Language selection

Presentation to Canadian Ferry Operators Association (CFOA) Annual General Meeting

 View document in PDF [1149 KB]

John Clarkson
Member, Transportation Safety Board of Canada
Vancouver, BC, 14 September 2015

Check against delivery.

Slide 1: Title page

Slide 2: Outline

Slide 3: The TSB: Our Mission

To advance transportation safety in the marine, pipeline, rail, and air modes of transportation that are under federal jurisdiction by:

Slide 4: Who we are

The TSB was created by an Act of Parliament (the Canadian Transportation Accident Investigation and Safety Board Act) that came into force on 29 March 1990.

We are:

Slide 5: TSB offices

Head Office is in Gatineau, Quebec. The Engineering Laboratory is in Ottawa, Ontario. Map of TSB offices

Regional offices are located across the country to allow investigators to quickly reach the scene of an accident:

Slide 6: Watchlist 2014

In addition to Recommendations and Safety Concerns, one of the key tools for us to advance safety has been the Watchlist, which identifies those issues posing the greatest risk to Canada's transportation system. We first issued it in 2010, with newer iterations in 2012 and 2014, as progress allowed old issues to be removed and new ones added. This latest edition features some issues that have been expanded, as well as one new issue. There are also outstanding issues, where we have seen little or no progress.

Our goals for the Watchlist are simple:

Slide 7: Passenger vessel safety (removed in 2012)

That TC, CFOA and CCG “develop, through a risk-based approach, a framework that ferry operators can use to develop effective passenger accounting for each vessel and route.” (M08-01)

That TC “establish criteria, including the requirement for realistic exercises, against which operators … can evaluate the preparedness of their crews to effectively manage passengers during an emergency.” (M08-02)

But …

TSB is concerned by the lack of guidance to operators and the effectiveness of TC oversight of the implementation of new regulations TC, TSB currently in dialogue.

The issue of passenger vessel safety—specifically, emergency preparedness aboard ferries–was removed from the TSB's Watchlist in 2012.

In fact, two of the key underlying recommendations have both received our highest rating of “Fully Satisfactory.”

One recommendation deals with the development of a framework that operators can use to develop effective passenger accounting for each vessel/route… and the other deals with the establishment of criteria against which operators can evaluate the preparedness of crews to manage passengers during an emergency.


Both of these are “framework” recommendations, dealing with the development of tools and criteria. And if a tool isn't used effectively, the risk it is supposed to mitigate can remain unchanged. Specifically, we have concerns about the lack of guidance to operators and about the effectiveness of TC oversight of the implementation of new Fire and Boar Drill Regulations.

That's why the TSB continues to engage in dialogue with TC about this issue.

I'd now like to look at several recent occurrences that the TSB has investigated and which involve ferries.

Slide 8: TSB investigation report M12N0017 (Beaumont Hamel)

On 30 May 2012, the passenger ferry Beaumont Hamel experienced an electrical failure resulting in a loss of propulsion and steering while approaching Portugal Cove, Newfoundland and Labrador, and struck the wharf. The vessel sustained damage to the bow visor and caused minor damage to the wharf. One minor injury was reported.

The vessel had a history of electrical failures and, although previous repairs had addressed the mechanical causes, the risks that were identified after each occurrence were ineffectively mitigated.

The TSB's investigation found that the operator had a safety management system in place that was not effective at managing the operational risks posed by these recurring blackouts.

Slide 9: TSB investigation report M12C0058 (Jiimaan)

On 11 October 2012, the roll-on roll-off passenger vessel Jiimaan was travelling from Pelee Island to Kingsville, Ontario, with 18 passengers and 16 crew aboard. The crew had planned to sail parallel to and east of the charted channel leading to Kingsville Harbour to avoid an obstruction in the channel; however, winds pushed the vessel to starboard, and the vessel ran aground 130 metres from the harbour entrance. The next day, the vessel was refloated and escorted to Leamington, where the passengers were disembarked. There were no injuries, no pollution and no damage to the vessel.

The TSB's investigation found that the company's safety management system (SMS) did not include a risk assessment process. As such, the risks associated with deviating from the charted channel to avoid the obstruction were not adequately identified and mitigated.

Slide 10: TSB investigation report M13L0067 (Louis Jolliet)

On 16 May 2013, the passenger vessel Louis Jolliet ran aground off Sainte-Pétronille, Île d'Orléans, Quebec, while on a cruise with 57 passengers on board. The passengers and some crew were evacuated, the vessel sustained minor damage, and was refloated at high tide. There were no injuries or pollution reported.

The TSB's investigation found that, although present on the bridge at the time of the grounding, the master was not participating in or supervising the navigation of the vessel, leaving navigation to the recently-hired chief mate.

The investigation also determined that key crew members were not familiar with their emergency duties, and that the emergency procedures in place for the vessel had shortcomings with respect to passenger safety management—nor had crew members practiced such procedures in a realistic way.

