Marine transportation safety recommendation M08-01
Reassessment of the responses to
marine transportation safety recommendation M08-01
Accounting for passengers
At 2000 on 21 March 2006, the passenger and vehicle ferry Queen of the North departed Prince Rupert, British Columbia, for Port Hardy, British Columbia. On board were 59 passengers and 42 crew members. After entering Wright Sound from Grenville Channel, the vessel struck the northeast side of Gil Island at approximately 0021 on March 22. The vessel sustained extensive damage to its hull, lost its propulsion, and drifted for about 1 hour and 17 minutes before it sank in 430 m of water. Passengers and crew abandoned the vessel before it sank. Two passengers were unaccounted for after the abandonment and have since been declared dead.
The Board concluded its investigation and released report M06W0052 on 12 March 2008.
Board Recommendation M08-01 (12 March 2008)
The TSB recognizes the safety value of TC's and BC Ferries' actions to enhance the information collected and recorded for the purpose of accounting for passengers. Further, the scope of the action is limited to collecting and documenting passenger information and does not extend to the other critical aspects of accounting for passengers-counting and locating passengers aboard the vessel, and subsequently carrying out SAR operations. Although the Canadian Coast Guard has developed draft procedures and tools for accounting for rescued passengers, these have not yet been implemented. Other aspects of accounting for passengers, such as the means to efficiently and accurately perform counts of large numbers of passengers before abandonment, have not been identified. It is important that an integrated set of tools and procedures be developed to support the accounting for passengers by all groups involved in the management of their safety, from embarkation to arrival and throughout all activities undertaken during an emergency.
The Board believes that a tailored approach is required, not just for each operator or route but for each individual vessel-one that addresses both the potential risks of a particular voyage and the most appropriate means of addressing them. The Board, therefore, recommended that:
The Department of Transport, in conjunction with the Canadian Ferry Operators Association and the Canadian Coast Guard, develop, through a risk-based approach, a framework that ferry operators can use to develop effective passenger accounting for each vessel and route.
Transportation Safety Recommendation M08-01
In its letter of 03 June 2008 Transport Canada (TC) indicated agreement with the intent of the recommendation.
The response referred to the regulatory requirements, under the Canada Shipping Act, 2001, stating that no master or owner of a passenger vessel shall operate a vessel with a number of passengers in excess of the number indicated on the inspection certificate. The response also made reference to the Ship Safety Bulletin, issued in August 2007 (SSB 06/2007), advising passenger vessel owners and masters of the international requirements being adopted by Canadian vessels. The intent of this SSB is for owners and masters to have readily available information on all persons on board that will be of assistance during emergency situations and search and rescue missions. The SSB outlines the need for all persons on board to be counted and recorded prior to departure, special needs of passengers to be declared, and the information communicated to the master.
The response also indicated that TC intends to adopt Regulation 27 of Chapter III of the SOLAS Convention in regard to information on passengers as part of Regulatory Reform. This regulatory requirement will be incorporated into the regulation as part of the Canada Shipping Act, 2001 Regulatory Reform project.
At a follow-up meeting with TC officials on 03 July 2008, TC indicated that its officials met with the members of the Canadian Ferry Operator Association (CFOA), during the National CMAC meeting in May 2008, and discussions were held in relation to recommendation M08-01. TC stated the need to work together to prepare passenger manifest requirements and also discussed the development of realistic exercises. TC indicates that further meetings will be scheduled this fall to discuss these initiatives.
Subsequent to the follow-up meeting, TC provided information on an initiative titled "Casualty Tracking System for Multiple Casualty Incidents" (CASTRACK). This initiative, taken by the Canadian Coast Guard (CCG) Pacific Region in July 2007, will develop a system to track and account for all casualties involved in a major marine incident. While this two-year project is focused on a CCG application pertaining to large passenger vessels, the intent is to have the system used by other potential response agencies.
Furthermore, during another meeting on 13 November 2008, TC provided a draft and discussion paper of the new proposed Fire and Boat Drill Regulations. The discussion paper and proposed regulations had been presented at the Canadian Marine Advisory Council (CMAC) the previous week. These new regulations are based, amongst other things, on comments and suggestions received since the release of the Joint Ship and Shore Fire Drills Policy and the national CMAC meeting of April 28 to May 1, 2008. In drafting the new regulations, the safety recommendations that were received from the TSB following the "Queen of the North" accident were taken into account.
The discussion paper included the following notes for proposed changes:
- include the addition of requirements to record passenger details in order to have this information readily available for search and rescue teams. This includes a requirement for the master of a vessel carrying passengers, before the vessel embarks on a voyage, to:
- Record the number of persons on board and the details of all persons who have declared a need for special care or assistance in an emergency.
- Record the names and genders of all persons on board in a way that distinguishes between adults, children, and infants for the following voyages:
- unlimited voyages or near coastal voyages, Class 1;
- voyages longer than 12 hours; and
- overnight voyages or voyages on which there is at least one assigned berth.
- Ensure that the information recorded is kept on shore in a manner that is readily available to search and rescue services and is updated if passengers embark or disembark during the voyage.
