Communiqués

TSB # M 05/2001

(Port Elgin, Ontario, 11 May 2001) - When the "TRUE NORTH II" left Flowerpot Island, bound for Tobermory Harbour, on the morning of June 16, 2000, a combination of rough weather and pre-existing safety deficiencies contributed to its fate. The vessel foundered and sank in high waves, and tragically took the lives of two school children. Eighteen others, including 11 of their school companions, made it to shore.

In its investigation into this fatal accident the Transportation Safety Board of Canada (TSB) found that modifications to this vessel had compromised its watertight integrity, life-saving equipment was not readily available, and there was only one crew member when two were required. Over the years, none of these and other deficiencies were noted in regulatory inspections.

"The sinking of the 'TRUE NORTH II' was one of those situations where many things were wrong. No one thing alone would have caused the accident, but all of them together created a disaster. Small factors, which in and of themselves would appear insignificant, combined to produce fatal results," said Benoît Bouchard, the Chairman of the TSB, today in Port Elgin, Ontario. He was speaking as the TSB released the report of its investigation into the sinking of the "TRUE NORTH II".

Mr. Bouchard went on to state, "For every passenger vessel that crosses Georgian Bay, for every whale-watching vessel on the west coast and deep-sea fishing charter on the Atlantic coast, we need a safety culture that says: This boat is safe for passengers and crew. It should not take an accident like this for us to think about safety. And therefore, we must learn from it, in the hope that such a thing will never happen again. It is what the families would want. It is what all Canadians expect."

The Board has made three recommendations that it believes will foster this safety culture.

First, the Board calls on the regulator, the Department of Transport, to expedite its review of the deficiencies in the inspection and certification process. And the TSB recommends that the regulator publish progress reports to let Canadians know how the problems are being corrected.

Second, the Board recommends that Transport Canada's Marine Safety branch develop within its organization an approach to safety that would enable managers and safety inspectors to identify and address all unsafe practices and conditions and not limit inspection only to compliance with the rules.

The Board believes there is an intent behind those rules, and that intent is to keep crew members and passengers safe, by recognizing and addressing unsafe practices and conditions not necessarily proscribed by regulations.

And third, the Board recommends that Transport Canada require small passenger vessel operators to take a number of specific actions to improve safety. These include briefing travellers before departure about safety equipment and emergency procedures. The vessels should also be equipped with a readily deployable liferaft, easily accessible life-saving equipment and a mechanism to immediately alert others of an emergency situation.

In addition, the Board is concerned that in some cases boat operators may not be adequately trained and the certification system may not catch these shortcomings.

Transport Canada, which regulates marine and other modes of transportation, is working on a number of measures in the wake of this accident. For instance, Transport Canada has announced that it intends to require small vessels to carry liferafts that float free if the vessel sinks. It is also developing a series of initiatives to improve the hiring, training and monitoring of inspectors. And it has pledged to review the quality of selected inspection reports on passenger vessels.

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.

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BACKGROUNDER

(11 May 2001) - On 16 June 2000, while returning to Tobermory, Ontario, from Flowerpot Island, Georgian Bay, Ontario, in moderate sea and weather conditions, [rough weather for a vessel of this size] the small passenger vessel "TRUE NORTH II" was swamped by a series of waves which smashed in the vessel's bridge front door, flooded the main deck and downflooded into the hull. The vessel sank rapidly in 15 metres of water approximately 200 metres off Flowerpot Island at about 1030 local time. Of the 20 people on board, 18 drifted ashore on two buoyant apparatus. Two grade-seven school children drowned.

Vessels such as "TRUE NORTH II" are required to be inspected annually to ensure that the structural condition of the hull, the condition of the machinery, electrical, life-saving, navigation and communication equipment are fit for safe operation. The inspection also includes a process to make sure that not only the vessel and its equipment are fit but that crews are competent to safely operate their vessels.

Adequacy of TCMS Inspection Regime and Safety Culture

The operators of passenger vessels such as "TRUE NORTH II", small vessels and small fishing vessels alike, may not always have comprehensive knowledge of safe operating practices and the safety requirements of their vessels. As such, the safety of passengers can become dependent upon safety inspections as a means of ensuring that the condition of these vessels is safe for the intended operation, that adequate safety equipment is carried and that all safety requirements are met.

