Inadequate bridge resource management led to a 2017 striking occurrence at the Seaspan Ferries terminal, British Columbia
Richmond, British Columbia, 17 January 2019 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M17P0400) into a November 2017 occurrence during which the ferry Seaspan Swift struck berth No. 2 at the Seaspan Ferries terminal located on Tilbury Island, British Columbia. The report identifies inadequate bridge resource management as a contributing factor to this occurrence.
In the early afternoon of 15 November 2017, the roll-on/roll-off ferry Seaspan Swift, with 10 crew members on board, departed the Swartz Bay terminal in Victoria, BC, for the Tilbury terminal, near Delta, BC. Prior to departure, after a brief handover, the relief master took over the command from the regular master. Upon approaching berth No. 2, the relief master attempted to slow the vessel's forward speed. Instead, the vessel's speed increased. Although he attempted a crash stop manoeuvre, the vessel struck the berth, injuring two crew members and damaging the vessel's bow and the berth's ramp. No pollution was reported.
The investigation found that inadequate bridge resource management reduced the crew's ability to help identify issues during the approach for docking. The crew began completing the pre-arrival checklist but stopped at the step requiring the relief master to switch the manual steering control from the steering wheel to the pod handles (pod handles are used for manoeuvring in restricted waters and docking). As a result, the relief master was not reminded to switch over the steering control. When he turned the pod handle, the pod did not respond and remained thrusting in the ahead position. Realizing that the vessel's steering control was still set to the wheel, he quickly switched the steering control over to the pod handles and attempted a crash stop. As there was not enough time left, the vessel struck the berth at about 4.1 knots.
Moreover, one of the crew members was not required to obtain, and did not have, training in bridge resource management. If bridge members are not all required to take bridge resource management training and if they don't apply its key principles, they may not communicate and work effectively as a team, which increases the risk of accidents. In 1995, the Board issued two recommendations (M95-09 and M95-10) regarding bridge resource management training, both of which are still active.
The investigation also found that before arrival, a control console switch was inadvertently activated, causing a temporary power outage and confusion on the bridge. If bridge switches are not designed optimally, there is a risk of accidental activation, which could contribute to an accident.
Following the occurrence, Seaspan Ferries Corporation introduced pre-arrival checklists for each of its terminals with explicit steering control instructions. It also made ergonomic improvements, including new visual and audible cues for the steering control system and thrust direction indicator.
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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