Slide 11: TSB investigation report M13M0287 (Princess of Acadia)

On 07 November 2013, the roll-on roll-off passenger vessel Princess of Acadia was approaching the ferry terminal at Digby, Nova Scotia, with 87 passengers and crew aboard when the main generator blacked out. This caused a loss of electrical power and disabled the main propeller pitch control pumps. The propeller thrust then defaulted toward full astern while the engines were still running, causing the vessel to slow down, stop, and travel backward toward the shoreline until running aground.

Although there were no injuries or pollution reported, the TSB's investigation revealed maintenance deficiencies and a lack of adequate emergency procedures.

Slide 12: Common issues in ferry investigations

Every accident is a unique result of its specific causes and contributing factors. However, these four recent investigations have several issues in common.

Emergency preparedness

Safety management systems

Safety management is an ongoing process that involves identifying hazards, assessing risks, and putting measures in place to maintain risk at the lowest practicable level.

If you have an SMS, it needs to be effective. In other words, does it do what it's supposed to do? Does it measure risk? How do you know?

Bridge/Engine room communication

Is everyone on the same page at the same time?


Was the oversight—by either Transport Canada or the Responsible Organization (RO)—effective?

Now I'd like to look at one of these issues specifically, as it's on our Watchlist: safety management and oversight.

Slide 13: Safety Management and Oversight

“Some transportation companies are not effectively managing their safety risks, and TC oversight and intervention has not always proven effective at changing companies’ unsafe operating practices.” — TSB Watchlist 2014

And so… What to do about it?

The TSB has repeatedly emphasized the advantages of Safety Management Systems (SMS) as a framework within which a transportation company may manage safety risks in its operations, such as the risk to passengers' safety in an emergency.

Of the investigations previously described, the operating company of the Louis Jolliet was not required by TC to implement an SMS and nor had they done so. Although the operators of the Jiimaan and the Princess of Acadia had implemented SMS on a voluntary basis, third-party audits and inspections were ineffective at ensuring that fundamental safety procedures, such as those pertaining to passenger safety, had been effectively implemented. And in the case of the Beaumont Hamel, although the Department of Transportation and Works of Newfoundland and Labrador (DTW) had a safety management system in place, the system was not effective at mitigating the operational risks posed by the recurring blackouts.

The findings of these investigations are indicative of the key factors in moving forward on the issue of safety management and oversight as identified in the TSB's 2014 Watchlist: a clear regulatory framework requiring companies to implement some form of safety management processes that are effective in identifying hazards and mitigating risks; and balanced regulatory oversight.

So the question is: what to do about it?

Slide 14: SMS and oversight: what's needed?

Strong initiatives are required to address the issue of risk awareness and risk mitigation—both of which can be addressed through a formal, systematic approach to safety. TC, vessel operators, and marine management companies must work together to ensure that operating risks are identified and reduced to a minimum through the introduction of effective SMS. In particular:

Slide 15: Dealing with oversight—practically speaking

With respect to TC, two problems have been observed: a failure to identify companies' ineffective processes, and an imbalance between auditing processes versus traditional inspections.

For example, if TC inspectors do not assess muster lists and evacuation plans for compliance and adequacy—and if TC does not provide interpretive guidelines—then compliance with passenger safety regulations may be inadequate, thereby negating the potential safety benefits of such regulations.

TC is currently undertaking a Concentrated Inspection Campaign (CIC) to address specific areas where high levels of deficiencies have been encountered by inspectors.  This may also be based on incidents that have occurred on specific vessel types where TC feels further attention is required.

In addition, TC is improving the oversight processes that will further mitigate the risks associated with passenger ship safety, and also issued a FLAGSTAENET to inspectors reminding them of the Fire and Boat Drill Regulations with subsequent oversight.

For Responsible Organizations (ROs), such as Lloyd's Register, ABS, etc., the issues are more along the lines of crew proficiency—particularly with respect to emergencies—and also the issuance of safety management documentation.

After an incident, the effectiveness of a formal SMS should be reviewed, so that appropriate recommendations and changes are then made to correct any deficiencies.

Slide 16: Conclusions

The Watchlist is an evolving document, changing as progress is—or is not—made. Although the issue of emergency preparedness aboard ferries was removed as an issue in 2012, it could return, depending on what we find in our investigations. Certainly it has appeared as an issue in a number of recent investigations, and the TSB is in ongoing discussions with Transport Canada.

Meanwhile, it's critical that operators do their best to manage safety—and SMS is a proven tool to do exactly that. A good SMS is more than a paper exercise, more than a binder on a shelf somewhere. It's an ongoing process, a constant assessment of risks, and then taking steps to mitigate them. And above all, it's about being proactive.

Finally, as recent investigations indicate, it's vital that members of the bridge team focus on communication: making sure they're all on the same page at the same time.

Slide 17: Questions?

Slide 18: Canada wordmark