Russel Brothers Limited OWEN SOUND, ONTARIO Steelcraft Boat Builders
True North II
Canadian List of Shipping 1993: True North II [C.369046] registered at Collingwood, Ontario. Built in 1949 at Owen Sound, Ontario. Ex- Captain Ahab. 33'; 6 g.t.; 4 n.t. Owned by True North Charter Service, Ltd., Tobermory, Ontario. Canadian List of Ships 1997: Owned by True North Charter Service, Ltd., Tobermory, Ontario. Transport Canada List 2003: Owned by True North Charter Service, Ltd., Tobermory, Ontario. June 16, 2000 – True North II capsized near Tobermory, ON killing two youths. 18 people survived the ordeal. GAO Notes: See clipping file for pics. |
On 16 June 2000, while returning to Tobermory, Ontario, from Flowerpot Island, Georgian Bay, Ontario, in moderate sea and weather conditions, the small passenger vessel "TRUE NORTH II" was swamped by a series of waves which stove in the vessel's bridge front door, flooded the main deck and downflooded into the hull. The vessel sank rapidly in 15 metres of water approximately 200 metres off Flowerpot Island at about 1030 local time. Of the 20 people on board, 18 drifted ashore on two buoyant apparatus. Two grade-seven school children drowned.
For full Transport Canada investigation and report see http://www.tsb.gc.ca/en/reports/marine/2000/m00c0033/m00c0033.asp or below:
The Transportation Safety Board of Canada (TSB) investigated this
occurrence for the purpose of advancing transportation safety. It is not
the function of the Board to assign fault or determine civil or criminal
liability.
Marine Investigation Report
Sinking and Loss of Life Passenger Vessel "TRUE NORTH II" off
Flowerpot Island, Georgian Bay, Ontario 16 June 2000
Report Number M00C0033
Synopsis
On 16 June 2000, while returning to Tobermory, Ontario, from Flowerpot
Island, Georgian Bay, Ontario, in moderate sea and weather conditions, the
small passenger vessel "TRUE NORTH II" was swamped by a series of waves
which stove in the vessel's bridge front door, flooded the main deck and
downflooded into the hull. The vessel sank rapidly in 15 metres of water
approximately 200 metres off Flowerpot Island at about 1030 local time. Of
the 20 people on board, 18 drifted ashore on two buoyant apparatus. Two
grade-seven school children drowned.
Ce rapport est également disponible en français.
Table of Contents
1.0
Factual Information
1.1 Particulars of the Vessel 1.1.1 Description of the
Vessel 1.2 History of the Voyage 1.2.1 Outbound Trip to Flowerpot
Island 1.2.2 Decision to Sail 1.2.3 Returning from Flowerpot
Island 1.2.4 Swamping, Downflooding and Sinking 1.2.5
Abandonment 1.2.6 Alerting 1.2.7 Search and Rescue
Operations 1.3 Injuries to Persons 1.4 Vessel History 1.4.1
Construction History 1.4.2 Vessel Conversion History 1.4.3
Structural Modifications History 1.4.4 Vessel Structural
Condition 1.5 Vessel Condition on Recovery 1.6 Vessel
Stability 1.7 Downflooding and Sinking Sequence 1.8 Vessel
Inspection and Certification 1.8.1 Passenger Vessel
Inspection 1.8.2 "TRUE NORTH II" Inspection 1.9 Parks Canada
Operators' Permits 1.10 Master's Qualifications and
Certification 1.11 Weather Conditions 1.12 Navigation Aids and
Instruments 1.13 Communications 1.13.1 Radio
Communications 1.13.2 Distress Alerting Equipment 1.14 Passenger
Safety 1.14.1 Life-saving Equipment Plan 1.14.2 Crewing Level and
Safety Briefing 1.14.3 Lifejackets 1.14.4 Buoyant
Apparatus 1.14.5 Inflatable Liferaft 1.14.6 Lifebuoys
2.0
Analysis
2.1 Decision to Sail 2.1.1 Perception of Risk 2.1.2 Pressure
to Sail 2.2 Master Certification and Training 2.3 Crewing
Level 2.4 Meaning of "Fine Clear Weather only at Master's
