TSB: Crew’s response not coordinated in passenger overboard incident


When a passenger fell off an excursion ship in Humber Bay near Toronto, Ontario, and drowned on June 13, 2015, the crew’s emergency response was not coordinated, according to Canada’s Transportation Safety Board (TSB).

The 127-foot Northern Spirit I, owned by Spirit Cruise Line Ltd. of Toronto, was on an evening cruise out of the city when an intoxicated passenger started behaving erratically on the bow of the vessel. At about 1930, dspite the security guards’ attempts to intervene, he leaned over the starboard rail and fell overboard.

In its report, the TSB wrote that “the emergency signal to initiate the man-overboard procedures was not sounded so as not to further alarm the passengers. As a result, the crew’s response to the emergency was uncoordinated, and the roles and responsibilities they assumed did not correspond with those detailed in the vessel’s muster list.”

The master was notified by one of the security guards of the man overboard, and the deck hand — who learned of the incident by word of mouth — proceeded aft to prepare the emergency boat for launching. The deck hand designated another crewmember to point at the overboard passenger about 50 meters astern of the vessel but the passenger soon disappeared from view.

The chief officer (CO) was informed of the situation upon overhearing passengers shouting “man overboard.” He was met by a messenger sent from the deck hand positioned at the emergency boat asking for instruction. The CO went aft and advised the deck hand not to launch the boat because Northern Spirit I was still making way. At separate times, the CO and deck hand each went to the bridge to receive instructions from the master.

The emergency boat was eventually launched after the master had turned the vessel around, 45 minutes after the passenger went overboard. The CO and deck hand used the emergency boat to search the water for an hour, but the passenger could not be located. His body was recovered 18 days later.

The position of the emergency boat on the stern of Northern Spirit I.

Courtesy TSB

In its findings as to risk, the TSB wrote that “if intoxicated passengers are not detected by the crew during the pre-boarding process and are served alcohol while on board, there is a risk that they may participate in unsafe activities on the vessel.”

In addition, the TSB found that if the signal to initiate a set of emergency procedures is not given on a vessel in an emergency situation, the emergency response by crewmembers may be less effective. In addition, if the emergency procedures developed by a company in its safety management system or muster list lack key details and do not fully address or account for contingencies, there is a risk that opportunities to recover a person overboard may be missed.

The TSB also found that if crewmembers do not practice drills for emergency procedures, there is a risk that they may not be able to carry out these duties effectively in an emergency situation.

The report stated that the emergency team leaders as identified on the muster list had no portable means of communicating with the master on the bridge, although they could access a telephone unit with a direct link to the bridge at the stern of the vessel. In a statement to Professional Mariner, Mariposa Cruises said with 28 years of safe operation under Transport Canada regulation, it remains committed to the highest safety standards.

“We are carefully reviewing the report so that we can implement any improvements to our overall safety procedures so that this tragedy never reoccurs,” the statement said. “As an organization, we are continually striving for best safety practices, which as noted in the report is why we have a safety management system over and above what is required by regulation. Due to the ongoing litigation with the tragedy, we cannot comment further.”

By Professional Mariner Staff