TSB notes lack of familiarity of ferry crew with navigation gear

A bridge team member did not know how to properly use a new steering-mode selector switch or the night settings on the electronic chart system’s video display on the 410-foot-long ferry Queen of the North, which sank on March 23 after hitting rocks near Gil Island in British Columbia, resulting in the deaths of two passengers.

Crewmembers had different understandings of how to operate a new steering-mode selector switch installed at the aft steering station in early March, according to Paul van den Berg, a senior investigator/safety analyst at the Transportation Safety Board of Canada, which is investigating the sinking of the passenger-vehicle ferry.

In addition, some bridge team members were turning off the display monitor for the vessel’s electronic chart system (ECS) at night to reduce glare in the wheelhouse, according to a May 11 letter sent by Marcel Ayeko, the acting director of marine investigations for the TSB, to David Hahn, chief executive of BC Ferries. The monitor would be turned on momentarily only when needed. The video display, which had been in use at least since 2005, did have settings for night display, but not all of the bridge team knew about these settings, according to van den Berg.

“Although it is common for crewmembers to be familiarized using on-the-job training, concerning the operation of critical safety equipment, it is essential that crewmembers be thoroughly prepared in advance so they are able to operate the vessel safely from the outset,” Ayeko wrote.

The letter was sent out because of concerns TSB officials had as the investigation got underway. “It is our way of communicating safety deficiencies that are coming out early in our investigation,” said van den Berg, rather than waiting for the final report to address these concerns. “The safety issue for us was that any time there is something new put on a vessel, those who have to operate a piece of equipment should be familiar with it before you use it when you are underway,” he said.
Queen of the North failed to make a normal turn to port into Wright Sound. Instead, the ferry continued straight and struck the rocks on the north side of Gil Island at an estimated speed of 19 knots at about 0020. The ship was equipped with two radars and a GPS system that fed data into one radar and the ECS. A new autopilot system and changes to the aft steering station (the main steering station) were installed during annual maintenance on the vessel. The work was finished in early March, just a few weeks before the accident occurred.

The lack of knowledge of the proper use of the two pieces of bridge equipment was discovered during the TSB’s investigation into the sinking. As of late July, the agency had interviewed most of the crew and passengers.

Van den Berg said he could not comment on any other aspect of the ongoing investigation. “We’re looking at training; we’re looking at a number of areas,” he said.

The steering selector switch is not complicated, according to Capt. George Capacci, vice president of fleet operations for BC Ferries. “I don’t know of a course that tells you to flip from one position of a switch to another position of a switch,” he said. In addition, the vessel’s senior master posted a piece of paper near the main steering station with instructions on how to use the new selector switch. Capacci said the only copy of those instructions went down with the ship.

Even if the ECS video display was turned off at the time of the incident, the bridge team still had a radar unit that was operating properly, Capacci said. “Nobody reported any problems with the electronic equipment,” he said. “The senior master said the ship was in the best shape it has been in the last 15 years he’s sailed on this vessel.”

Capacci also pointed out that the crew sailed the vessel without incident for a week before the sinking. “This crew sailed that ship for over 1,000 miles before that fated night,” he said.

BC Ferries spends $3.5 million Canadian (About $3.1 million U.S.) each year for 75,000 hours of training for its 4,500 employees, he said. The company also adopted the International Safety Management Code, even though Canadian law does not require BC Ferries to do so.

Queen of the North had two steering stations on the bridge: the forward station, near the forward windows of the bridge, and an aft station near the aft bulkhead of the bridge. Before the annual maintenance session, the autopilot could only be used from the forward steering station, according to van den Berg. The preferred practice on this vessel was that hand steering was only done at the aft station, even though there were wheels at both stations.

During the ship’s annual maintenance work, a steering mode selector switch was installed at the aft station, according to van den Berg. For the first time, autopilot could be used at the aft station, he said. The autopilot function was just one setting on the new steering-mode selector, which included a setting for jog steering. Jog steering is a type of joystick that moves the rudder more quickly than the wheel and is used in harbors, Capacci said.

The settings on the aft steering station were autopilot, forward station, main station, starboard wing, port wing and jog.

“Members of the bridge team had different understandings of how the recently installed steering-mode selector switch worked, and what function each setting of the switch performed,” wrote Ayeko in the advisory letter.

For example, if the quartermaster was using the autopilot at the forward station and the officer of the watch wanted to switch to the aft station and hand steering, there was confusion about what setting the aft selector knob should be at to make that switch, according to Ayeko.

When new navigation equipment is introduced, more than one training session is needed, according to Walt Megonigal, director of training at the Maritime Institute of Technology and Graduate Studies in Linthicum Heights, Md. Mariners are first taught the function of the new equipment, “knobs, buttons, dials and gauges training,” he said. Then mariners are taught how to use the new equipment in a maritime environment.

“In all likelihood, if the crew hasn’t worked on something like that before, it will take a repetitive process to learn how to use it,” Megonigal said.

On June 15, a remotely operated submersible operated by the Canadian Scientific Submersible Facility of Sidney, British Columbia, dove nearly 1,400 feet to the wreck and removed the ECS, the AIS unit, the GPS receiver and the digital selective radio. Data from the ECS’s hard drive have been recovered and are being analyzed, according to van den Berg. The submersible also recovered a sheet of paper coated with plastic that had quick tips for the use of the ECS unit, he said.

David Tyler

By Professional Mariner Staff