TSB blames ferry sinking on poor watchkeeping, staffing

Queen of the North sank after failing to make a turn and striking Gil Island on March 22, 2006. The fourth officer and quartermaster were alone on the bridge and were engaged in a personal conversation at the moment when the fourth officer should have ordered the course change. The TSB declined to provide specifics about the conversation.

The 2006 sinking of the ferry Queen of the North happened because not enough qualified officers were on the bridge and the crew didn’t keep watch properly, the Transportation Safety Board of Canada has concluded.

On March 12, the TSB released its long awaited report on the sinking of the BC Ferries vessel in Grenville Channel on March 22, 2006.
“Essentially, the system failed that night in two significant ways,” said board chair Wendy Tadros. “The bridge watch lacked a third certified person, and sound watchkeeping practices that would have kept the vessel on course were not followed.”
As Queen of the North was steaming south in the narrow Grenville Channel, it failed to make the course change, the report said. No one noticed the mistake for 14 minutes, possibly because the bridge officers were distracted.
The vessel passed Sainty Point at 0007 without making the turn and struck Gil Island at 0021:20. It drifted for about one hour and 17 minutes before sinking.
There were 59 passengers and 42 crewmembers on board. After the ship was abandoned and sank, two passengers were unaccounted for. They were subsequently declared dead.
Three crewmembers had been on the bridge shortly before midnight on March 21, but the second officer departed for a scheduled meal break, leaving the fourth officer and the quartermaster on the bridge.
The fourth officer, who was the officer on watch, called Prince Rupert Traffic at 0002:34 on March 22 indicating that he was approaching Sainty Point on the mainland shore. At the time that he should have ordered the course change, he and the quartermaster were engaged in a personal conversation.
The TSB report confirms that the fourth officer and the quartermaster had a personal relationship that had ended two weeks before the accident. When the quartermaster went to the bridge for her turn at the helm, it was the first shift the two had served together alone since the end of their relationship. The board didn’t disclose the nature of their conversation.
“That level of detail really becomes not as important as … what was not going on on the bridge that night, which is to follow sound watchkeeping practices.” said senior marine investigator Capt. Pierre Murray.
BC Ferries disagrees with the TSB’s interpretation of the Canada Shipping Act on the issue of how many officers are required on the bridge.
“Having two people on the bridge was within Canada shipping standards,” Mark Stefanson, vice president of public affairs at BC Ferries, told Professional Mariner.
“The TSB said there were a number of distractions, including the conversion they had, and if there was a third person there, the accident could have been prevented. We don’t disagree with that,” Stefanson said.
Stefanson pointed out that the TSB itself is dissatisfied with ambiguities in the language of the crewing regulations of the Canada Shipping Act, particularly since they were superseded by the Marine Personnel Regulations in 2007.
In a letter to Transport Canada on Feb. 13, Yvette Myers, director of marine investigations at the TSB, wrote:
“The complexity of the minimum deck watch requirements of the Marine Personnel Regulations does not lend them to being readily understood by those who must apply them. Consequently the requirements may be subject to interpretation by vessel owners and operators.”
On the night of the accident, the vessel was encountering a rapidly moving squall, causing reduced visibility. There had also been a change in the steering selector during a recent refit. Not all crewmembers — including the quartermaster — were familiar with the changes in operation.
The report states that the setup of the navigational equipment hampered effective monitoring:
• The brightness on the electronic chart system (ECS) monitor had been turned down such that the display could not be read.
• The ECS cross-track alarm, which would have alerted the crew to any substantial deviation, was turned off.
• The navigation-danger alarm on the ECS, which could have indicated the proximity of Gil Island, was unavailable because a raster chart was loaded.
• Alarms available with other electronic navigational equipment — for example, radars — were not set up or enabled.
The report says basic principles of safe navigation were not observed by the bridge team, including:
• Verifying the course after Sainty Point.
• Reducing speed when the vessel encountered an area of reduced visibility.
• Calling the senior OOW or the master to the bridge when visibility became reduced and a radar target (the vessel Lone Star) was lost.
• Maintaining an effective lookout.
• Posting a dedicated lookout during a time of restricted visibility.
• Communicating with the target vessel.
• Locating and identifying the navigational lights at Point Cumming, Cape Farewell and Sainty Point.
• Monitoring the vessel’s progress visually, via radar and with the ECS.
• Frequent plotting to determine the vessel’s position.
• Maintaining appropriate bridge team composition.
The board recommended that the Canadian Ferry Operators Association, with the Canadian Coast Guard, develop a framework that ferry operators can use to ensure effective passenger accounting for each vessel and route.
Transport Canada has issued three Ship Safety Bulletins on the importance of keeping watertight doors closed. Queen of the North had at least two watertight doors open, in the forward and aft bulkheads of the main engine room.
BC Ferries President and CEO David L. Hahn said the TSB conclusions were consistent with the BC Ferries investigation released in March 2007, but he was disappointed with one aspect of the report.
“It is unfortunate that after two years of investigation, the TSB was unable to determine what occurred on the bridge in the final 14 minutes leading up to the vessel striking Gil Island,” Hahn said.
Since the sinking of Queen of the North, BC Ferries has made a number of changes to its practices including:
• A new bridge resource-management training program for masters and deck officers.
• A new voyage data recorder program, with 17 already installed.
• New sign-off procedures to confirm that navigational watch officers have been fully familiarized with any newly installed or modified bridge equipment before taking over navigational duties.

• A fleet directive requiring watertight doors to always be closed at sea. This has been reinforced by management on ships and by internal inspections.

By Professional Mariner Staff