Trans-Talk

The Transportation Safety Board of Canada (TSB) released today its final report (M06W0052) into the sinking of the BC Ferries Queen of the North, after it struck Gil Island, Wright Sound, BC on March 22, 2006. The collision breached the vessel’s single hull, which lost its propulsion, and drifted for 1 hour and 17 minutes before it sank in 430 m of water. Two passengers were unaccounted for after abandonment and have since been declared dead.

“Essentially, the system failed that night. Sound watchkeeping practices were not followed and the bridge watch lacked a third certified person,” said TSB Chair Wendy Tadros in a press release. “The recommendations we are making today go beyond the cause of this sinking to ensure that Canadians will always reach port safely. Passengers are the focus of our first two recommendations. In an emergency, all passengers must be accounted for and evacuated to safety. Our third recommendation calls for voyage data recorders on all of Canada’s large vessels,” she added.

To the consternation of many, the TSB was unable to pinpoint the exact cause of the accident, the “smoking gun” that would explain causes specifically. The report merely says that Karl Lilgert, the senior officer on the bridge, failed to order a course correction and that the junior officer, Karen Bricker, didn’t make that correction, without explaining why they didn’t make it. The TSB notes that there should have been an appropriately certified third person on the bridge and that three distractions likely contributed to the failure to order the course change.

Lilgert and Bricker previously had an intimate relationship (the night of the sinking was their first shift together since ending their relationship two weeks previously) and the TSB says that when they missed the course correction, they were “engaged in a conversation of a personal nature,” but they also faced distraction from a rapidly moving squall that reduced visibility and a visual alarm indicating a loss of navigation target. The TSB surmises that:

In dealing with the immediate requirement to identify the position of the lost target, combined with the effects of entering the squall, the 4/O [Fourth Officer Lilgert] was likely distracted at some point between logging the radio communication and carrying out the course change. As a result, he believed he had called for and verified the course alteration. In addition, the ECS display was dimmed and the audible alarms had been deactivated, thereby negating any warning that may have been provided by the waypoint alarm. As a result of these combined factors, the vessel continued past Sainty Point and into Wright Sound without changing course.

Typically, the passage through Wright Sound from Sainty Point to the next course change at Point Cumming is about 27 minutes of travel across deep, open water with few hazards. Crews normally consider that part of the voyage to be less difficult, particularly compared with the upcoming southerly, more complex legs of the Inside Passage. It was in anticipation of transiting Wright Sound that the 2/O [Second Officer] took a lunch break, leaving the 4/O and QM1 [Quartermaster I] alone on the bridge.

Believing he had made the course alteration at Sainty Point, the 4/O didn’t monitor the vessel’s progress and only determined his error less than a minute before collision with Gil Island, about 17 minutes after the missed course correction.

Lilgert is faulted for substandard watchkeeping practices which had been allowed to develop through inappropriate informality in the working environment on the ship’s bridge. The basic principles of safe navigation not observed by the bridge team were:
• verifying the course after Sainty Point;
• reducing speed when the vessel encountered an area of reduced visibility;
• calling the senior OOW or the master to the bridge when visibility became reduced and the radar target (Lone Star) was lost;
• maintaining an effective lookout;
• posting a dedicated lookout during a time of restricted visibility;
• communicating with the target vessel;
• locating and identifying the navigational lights at Point Cumming, Cape Farewell, and Sainty Point;
• monitoring the vessel’s progress visually, via radar and with the ECS;
• frequent plotting to determine the vessel’s position; and
• maintaining appropriate bridge team composition.

The report faults BC Ferries (BCF) on several points:

• failure to make passenger manifests;
• inadequate training for crew after vessel refits;
• operating vessels with some watertight doors open;
• ineffective internal and external International Safety Management Code (ISM Code) safety audits that miss potentially unsafe practices/conditions;
• lack of a requirement for voyage data recorders (VDRs) or simplified VDRs (S-VDRs) on vessels;
• lax attitudes towards drug and alcohol use by off-duty crew aboard vessels, which can impair their effectiveness during an emergency.

BCF has taken steps to address most of the TSB concerns, based on interim reports into the sinking.

The TSB does not assign blame, but a continuing RCMP investigation may eventually result in criminal charges. Several private lawsuits are also in process.

Download the full report (Number M06W0052, 81 pp., 1.2 MB pdf) or review it online.

Update, Thu. March 13, 2008

• The TSB has made available an 80-minute webcast of Wendy Tadros’ Vancouver press conference of yesterday, which includes an animated simulation of the Queen of the North’s final moments. Tadros and TSB colleagues Yvette Myers and Pierre Murray struggle to direct public focus, appropriately, toward the issue of public safety, but the reporters present focus intently on public prurience, repeatedly rephrasing the same question about what exactly Lilgert and Bricker said to each other in the 16 minutes before the grounding. Perhaps the public really needs to feed its bloodlust with scandal, blame and sensationalism, but I for one would welcome more media questions in the public sphere that might affect me as a patron of BC Ferries, such as: “Are passengers more likely to survive a similar disaster now, than they were two years ago?” (BCF spent $1.2 million more on crew training in 2007 than it did in 2006 and launched its SailSafe program.); or, “By how much will the costs of complying with TSB safety recommendations raise ticket prices?” (BCF is buying 40 VDRs to outfit its entire fleet from Rutter and making other safety enhancements).
  Earlier videos showing the ferry resting on the sea floor are still available too.
• BC Ferries has responded with a press release outlining its compliance with the TSB’s recommended safety improvements. CEO David Hahn regrets that, “It is unfortunate that after two years of investigation, the TSB was unable to determine what occurred on the bridge in the final 14 minutes leading up to the vessel striking Gil Island.”
• Karl Lilgert issued a public apology through the BCFMWU (BC Ferry and Marine Workers Union). Follow the Globe and Mail link below for text.
• Calls for a full public enquiry came from Lawyer David Varty, representing a class action suit against BCF by survivors, and spokespersons for the children of victims Shirley Rosette and Gerald Foisy.

(Sources: Globe and Mail, page A8, “Ferry worker apologizes, two years later“; TSB videos available in various formats)

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