- for vessels that carry passengers, the muster list must include a description of the duties assigned to crew members that includes locating and rescuing passengers who are trapped in their staterooms or who are "otherwise unaccounted for" during an emergency. The obligation of searching for passengers who are "otherwise unaccounted for" will also be added to the requirements for practice musters, fire drills, and survival craft drills.
The intention is that the new regulations will be published in Part I of the Canada Gazette in the spring of 2009.
Board Assessment of Response to M08-01 (13 January 2009)
The response made reference to SSB 06/2007, which advises owners and masters of passenger vessels of Transport Canada's intent to adopt passenger count requirements, and encourages owners and masters of passenger vessels to adopt this measure voluntarily. SSB 06/2007 is not a mandatory standard and so far only recommends voluntary implementation.
However, with the proposed Fire and Boat Drill Regulations it will become mandatory for passenger vessels to record the number of persons on board and the details respecting all persons who have declared a need for special care or assistance in an emergency. Furthermore the names and genders of all persons on board the vessel are recorded for: unlimited voyages or near coastal voyage, Class 1; a voyage longer than 12 hours; or an overnight voyage on which there is at least one assigned berth. This tailored approach to the various voyage types in Canadian water reduces the residual risk relating to accounting for passengers in case of an emergency. The proposed regulations will cover all passenger vessels except those of 15 gross tonnage or less that carry 12 or fewer passengers and cable ferries.
In the report the Board stated that the scope to date had been limited to collecting and documenting passenger information and as such did not extend to the other critical aspect of passenger accounting such as counting and locating passengers aboard the vessel.
The proposed Fire and Boat Drill Regulations will expand this scope and will include critical aspects of passenger accounting. The proposed regulations will go beyond current practices in that:
- the muster list shall contain information, amongst other things, specific duties assigned to crew member(s) in regards to mustering of passengers.
- in addition the muster list shall contain information in regards to description of duties assigned to crew members to carry out in relation to passengers during an emergency including:
- warning the passengers of the emergency,
- ensuring that the passengers are suitably dressed for protection against exposure and have put on their lifejackets correctly,
- assembling the passengers at their designated muster stations,
- locating and rescuing passengers who are trapped in their staterooms or who are otherwise unaccounted for during an emergency,
- keeping order in the passageways and on the stairways and generally controlling the movements of passengers
- the master of a vessel that carries passengers shall ensure that procedures are in place for locating and rescuing passengers who are trapped in their staterooms or who are otherwise unaccounted for during an emergency.
If the current proposed Fire and Boat Drill Regulations are implemented in full, the risks to fare-paying passengers will be significantly reduced, as such the response is considered to be Satisfactory Intent.
Next TSB Action (13 January 2009)
The Board will monitor the progress of the implementation of the proposed regulations and will reassess the deficiency on an annual basis or when otherwise warranted.
Response to M08-01 (March 2010)
TC's update, dated March 2010, indicated that the proposed Fire and Boat Drills Regulations will require vessel owners and operators to:
- have procedures respecting the preparedness of the crew to respond to emergencies on board vessels and to strengthen the ability to ensure safety of passengers;
- require masters of all passenger vessels to account for the number of all passengers on board, maintain details of those who have declared a need for special care or assistance in an emergency, and any additional personal details on specific voyages;
- require masters to prepare procedures to be able to locate and rescue passengers who are unaccounted for during an emergency, and to practice these procedures during emergency drills.
The proposed Fire and Boat Drills Regulations were pre-published in Part I of the Canada Gazette on October 10, 2009, and are anticipated to receive final approval and be published in Canada Gazette, Part II, in the second quarter of 2010.
In regards to a risk-based approach, passenger-carrying vessels, through an on-going initiative, are being encouraged to adopt a safety management system. This system will aid passenger-carrying vessels to meet the intent of subsection 106(1) of the Canada Shipping Act, 2001, which is to develop procedures and instructions for the safe operation of vessels and responding to emergencies.
Board Assessment of Response to M08-01 (28 July 2010)
The new Fire and Boat Drills Regulations, which apply to passenger vessels of more than 15 gross tonnage that carry more than 12 passengers, were published in the Canada Gazette, Part II, on May 12, 2010, and are now in effect. The regulations require the master of a vessel that carries passengers to ensure that the number of persons onboard and the details of persons who have declared a need for assistance in an emergency are recorded. On certain voyages, and on voyages where there is at least one assigned berth, the master must also ensure that the name and gender of each person on board is recorded in a way that distinguishes between adults, children and infants, and that this information is kept on shore and readily available to search and rescue services.
With respect to improving operational preparedness of crews, the new regulations require the master of a vessel to evaluate the entire crew during each drill to ensure they are competent and ready to perform the required emergency procedures. It is now required that the muster list duties include locating and rescuing passengers who are trapped in their cabins or are otherwise unaccounted for, and controlling the movements of passengers to their muster stations. The regulations also require the posting of illustrations and instructions for passengers to ensure that passengers are aware of the emergency alarm signals.
The action taken will substantially reduce the risks associated inadequate passenger accounting. Therefore, the assessment of the response is considered Fully Satisfactory.
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