MARINE Reports - 2005 - M05W0111

Table of Contents

1. 1.0 Factual Information
   1. 1.1 Particulars of the Vessel
   2. 1.1.1 Description of the Vessel
   3. 1.1.2 Engine Room and Wheelhouse Manoeuvring Stations
   4. 1.1.3 Two Modes of Propulsion
   5. 1.1.4 Mode Selection Switches on the Control Consoles
   6. 1.1.5 Description of a Typical Berthing and Unberthing Manoeuvre
   7. 1.2 History of the Voyage
   8. 1.3 Damage
   9. 1.4 Speed Regulation of the Main Engines
   10. 1.4.1 Post-Accident Faults Found on Main Engine Fuel and Governor Linkages
   11. 1.4.2 Description of Linkages on Main Engine and Governors of Other Vessels
   12. 1.5 Protection Devices on the Main Engines
   13. 1.6 Mid-Life Upgrade
   14. 1.6.1 Work Generation, Tracking, and Control
   15. 1.6.2 Crewing and Watchkeeping
   16. 1.6.3 Procedure for Repairing the Governors
   17. 1.7 Description of Post-Repair Sea Trials
   18. 1.8 Safety Management System and Fleet Regulations
   19. 1.8.1 Inspection and Planned Maintenance Procedures
   20. 1.8.2 Internal Communications and Record Keeping
   21. 1.9 Vessel and Crew Certification
2. 2.0 Analysis
   1. 2.1 Loss of Propulsion
   2. 2.1.1 Absent Split Pin on the Securing Nut of the Governor Link Pin
   3. 2.2 Engine Shutdown and the Effect on Interconnected Engines
   4. 2.2.1 Overspeed Shutdowns
   5. 2.2.2 Shutdowns Caused by Other Fault Conditions and Design of the Stop Switch
   6. 2.3 Evaluation of Emergency Situations
   7. 2.4 Safety Management System
   8. 2.4.1 Internal Communications and Record Keeping
   9. 2.4.2 Actions of the Wheelhouse and Engineering Crews
   10. 2.4.2.1 Anchor Deployment
   11. 2.4.2.2 Emergency Response
   12. 2.4.3 Inspection and Planned Maintenance Procedures
   13. 2.4.4 Supervision of Tasks
3. 3.0 Conclusions
   1. 3.1 Findings as to Causes and Contributing Factors
   2. 3.2 Findings as to Risk
4. 4.0 Safety Action
   1. 4.1 Action Taken
   2. 4.1.1 Transportation Safety Board of Canada
   3. 4.1.2 British Columbia Ferry Services Inc.
   4. 4.2 Safety Concern
5. Appendices
   1. Appendix A - Glossary
6. Photos
   1. Photo 1 - Queen of Oak Bay Aground in Sewell's Marina
   2. Photo 2 - Wheelhouse Control Console
   3. Photo 3 - Mimic Board in Engine Room
   4. Photo 4 - No. 1 Main Engine Governor and Disconnected Fuel Rack Linkage
7. Figures
   1. Figure 1 - General Arrangement of Compartments at Midships
   2. Figure 2 - Mode 1 and Mode 2
   3. Figure 3 - Aerial View of Horseshoe Bay

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