Marine Investigation Report M06W0052

Appendices

  • Appendix A - Sketch of the Area
  • Appendix B - Electronic Chart System Recording of the Vessel's Track (Based on Digital Global Positioning System Data)
  • Appendix C - Major Amendments to the SOLAS Convention
  • Appendix D - Glossary

Appendix A - Sketch of the Area

Appendix A - Sketch of the Area

Figure 3.  Track of the Queen of the North

Appendix B - Electronic Chart System Recording of the Vessel's Track (Based on Digital Global Positioning System Data)

Appendix B - Electronic Chart System Recording of the Vessel's Track (Based on Digital Global Positioning System Data)

Figure 4.  Course as it would have happened on a vector chart

Click to see larger image

The above graphic shows the track of the Queen of the North as it would have appeared on a vector chart, which, while not available at the time of the accident, clearly shows the vessel's course both across Wright Sound before and after the striking. The fixes in the electronic chart system data log were updated every minute for the following: date, time, latitude, longitude, heading, course over ground, and speed over ground. Ten-second positions of latitude and longitude depict the vessel's track moments after the striking.

Appendix C - Major Amendments to the SOLAS Convention

Damage Stability for Roll-on/Roll-off Passenger Vessels

REFERED TO AS AMENDMENT SUBJECT OF THE AMENDMENTS
1990 SOLAS New standards on residual damage stability applicable for vessels built on or after 29 April 1990 (new vessels) in order to provide survivability following damage (Chapter II-1, Regulation 8).
1994 SOLAS or 1992 amendments Most vessels built before 29 April 1990 (existing ships) to comply with the 1990 SOLAS, in accordance with a phase-in schedule from 1994 to 2005, depending on a vessel's survivability characteristics.
1995 SOLAS All existing vessels to comply with the 1990 SOLAS, in accordance with a phase-in schedule from 1998 to 2005, depending on a vessel's survivability characteristics (Chapter II-1, Regulation 8-1).

Vessels carrying 400 persons or more must comply with the 1990 SOLAS, as a two-compartment subdivision vessel, if:

• built on or after 01 July 1997; or

• built before 01 July 1997, in accordance with a phase-in schedule from 1998 to 2010, depending on the vessel's survivability characteristics, number of persons carried, and vessel's age (Chapter II-1, Regulation 8-2).

Appendix D - Glossary

AIS automated identification system
B.C. British Columbia
BC Ferries British Columbia Ferry Services Inc.
BCFMWU BC Ferry & Marine Workers' Union
BRM bridge resource management
CCG Canadian Coast Guard
CCGS Canadian Coast Guard ship
CFOA Canadian Ferry Operators Association
cm centimetres
CMCC Canadian Mission Control Centre
C/O chief officer
COG course over ground
DGPS differential global positioning system
DSC digital selective calling
ECDIS electronic chart display and information system
ECS electronic chart system
EPIRB emergency position-indicating radio beacon
GPS global positioning system
IMO International Maritime Organization
ISM Code International Safety Management Code (International Management Code for the Safe Operation of Ships and for Pollution Prevention)
JRCC Joint Rescue Coordination Centre
km kilometres
kW kilowatts
m metres
mm millimetres
MCTS Marine Communications and Traffic Services
MED Marine Emergency Duties
MSA Marine Safety Advisory
N north
nm nautical miles
OOW officer of the watch
OSC on-scene coordinator
QM quartermaster
ro-ro roll-on/roll-off
ROV remote operating vehicle
SAR search and rescue
SEN Simulated Electronic Navigation
SI Ship Inspection Notice
SIC Ship Inspection Certificate
SMS Safety Management System
SOLAS Convention International Convention for the Safety of Life at Sea
SSB Ship Safety Bulletin
STCW Convention International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978, as amended in 1995
S-VDR simplified voyage data recorder
T true
TC Transport Canada
TP technical publication
TSB Transportation Safety Board of Canada
VDR voyage data recorder
VHF very high frequency
VISORS Voluntary Individual Safety Observation Reporting System
W west
W/T watertight
XTE cross-track error (alarm)
° degrees
°C degrees Celsius
' minutes
2/O second officer
3/O third officer
4/O fourth officer

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1. See Glossary at Appendix D for all abbreviations and acronyms.

2. Units of measurement in this report conform to International Maritime Organization (IMO) standards or, where there is no such standard, are expressed in the International System of units.

3. British Columbia Ferry Services Inc. and its predecessor, British Columbia Ferry Corporation, are referred to as BC Ferries throughout this report.

