Watchlist issue highlighted in August 2014 fire and abandonment involving passenger vessel La Relève II
Québec, Quebec, 24 November 2015 – The Transportation Safety Board of Canada (TSB) investigation into the fire and abandonment of the passenger vessel La Relève II determined that the company wasn't effectively managing their safety risks and that Transport Canada (TC) oversight and intervention had not identified safety deficiencies, according to its investigation report (M14C0156) released today.
On 11 August 2014, the passenger vessel La Relève II was on a sightseeing cruise off Havre-Saint-Pierre, Quebec, when a fire started in the engine compartment. The 33 passengers were evacuated onto the vessel’s life rafts. During the evacuation, one passenger was injured and two of the life rafts malfunctioned. The vessel’s engine sustained damage and there was no pollution.
The investigation determined that the engine lost coolant when the rubber hose connected to the exhaust manifold outlet burst, most likely due to wear. The engine then overheated, causing a crack to develop in the exhaust manifold and damaged the insulation, exposing a layer of polyurethane foam. The foam became soaked in oil and ignited as it was exposed to the hot exhaust gases.
The investigation also found that the vessel lacked written emergency procedures, formally assigned emergency duties, and training in these duties. A documented approach to safety management known as a safety management system (SMS) helps to ensure that individuals at all levels of an organization have the information needed to make sound decisions in both routine and emergency operations. In this case, the company did not have an SMS, nor was the vessel required to have one by regulation.
A 2004 TSB recommendation that TC take steps to ensure that small passenger vessel enterprises have an SMS is still outstanding, and assessed as Unsatisfactory. The Watchlist is the TSB’s list of issues that pose the greatest risk to Canada’s transportation system and Safety management and oversight is one of these issues. The Board has called for TC to implement regulations requiring operators to have formal safety management processes and for TC to oversee these processes.
The investigation also identified the requirement for TC-inspector guidance in assessing the severity of a deficiency. Without this guidance, there is a risk that vessels will be certified and operated with major deficiencies. Subsequent to the occurrence, TC issued a notice reminding inspectors to review the approved plans for vessels, and to verify any notations to ensure a thorough inspection.
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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