Marine Investigation Report 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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