Discretion" 2.5 Vessel Condition After Recovery 2.6 Vessel
Inspection 2.7 Passenger Safety Briefings 2.8 Life-saving
Equipment 2.8.1 Carriage and Stowage of Lifejackets 2.8.2 Buoyant
Apparatus and Lifebuoys 2.8.3 Inflatable Liferaft Securing and
Deployment 2.9 Emergency Communications
3.0
Conclusions
3.1 Findings as to Causes and Contributing Factors 3.2 Findings
as to Risk 3.3 Other Findings
4.0
Safety Action
4.1 Action Taken 4.1.1 Advisory on Liferaft Release
Mechanism 4.1.2 Review of Passenger Vessel Inspection and
Certification 4.1.3 Weather Limitation 4.2 Action
Required 4.2.1 Adequacy of TCMS Inspection Regime and Safety
Culture 4.2.2
Emergency Preparedness and Survivability 4.3 Safety
Concern 4.3.1 Crew Competency Evaluation and Certification Process
5.0 Appendices
List of Illustrations
1.0 Factual Information
1.1 Particulars of the Vessel
|
"TRUE NORTH II" |
Official Number |
369046 |
Port of Registry |
Collingwood, Ontario |
Flag |
Canada |
Type |
Passenger Vessel |
Gross Tonnage[2] |
5.67 |
Voyage Classification |
Inland Waters Voyage, Class II |
Length Overall |
10.6 m[2] |
Draught |
Forward: 0.9 m Aft: 1.0 m |
Built |
1948, Russel Brothers Inc., Owen Sound,
Ontario |
Propulsion |
One 120-kW Cummins six-cylinder diesel engine |
Crew |
1 |
Passengers |
19 |
Owner |
True North Charter Services Ltd., Tobermory,
Ontario |
1.1.1 Description of the Vessel
The "TRUE NORTH II " is a small passenger vessel of closed
construction, with a single chine hull form of all-welded steel, a transom
stern, and a wooden open superstructure. The vessel is powered by a
Cummins six-cylinder marine diesel engine rated at 120 kW, which drives a
single fixed-pitch propeller, and gives a maximum speed of approximately
10 knots. The basic layout of the vessel is shown in the "Outline General
Arrangement" (Figure 1).
The hull below the main deck is a common compartment extending from
stem to stern, and contains the propeller stern tube gland and main
engine, located near midships, and the rudder trunk gland and steering
gear quadrant at the after end, near the transom.
A watertight steel trunk, arranged on the centreline forward of
midships, extends above main deck level and encloses clear plastic panels
fitted in the bottom shell plating. The clear panels allow viewing of
underwater features such as shipwrecks at Fathom Five National Marine
Park.
|
Photo 1 - The "TRUE NORTH" underway some time
before the sinking |
The wooden superstructure, which provides shelter from the weather for
deck passengers, is open at the after end and has large passenger
embarkation openings in the port and starboard sides forward of midships.
The steering position is at the forward end of the superstructure, on
the port side. A door on the starboard side of the bridge front gives
access to the open foredeck.
An inflatable liferaft and two buoyant apparatus are located on top of
the superstructure. Two lifebuoys are stowed inside the viewing well
coaming. The lifejackets are stowed in the upper port side of the main
engine wooden casing.
1.2 History of the Voyage
1.2.1 Outbound Trip to Flowerpot Island
On 15 June 2000 a group of 13 school children, two supervisory teachers
and two chaperons left the Bruce Township Central Public School, in
Underwood, Ontario, for an overnight camping trip on Flowerpot Island. The
"TRUE NORTH II" had been used by the school on four previous occasions to
ferry grade-seven classes to Flowerpot Island. The island is within Fathom
Five National Marine Park and is the only island with facilities for the
public within the park. Access to the island is available through
commercial tour vessels, which have permits issued by Parks Canada.
