News release

Today, the Transportation Safety Board of Canada (TSB) published its investigation report (M22C0231) into a 2022 occurrence in Toronto, Ontario, where the passenger ferry Sam McBride struck the dock at the Jack Layton Ferry Terminal. The investigation found safety deficiencies related to passenger safety management, which led the Board to issue three recommendations to Transport Canada.

On August 20, 2022, the Sam McBride departed Centre Island toward Toronto’s Jack Layton Ferry Terminal with six crew and approximately 910 passengers on board. Earlier that day, the ferry had completed eight crossings, six of which were at full capacity. It was behind schedule, which is not unusual on a busy summer day. Shortly after 5:00 PM local time, the ferry struck the dock while berthing, resulting in approximately 20 passengers standing on or above the stairs being injured, mainly from losing their footing and falling.

The TSB determined that at the time of the occurrence, the vessel approached the dock faster than it had on earlier trips that day; and that only one of the vessel’s two propellers was turning as it approached the dock. Given the vessel’s speed and distance from the dock, one propeller alone was not enough to stop the ferry. Both engines and their control systems were subsequently examined and found to be in good working order, without indication of a malfunction.

The investigation found that the City of Toronto did not have written procedures addressing issues like safe approach speed for docking. Instead, masters were left to operate in the way that they deemed appropriate. Without written procedures that defined safe practices for docking, decisions around travel or docking speed may have been influenced by operational pressures.

Recommendations to Transport Canada

When the TSB investigates an occurrence, it not only looks at the event, but also the circumstances around it. In this occurrence, there were few serious injuries reported and it occurred close to shore. The crew on the Sam McBride were not trained in emergency passenger management because this training was not required. As such, had there been an emergency away from shore, the crew and those on board would not have been prepared to respond quickly and effectively.

Therefore, the Board recommends that

In Canada, all passenger vessels are required to have emergency procedures that dictate how all passengers and crew will evacuate from a vessel within 30 minutes of an abandon ship signal. Despite this being a regulatory requirement, Transport Canada has no formal procedure to assess if the requirement is being met.

The investigation found that the ferry’s evacuation procedures were unrealistic, leaving only six crew members to manage over 900 passengers, while potentially completing multiple competing tasks at once throughout the vessel.  Therefore, the Board recommends that

On voyages of less than 12 hours, there is no requirement to keep a separate count of the children and infants on board. On the Sam McBride, counts were estimated and tracked using a hand-held tally counter; children, infants, and those who may require extra assistance were not counted separately. In the event of an emergency, it would be impossible to account for all passengers on board or ensure that there are an adequate number of appropriately sized life jackets available. Therefore, the Board recommends that

Since the occurrence, the City of Toronto has increased the size of the Sam McBride’s crew to 13. They have also addressed passenger safety issues, including updating the pre-recorded safety briefings, adding additional signage, and warning passengers to not stand on the stairs while the vessel is moving.

See the investigation page for more information.