Informal practices contributed to August 2018 emergency drill accident on the Spirit of Vancouver Island ferry
Richmond, British Columbia, 27 December 2019 – In its investigation report (M18P0257) released today, the Transportation Safety Board of Canada (TSB) determined that a combination of inadequate risk assessment, informal practices, and insufficient supervision led to two crew members falling overboard during an emergency drill on a passenger ferry owned and operated by British Columbia Ferry Services Inc. (BC Ferries).
On 31 August 2018, two crew members from the Spirit of Vancouver Island fell from the vessel’s No. 1 rescue boat into the water below while it was being slewed out during emergency drills at Swartz Bay Ferry Terminal in North Saanich, British Columbia. The crew members were subsequently retrieved from the water and transported to hospital. One crew member was uninjured, and the other was treated for minor injuries. The rescue boat sustained minor damage to its bottom hull.
The investigation determined that the rescue boats onboard the vessel were replaced with a variant that had different physical characteristics from the original, including having a greater overall height. However, the existing davits were not changed. The changes to the system resulted in the brake release line being out of adjustment, and following a previous incident, some of the crew responsible for the launching and retrieval of the boats had developed an informal practice to compensate. Further, in this occurrence, the chief officer’s high workload and simultaneous tasks at multiple locations meant he was not available to supervise the drill at rescue boat station No.1. Although the coxswain of the rescue boat assumed the duties of officer in charge, his ability to supervise was limited as he was actively engaged with his own duties. Without the chief officer or another deck officer present to supervise, the informal practice of compensating for the maladjusted brake release line allowed the line to snag while the rescue boat slewed out from the davits. The snag created tension on the brake line, to the point that the davit arm brake released. The rescue boat dropped suddenly, hit the edge of the deck, and tipped outboard—resulting in both crew members falling into the water.
Safety management and oversight is a Watchlist 2018 issue. Although not required, BC Ferries voluntarily adopted a Safety Management System (SMS) that complies with the International Safety Management Code. As this occurrence demonstrates however, the SMS did not identify hazards related to changing the rescue boat type. If key components of an SMS, such as risk assessments, reporting non-conformities, emergency drill planning, and valid checklists are not put into practice by companies and crews, there is a risk that the safety of passengers and crew will be compromised.
Following the occurrence, BC Ferries made a number of changes to policies and procedures related to rescue boat operations.
See the investigation page for further information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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