4. All times are Pacific standard time (coordinated universal time minus eight hours).

5. A deckhand who has received training and is clear to carry out steering duties is referred to as a quartermaster.

6. Hereafter referred to as the "aft steering station."

7. While on standby, a vessel is hand-steered, and both watch officers are required on the bridge with the engineering watch officers stationed in the engine control room. Both steering pumps are also activated.

8. A creek that flows into Grenville Channel, approximately 22 nm north of Sainty Point light; it is generally considered to mark the beginning of the narrow portion of the channel.

9. Commercial vessels of 20 m or more in length or private yachts of 30 m or more, operating inside of the Prince Rupert vessel traffic services system, and required to report to Marine Communications and Traffic Services (MCTS).

10. ECS is a navigation information system that electronically displays vessel position and relevant nautical chart data and information from an ECS database on a display screen, but does not meet all the IMO requirements for electronic chart display and information system (ECDIS) and is not intended to satisfy the International Convention for the Safety of Life at Sea (SOLAS Convention) Chapter V requirements to carry a navigational chart. ECDIS refers to a navigation information system that, with adequate backup arrangements, can be accepted as complying with the up-to-date chart required by regulations V/19 and V/27 of the 1974 SOLAS Convention.

11. The call was made with the vessel's position 1.2 nm from the specified calling-in point.

12. MCTS Prince Rupert is comprised of Prince Rupert Traffic, which provides vessel traffic services, and Prince Rupert Coast Guard Radio, which provides marine radio services.

13. He was a supernumerary officer being familiarized as a chief officer on this vessel.

14. Boat and liferaft stations were on Deck 7 (see Figure 1).

15. For example, one passenger found a cabin door temporarily jammed.

16. Clearing procedures call for a physical search of the cabin and, upon completion, that the door be marked with chalk.

17. The two missing passengers had been allocated a cabin on the aft port side of Deck 7.

18. Although crew members were not familiar with the need to prevent re-entry to the vessel interior, this procedure was documented in the 1998 emergency operating procedures. Note also that, for this report, the terms "evacuation" and "abandonment" are used interchangeably.

19. At 0158, the C/O of the Queen of the North informed Prince Rupert Coast Guard Radio using a hand-held VHF radio that there had been 102 persons on board. At 0833, BC Ferries reported to JRCC Victoria that an examination of the lists indicated only 99 persons on board (42 crew members and 57 passengers).

20. A barrier search is used to detect an object that is being swept away by current. It is conducted by searching downstream and perpendicular to the direction of the drift.

21. At the time of the occurrence, a previously approved plan with noted revisions was posted on board, while a revised plan was with TC and awaiting approval.

22. Hull Construction Regulations, Subsection 16 (10).

23. At this time, passengers were also accommodated on Deck 2. More recently, the vessel's inspection certificate restricts berthed passengers to Decks 6 and 7 only.

24. These two vessels were unique in the fleet in that they carried berthed passengers below the vehicle deck.

25. British Columbia, Office of the Auditor General, Performance Audits: British Columbia Ferry Corporation, 1995/96, Report 2, ISBN 0-7726-2697-9.

26. The Board of Steamship Inspection is a body within TC that adjudicates on ship safety matters.

27. Subsection 16 (10) of Part I of the Hull Construction Regulations, Board Decision 6175.

28. An imaginary line used in making calculations regarding hull flooding, the margin line is drawn at least 76 mm below the upper surface of the bulkhead deck, which in this case is the vessel's main car deck.

29. This was kept in the vessel-specific manual in the engineering department ashore.

30. Two S-Band radars and one X-Band radar. Weather-related interference is less of an issue on 10 cm S-Band radars than on 3 cm X-Band radars.

31. The ECS had been installed on the bridge in 1998.

32. ECS is not a substitute for any required navigation equipment or paper charts.

33. Raster charts are produced by converting paper charts to digital image by scanner; the resulting image is similar to a digital camera photograph. Vector charts are digitally created and may contain information additional to that available on a paper chart, such as sailing directions.

34. In contrast, the colour coding on vector charts is altered between day and night modes.

35. VDRs are also required on certain passenger vessels constructed before July 2002 and certain ships other than passenger ships constructed on or after July 2002. In addition, cargo ships constructed before July 2002 are subject to a phased-in requirement beginning in 2006 and ending in 2010.

36. The interference of previous learning in the process of learning something new.

37. 1986 for SOLAS-compliant vessels.

