 autos. The ferry was working the 20-minute route between Nanaimo Harbor and Gabriola Island, along the coast of Vancouver Island in the Strait of Georgia.
Mathew said the deck crew and pickup driver had only about 15 seconds to recognize that the boat was moving and to jump to safety. The ferry’s trestle separated from the shore-mounted articulated ramp, which became unsupported and fell as much as 40° below horizontal.
The ferry was taken out of service for only a day or two. Technicians from BC Ferries and right-angle drive manufacturer Medtronics Technology — with Transport Canada officials observing — tested the propulsion systems for mechanical problems. They found nothing wrong.
Quinsam has four azimuthing right-angle drive units — one at each corner of the hull. The equipment was new in 2002. The ferry, including all four drive units, had passed a government inspection just four hours before the accident.
The TSB concluded that the two stern thrusters probably had reacted to an electronic malfunction in the steering control system or “the inadvertent rotation of the RAD control stick,” according to the agency’s Jan. 16 Marine Safety Advisory to BC Ferries.
In 2002, a similar incident on another BC Ferries vessel, at Gabriola Island, was attributed to defective printed circuit boards in the automatic control systems.
“The two right-angle drive units rotated away from their normal â€˜pushing in’ position,” the TSB’s advisory said of the recent Quinsam accident. “This resulted in the ferry breaking one of its mooring chains and rapidly backing away from the berth.”
Mathew said Quinsam‘s chief officer was at the controls at the time of the incident. Although the master was on break, he was in the wheelhouse too. They learned of the sudden movement out of berth when a deck hand saw the problem and announced it on a microphone.
The inquiry, in which the Marine Workers Union participated, said a mechanical or electric malfunction is highly unlikely. Each unit is controlled separately, so two RAD units making the same mistake is probably human error. The report suggested two possible scenarios.
One possibility is that the two aft RADs were not rotated to push into the dock after arrival at Nanaimo Harbor. The master had taken a phone call at the time, and the mate at the controls may have been distracted by the phone conversation. Procedures perhaps were not followed to ensure verbal or visual confirmations that all four RADs were pushing into the dock, the Jan. 26 report said.
The other hypothesis suggests that the master or mate initiated a “hot transfer” to switch control from the inshore console to the offshore console in anticipation of departure “at a time when the combinator handles on the offshore console were set to departure positions,” the report said.
BC Ferries specified several remedies, including tighter departure safety procedures, crew training and better nighttime illumination of the combinator handles.
Mathew said warning alarms would be helpful, because it is not practical for the officers on the bridge to devote constant, undivided attention to the steering system and joystick.
“They have eight- to 10-hour shifts, and it’s physically impossible to keep your eyes stuck on that,” he said. “In 15 seconds, you could be writing something in the log book or answering a call on the radio.”
The TSB’s advisory urged BC Ferries to install an alarm system that provides an early warning to the bridge that the steering system is acting contrary to joystick position. The investigators noted that BC Ferries operates several other vessels fitted with similar RAD systems, which have a documented history of erratic behavior.
“Though not mandatory, alarm systems providing audio-visual indications of the operational direction of the propulsion system are advantageous since they can provide timely warning of positional RAD errors and can also be used as a diagnostic tool to isolate incidents involving component failure,” the TSB wrote.
The Victoria-based ferry operator agreed.
“BC Ferries supports Transportation Safety Board’s view regarding audio-visual alarms and has already made a commitment to install such devices on the nine vessels in the fleet equipped with RAD units,” BC Ferries President and Chief Executive David Hahn said Jan. 16.
The TSB investigators also deemed Quinsam‘s mooring lines to be insufficient. The engines powering the 1,458-gross-ton ferry generate a total of 2,080 horsepower. The starboard chain parted in the incident.
“Based on a visual examination of the wires, chains and securing arrangements used for mooring Quinsam at the time of the accident, it does not appear that they were sufficiently robust to hold the vessel in dock, in the event of an inadvertent backing away of the vessel,” the TSB advisory said.
The agency noted that other BC Ferries vessels use mooring systems similar to those used on Quinsam‘s route between Gabriola Island and Nanaimo Harbor. The investigators said stronger systems are necessary. The advisory did not specify the equipment in place at the time of the accident. Nor did it suggest a specific solution.
In a statement, BC Ferries agreed that “a more robust mooring arrangement would help ensure overall safety and, immediately after the MV Quinsam incident, a review of its tie-up procedures and arrangements was initiated throughout the fleet.”
An internal inquiry recommended that “all terminal securing arrangements for vessels should be reviewed to ensure that the terminal and vessel arrangement is suitable and adequate for holding a vessel in position during propulsion failure, taking into account the reflex action of the wing-walls.”
The Quinsam accident damaged the terminal apron hoist unit. That unit and the parted tie-up cable were promptly replaced. •