MARINE Reports - 2006 - M06W0052

Table of Contents

1. 1.0 Factual Information
   1. 1.1 Particulars of the Vessel
   2. 1.1.1 Description of the Vessel
   3. 1.2 History of the Voyage
   4. 1.2.1 Events Following Striking
   5. 1.3 Abandonment Phase
   6. 1.3.1 Passenger Muster
   7. 1.3.2 Clearing of Cabins and Passenger Spaces
   8. 1.3.3 Abandonment
   9. 1.3.4 Abandonment Concerns
   10. 1.4 Search and Rescue Operation
   11. 1.5 Injuries to Persons
   12. 1.6 Damage to the Vessel
   13. 1.7 Geographical, Weather, and Current Information
   14. 1.8 Vessel Certification
   15. 1.9 Watertight Doors
   16. 1.10 Navigation Equipment
   17. 1.10.1 Dive Operations and Data Recovery
   18. 1.10.2 Navigation Equipment Alarm Features
   19. 1.10.3 Electronic Chart System Setup on the Queen of the North
   20. 1.10.4 Electronic Chart System Recorded Data
   21. 1.11 Voyage Data Recorders
   22. 1.12 Steering-Mode Selector Switch
   23. 1.13 Lifesaving Equipment
   24. 1.14 Damage Stability
   25. 1.14.1 Damage Stability and Subdivision Concepts
   26. 1.14.2 International Standards
   27. 1.14.3 Canadian Standards
   28. 1.14.4 Damage Stability of the Vessel
   29. 1.15 Relationship Between the Fourth Officer and the Quartermaster
   30. 1.16 Crew Work/Rest History
   31. 1.17 Personnel Certification and Experience
   32. 1.18 BC Ferries Employment Policies
   33. 1.18.1 Familiarization and Clearance Procedures
   34. 1.19 BC Ferries Crew Training
   35. 1.20 Bridge Watch Procedures and Practices
   36. 1.21 Navigation Practices on the Queen of the North
   37. 1.22 Responsibilities of the Senior Master and Master
   38. 1.23 Passenger and Traffic Manifests
   39. 1.24 Safety Management System
   40. 1.24.1 Emergency Preparedness
   41. 1.25 Cannabis Use on the Queen of the North
   42. 1.25.1 Effects of Cannabis on Performance
2. 2.0 Analysis
   1. 2.1 Overview
   2. 2.1.1 Missed Course Change
   3. 2.1.2 Passage Toward Gil Island
   4. 2.1.3 Striking Sequence
   5. 2.2 Familiarity with the Steering System
   6. 2.3 On Board Navigational Practices and Safety
   7. 2.3.1 Bridge Watch Composition
   8. 2.3.2 Crewing Regulations-Interpretation
   9. 2.4 Watertight Doors
   10. 2.5 Navigation Equipment Alarm Features
   11. 2.6 Voyage Data Recorders
   12. 2.7 Liferafts
   13. 2.8 Damage Stability and Regulatory Concerns
   14. 2.9 Accounting for Passengers and Crew
   15. 2.9.1 Passenger Manifest
   16. 2.10 Emergency Preparedness
   17. 2.10.1 Planning
   18. 2.10.2 Training
   19. 2.10.3 Exercises and Drills
   20. 2.10.4 Evacuation Procedures
   21. 2.10.5 Passenger Vessel Abandonment and Technology
   22. 2.11 Crew Training and Familiarization
   23. 2.11.1 Familiarization with New Equipment
   24. 2.11.2 Familiarization and Clearance for Assigned Duties
   25. 2.11.3 Training and Continued Proficiency
   26. 2.12 Quality of Safety Management System Audits and Reviews
   27. 2.13 Alcohol and Drug Use on Board Vessels
3. 3.0 Conclusions
   1. 3.1 Findings as to Causes and Contributing Factors
   2. 3.2 Findings as to Risk
   3. 3.3 Other Findings
4. 4.0 Safety Action
   1. 4.1 Action Taken
   2. 4.1.1 BC Ferries Passenger Manifest
   3. 4.1.2 Guidelines for Passenger Manifest
   4. 4.1.3 Crew Familiarization of Equipment
   5. 4.1.4 Passenger Safety Management Training
   6. 4.1.5 BC Ferries Divisional Inquiry
   7. 4.1.6 Review of Operational Safety at BC Ferries
   8. 4.1.7 Cannabis Use in the BC Ferries Northern Fleet
   9. 4.1.8 Location of Crew Accommodation
   10. 4.1.9 Installation of Voyage Data Recorders
   11. 4.1.10 Inflatable Liferafts
   12. 4.1.11 Audit Plans
   13. 4.1.12 Bridge Watch Composition
   14. 4.2 Action Required
   15. 4.2.1 Accounting for Passengers
   16. 4.2.2 Preparation Before Abandoning a Vessel
   17. 4.2.3 Carriage of Voyage Data Recorders
   18. 4.3 Safety Concerns
   19. 4.3.1 Watertight Doors
   20. 4.3.2 Damage Stability
   21. 4.3.3 Auditing Voluntary Adopted Safety Management Systems
5. Appendices
   1. Appendix A - Sketch of the Area
   2. Appendix B - Electronic Chart System Recording of the Vessel's Track (Based on Digital Global Positioning System Data)
   3. Appendix C - Major Amendments to the SOLAS Convention
   4. Appendix D - Glossary
6. Photos
   1. Photo 1 - Queen of the North
7. Figures
   1. Figure 1 - General Arrangement
   2. Figure 2 - Layout of the Bridge
   3. Figure 3 - Track of the Queen of the North
   4. Figure 4 - Course as it Would Have Appeared on a Vector Chart
8. Tables
   1. Table 1 - Procedural Differences for Switching from Autopilot to Aft Steering Station

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