This investigation has found procedural, performance and management deficiencies associated with the safety inspection regime of the safety inspection program. These deficiencies included the following:

• The inspections did not identify modifications that negatively affected the watertight integrity and overall safety of the vessel;
• Transport Canada (TC) Board of Steamship Inspection (Meeting 3470) placed a voyage limitation and listed crewing and life-saving requirements for the vessel. These requirements were never transmitted to the vessel's owner;
• The existing Transport Canada Marine Safety (TCMS) inspection regime did not ensure that the TC Board of Steamship Inspection decisions were implemented or monitored;
• The inspections did not identify that the lifejackets and the liferaft were not readily accessible in the event of an emergency;
• The safety implications of the above shortcomings were not recognized by the inspectors and the annual inspection certificate (SIC 16) was routinely issued;
• There was no quality control or audit function that might have identified performance deficiencies and non-conformities to alert management to the need for corrective action.

The deficiencies in the TCMS ship inspection regime, found in this investigation, are not limited to this vessel, or this region. Since 1990 the TSB has conducted several investigations into marine accidents in which deficiencies related to the ship inspection regime have been noted.

Modifications to the "TRUE NORTH II", such as the addition of equipment, the welding-shut of freeing ports and the non-watertight integrity of the deck, went unnoticed and therefore were unaccounted for by inspectors during their routine inspections.

As a result of this accident, TCMS, Ontario Region, is conducting its own review of the inspection and certification process in regard to the "TRUE NORTH II" and similar vessels. The Board understands that the review and audit will not be restricted to this vessel or this region alone and will extend throughout the TCMS organization. The Board is encouraged and hopes that this will lead to the timely identification of safety deficiencies and to effective risk mitigation. The Board also notes that although some actions recommended by this review may have been completed, many issues have not yet been addressed and several are currently in the planning stage. In view of the fact that quality safety inspections and timely identification of unsafe practices and conditions are critical to the safety of crews and passengers, particularly those carried on small vessels, the Board recommends that:

• The Department of Transport establish a timetable to expedite the review of the deficiencies in the inspection and certification process, and that it make interim progress reports to the public demonstrating the extent to which these deficiencies have been resolved. [M01-01]

The Board believes that for the TCMS ship inspection regime to achieve its safety objectives, current systemic deficiencies need to be addressed in a broader context. TCMS bases its safety philosophy on a foundation of compliance with rules. At the same time, however, extensive grandfathering of vessels takes place, and this permits vessels that have actual or potential safety deficiencies to operate outside appropriate rules. While the Board believes that compliance with rules is necessary, rule compliance alone is not sufficient. Such an approach can produce too narrow a focus where safety inspectors do not address those safety deficiencies not covered by regulations and, as a consequence, the deficiencies are routinely not corrected.

The most rigorous set of rules will not cover every aspect of a safety system. The interpretation and judgement of safety inspectors is necessary to identify unsafe conditions both inside and outside the regulatory framework. The Board believes that, with appropriate management support and guidance, TCMS ship inspectors are capable of recognizing and addressing unsafe practices and conditions not proscribed by regulations. Therefore the Board recommends that:

• The Department of Transport, Marine Safety, instill within its organization an approach to safety that would enable management and safety inspectors to identify and address all unsafe practices and conditions and not limit inspection only to compliance with rules. [M01-02]

Emergency Preparedness and Survivability

In rapidly developing distress situations, such as those encountered by the "TRUE NORTH II", it is critical that life-saving equipment be readily available and accessible for use by crews and passengers.

Previous accidents have convinced the Board that pre-departure safety instructions can increase the chances for survival in an emergency situation. Since there was no life-saving equipment plan or pre-departure safety briefing, the passengers were unprepared for an emergency and did not know the location of the lifejackets or the other emergency equipment and life-saving appliances. The use of this equipment was not demonstrated before departure; such a demonstration is not a common practice among small passenger vessel operations.