38. This implies that any one main transverse watertight bulkhead may be damaged, and two adjacent main compartments breached.

39. SOLAS Convention, Chapter II-1, Part B. The Convention specifies minimum safety standards for the construction, equipment, and operation of vessels engaged on international voyages.

40. The new damage stability requirements of the SOLAS Convention were brought forward following the Herald of Free Enterprise and Estonia disasters, which happened in March 1987 and September 1994, respectively.

41. Transport Canada, Ship Safety Passenger Ship Operations and Damaged Stability Standards (Convention Ships), TP 10405.

42. Transport Canada, Ship Safety Passenger Ship Operations and Damaged Stability Standards (Non-Convention Ships), TP 10943, 1991.

43. The CFOA counts among its membership almost all major ferry operators in Canada.

44. The intent is to phase in the updated standards over a five-year period, depending on the area of operation, the age, and a vessel's size. Typically, newer vessels will have a longer phase-in period.

45. Transport Canada, Passenger Vessel Operations and Damaged Stability Standards (Non-Convention Vessels), TP 10943, Second Edition, October 2007.

46. According to the preamble of the amended TP 10943, its damage stability requirements are to be applied in advance of updating the Hull Construction Regulations.

47. One of the modifications made in 1999 was the addition of two sets of flood-control doors on the main car deck as a result of the investigation into the sinking of the Estonia in September 1994.

48. D.I. Tepas and T.H. Monk, "Work Schedules," G. Salvendy (Ed.), Handbook of Human Factors, New York: John Wiley & Sons, 1987, pp. 819-843.

49. An "exempt" employee does not belong to the union.

50. There were eight quartermasters on board the Queen of the North.

51. Canada Shipping Act, Crewing Regulations, Section 40. Note that these regulations were repealed on 01 July 2007. Similar provisions may be found in Section 216 of the new Marine Personnel Regulations of the Canada Shipping Act, 2001.

52. A "non-exempt" employee belongs to the union.

53. Crewing Regulations, subsections 21.1 (1) and (2).

54. BC Ferries Guide on the IMO's ISM Code (March 1996).

55. Crewing Regulations, Section 40.

56. Transport Canada, Ship Safety Bulletin 16/1999, Information on Passengers, 07 December 1999.

57. This is an independent examination conducted by the government of the state whose flag the ship is entitled to fly, or an organization recognized by the government of the state-such as a ship classification society - to determine whether the company continues to operate its SMS in accordance with the requirements of the ISM Code. The BC Ferries SMS is audited by the classification society of Lloyd's Register.

58. These include a muster list with assigned crew responsibilities, emergency response instructions in Fleet Regulations, lifesaving equipment plan, vessel-specific manual, crew familiarization booklet, and the emergency operation procedures.

59. BC Ferries Fleet Regulations, Section 8.02, Contingency Plans and Drills.

60. BC Ferries, Come Sail With Us, (G) General Policy: Alcohol/Drugs, pp. 62-63.

61. G.L. Morfitt, Safety and B.C. Ferries: A Review of Operational Safety at British Columbia Ferry Services, Inc., January 2007, p. 33.

62. Australian Transportation Safety Board, Accidents and Incidents Involving Alcohol and Drugs in Australian Civil Aviation, 01 January 1975 to 31 March 2006, Aviation Safety Research and Analysis Report: B2006/0169.

63. A.M. Smiley, "Marijuana: on Road and Driving Simulator Studies," H. Kalant, W. Corrigal, W. Hall, R. Smart (eds.), The Health Effects of Cannabis, Toronto: Addiction Research Foundation, 1999, pp. 173-191.

64. Australian Transportation Safety Board, Accidents and Incidents Involving Alcohol and Drugs in Australian Civil Aviation, 01 January 1975 to 31 March 2006, Aviation Safety Research and Analysis Report: B2006/0169.

65. A.M. Smiley, "Marijuana: on Road and Driving Simulator Studies," H. Kalant, W. Corrigal, W. Hall, R. Smart (eds.), The Health Effects of Cannabis, Toronto: Addiction Research Foundation, 1999, pp. 173-191.

66. Guidelines for the Accident Investigator in the Interpretation of Positive THC (Cannabinoids) Results, produced by Dr. Vern Davis for the Transportation Safety Board of Canada, 2001.

67. V. Leirer, J. Yesavage, and D. Morrow, "Marijuana Carry-Over Effects on Aircraft Pilot Performance," Aviation, Space, and Environmental Medicine, March 1991, pp. 221-227.

68. A.M. Smiley, "Marijuana: on Road and Driving Simulator Studies," H. Kalant, W. Corrigal, W. Hall, R. Smart (eds.), The Health Effects of Cannabis, Toronto: Addiction Research Foundation, 1999, pp. 173-191.

69. J. Reason, Human Error, New York: Cambridge Press, 1990.

70. Parts 2, 3, and 3-1 of Section A-VIII/2 of the STCW Code.

71. R.S. Nickerson, "Confirmation Bias: A Ubiquitous Phenomenon in Many Guises," Review of General Psychology, 2, 1988, pp. 175-220.

72. B. Dawe (Rutter Technologies) in a presentation to the International Symposium on Vehicle Recorders in Arlington, Virginia, United States, in 1999.

73. Canadian Ferry Operators Association, 2006 Annual Report.

74. W.D. Molyneux, National Research Council Canada, Safety Initiatives from the SNAME Ad Hoc Ro-Ro Safety Panel, IR-1996-11.

75. SOLAS Convention, Regulation III/27, Information on Passengers. Information includes the name and gender of all persons on board, and whether he or she is an adult, child, or infant.

76. National Transportation Safety Board, Fire on Board the Netherlands-registered Passenger Ship Nieuw Amsterdam, Glacier Bay, Alaska, 23 May 2000, report No. MBR-01/01, NTIS No. PB2001-916402.

77. TSB Marine Investigation Report M90M4025, Recommendation M93-04

78. Transport Canada, Ship Safety Bulletin 16/1999, Information on Passengers, 07 December 1999

79. TSB Marine Investigation Report M03N0050.

80. Shorter voyages and turn-around times, for example, may preclude collecting detailed passenger information.

81. BC Ferries internal training.

82. TSB Marine Safety Advisories (MSA) 18/92 and 24/92, and TSB reports M92W1022 and M92L3011, respectively.

83. TSB Marine Investigation Report M90M4053.

84. TSB Marine Investigation Report M03N0050.

85. The Marine Personnel Regulations entered into force 01 July 2007; there has been no change in the above-noted scope of application for the passenger safety management training requirement.

86. TSB Marine Investigation Report M03N0050.

87. Canada Shipping Act, Life Saving Equipment Regulations, Part III, Operational Requirements and Equipment Standards, Evacuation Procedures.

88. Clearing away is the preparation of survival craft for launch, normally carried out after crew members are sent to boat stations and before the final abandonment order is given.

89. One such technology in use in the oil industry is the personnel on board monitor, which keeps track of the personnel on board an installation by means of a badge that is worn.

90. Non-conformity means the non-fulfillment of a specific requirement of the ISM Code.

91. An observation is defined as a statement of fact made during an audit, which if not addressed, may lead to a non-conformity.

92. TSB Marine Investigation Report M02W0061.

93. TSB Marine Investigation Report M03W0073.

94. In 2005.

95. SOLAS Convention, Chapter III, Regulation 27.

96. TSB Marine Investigation Report M03N0050.

97. G.L. Morfitt, Safety and B.C. Ferries: A Review of Operational Safety at British Columbia Ferry Services, Inc., January 2007.

98. June 2002.

99. For example, the east coast ferry operator Marine Atlantic has an alcohol and drug policy that includes a wide range of approaches, including several situations where testing is permitted.

100. Canadian Ferry Operators Association, 2006 Annual Report.

101. Canadian Coast Guard, Casualty Tracking (CASTRACK) System.

102. The SAREX 2006 "Ship-to-Shore" exercise was held on 15 October 2006 to evaluate inter-agency response to a major marine disaster on the British Columbia coast. The exercise included the evacuation of 200 volunteers from the BC Ferries vessel Queen of Nanaimo. The exercise was designed to improve inter-agency communications and operations during a large-scale emergency operation.

103. Applies only to vessels more than 500 gross tons carrying more than 12 passengers and engaged on a voyage other than sheltered waters.

104. Boat and Fire Drill and Means of Exit Regulations.

105. Canadian Transportation Accident Investigation and Safety Board Act, Section 28.

106. SSBs 03/78, 01/85, and 16/92.

107. TSB Recommendation M92-04 following the sinking of the Northern Osprey, TSB Marine Investigation Report M90M4020.

108. Lloyd's Register, American Bureau of Shipping, Bureau Veritas, Germanischer Lloyd and det Norske Veritas.