It has also been learned that the ready availability of life-saving equipment is crucial to its deployment and use in an emergency situation. Although lifejackets were carried aboard the vessel, they were stowed in such a way that they were not readily available. Two lifebuoys were also carried in such a way that they were not readily available to the passengers in distress. All this life-saving equipment was intended to be used by passengers in an emergency situation, but it was not used. The inflatable liferaft on "TRUE NORTH II" was not fitted with a hydrostatic release unit, nor was it able to float free; it required human intervention to deploy. In addition, it was secured on top of the superstructure, to which there was no means of easy access. Consequently, it sank with the vessel.

After the accident, the TSB conducted an impromptu survey of 25 vessels in the Toronto and Tobermory areas to examine the securing arrangements of liferafts and buoyant apparatus. The survey found that many liferafts on board passenger vessels were installed and secured in such a way that they would not deploy as intended and thus would likely not be of assistance in a distress situation. Subsequently, the TSB apprised TCMS of these unsafe conditions (Marine Safety Advisory letter, MSA 09/00).

It is essential that shore-based facilities be able to respond to emergency situations without delay. The speed at which the "TRUE NORTH II" sank precluded a Mayday transmission. The rescue effort began once search and rescue authorities were informed of the accident by a vessel which happened to pass by and noticed the people in the water.

There are a number of means, available on the market, of alerting others of an emergency situation, other than calling on a marine VHF radiotelephone. These include emergency position-indicating radio beacons (EPIRBs) and search and rescue transponders (SARTs). While EPIRBs and SARTs are required to be carried on vessels, they are not required on small vessels such as the "TRUE NORTH II" in her area of operation.

Despite identification of these safety deficiencies, the Board's recommendations and Transport Canada's subsequent action taken, the Board's investigations continue to demonstrate that these safety deficiencies remain unresolved. The Board therefore recommends that:

• The Department of Transport require small passenger vessels to provide pre-departure briefings, and to be equipped with a liferaft that is readily deployable, life-saving equipment that is easily accessible, and the means to immediately alert others of an emergency situation. [M01-03]

Safety Concern

The assessment of the competence of the operator of the "TRUE NORTH II" was based on his possession of an existing certificate and on his experience working in the Tobermory area for a long time. However, throughout this time he had operated his vessel with a number of unrecognized unsafe conditions and practices that compromised safety.

The investigation found that the following unsafe conditions and practices had become the norm over a period of several years:

• the lifebuoys and the liferaft were stowed or fitted in a manner that made them not readily available for deployment, and they sank with the vessel;
• the lifejackets were wrapped in plastic bags and were stowed in a compartment that was neither easily accessible nor readily identifiable;
• two freeing ports had been welded shut, which prevented water shipped on deck from draining overboard;
• the vessel was operated without a means of closing the openings in the main deck;
• the vessel was operated with insufficient freeing-port area, such that water shipped on deck was entrapped, to the detriment of vessel stability; and
• a ventilation opening in the engine-room casing compromised the watertight integrity of the hull.

Individually, these deficiencies might not have resulted in the sinking of the vessel and the loss of life, but together they did. For an operator to take the measures necessary to minimize risk, the operator must be aware of safety deficiencies. This awareness depends on an operator having sufficient knowledge to understand how the deficiencies present a risk to safety.

In the past decade, the TSB has identified deficiencies in training, knowledge and certification requirements for operators in several of its investigations into accidents involving small passenger vessels, work boats, and small fishing vessels.

Previous findings and recommendations by the TSB have underlined the critical importance of the knowledge, skill, and competency of masters and officers to the safety of persons on board. TCMS's initial certification and renewal process is to confirm that operators possess and continue to possess the knowledge and competence necessary for the safe operation of the vessel and for the safety of the people it carries.

The Board is concerned that any shortcoming in the evaluation and certification process may result in allowing operators with inadequate competency to maintain and operate vessels, thereby inadvertently placing crews and passengers at undue risk in emergency situations. The Board will be monitoring the situation to determine if appropriate remedial action is being taken and will assess the need for further action on this issue.