Upon arrival in Tobermory, the group loaded their gear and boarded the
"TRUE NORTH II". At 1030 eastern daylight time, the vessel departed for a
scenic tour of the harbour and the crossing to Flowerpot Island.[3]
During the crossing, it was arranged that the "TRUE NORTH II" would return
the next day to pick up the group at 1000 if the conditions were not too
rough. Although the school group had a cellular telephone with them, it
was normally turned off to save the batteries. No communications
arrangements were made in the eventuality that the vessel was unable to
return on time on the following day.
1.2.2 Decision to Sail
On June 16, before he left home, the master listened to the weather
forecast on 90.7 FM, the Parks Canada Weather and Activities Information
radio broadcast, to decide whether he would sail. The master recalled that
the forecast indicated winds south, 10 to 20 knots, increasing in the
morning to 15 to 25 knots from the south-southwest, and that a small craft
warning was in effect. The master continued listening to the weather
forecast while driving to the harbour, as there was also a thunderstorm
advisory.
The Environment Canada publication Wind, Weather & Waves: A
guide to marine weather in the Great Lakes region mentions the area of
the occurrence as being subject to a build-up of confused seas as a result
of refraction. Due to the forecast and prevailing weather conditions, some
local tour boat operators cancelled their trips for that morning.
At 0930 the master, accompanied by his dog, boarded the "TRUE NORTH
II". There was no one else on board. The vessel departed Tobermory and
proceeded directly to Beachy Cove, Flowerpot Island, to pick up the school
group as agreed. As the vessel approached the south shore of Flowerpot
Island, the master observed waves 1.0 m high, with some white caps and sea
spray. The vessel arrived without incident at Beachy Cove at about 1000.
1.2.3 Returning from Flowerpot Island
After docking the vessel at the Parks Canada dock in Beachy Cove, and
prior to loading the vessel with the camping equipment, concern was
expressed to the master regarding the prevailing weather and sea
conditions. The master gave reassurances and proceeded to load the vessel.
Two adult tourists, who had been brought to the island the day before
by another boat operator, asked if they could return to Tobermory on the
"TRUE NORTH II". The master agreed.
At 1012, when all of the 19 passengers were on board and their personal
gear stowed, the master turned the vessel and left the cove at slow speed.
The bridge front door leading to the foredeck was open. Upon departure,
the master directed passengers to move forward to trim the vessel to
ensure greater underkeel clearance at the after end while transiting the
shallow entrance marked by two buoys near the breakwater.
At about 1022, when clear of the entrance, the master steered the
vessel toward Tobermory (to the southwest) and generally bow into the wind
and waves. At that point, the wind had increased to about 30 knots.
Passengers on the open foredeck became wet from the heavy spray of the
waves hitting the bow. One adult passenger fell to the deck due to water
shipped over the bow. When the passengers on the foredeck entered the
superstructure to seek shelter, the master left the wheel to close the
door, secured it with its barrel bolt latch, and increased speed to
approximately 7 knots.
1.2.4 Swamping, Downflooding and Sinking
Shortly after the passengers cleared the foredeck, a large wave was
shipped over the bow and struck the bridge front door, reaching a height
halfway up the front window. About 30 cm of water was trapped inside the
bulwarks. Another wave was shipped and the accumulation of water retained
on the foredeck reached the height of the bulwark top rail. The vessel
became heavier by the bow. The master observed that the shipped water was
draining slowly through the port and starboard scuppers. He instructed the
passengers to move aft to help raise the bow as he maintained his course
and speed into the waves.
At about 1025, as the vessel pitched and rolled into the waves, the
master reduced the engine revolutions and put the rudder to starboard to
turn the boat toward the island. Shortly after, a wave was shipped over
the bow which stove in the bridge front door and window; waves were also
shipped on the port side through the large side openings in the
superstructure. Water flooded aft along the port side passageway. The
shipped water was retained on deck inside the steel bulwarks at the after
end of the vessel. Water retained on the foredeck and in the forward end
of the superstructure flowed aft toward the stern and downflooded through
various openings in the main deck. Passengers proceeding aft in the port
side passageway had water suddenly reaching their knees, as the vessel
heeled to port and more shipped water rapidly swamped the deck space. At
about 1026 the vessel returned briefly to the upright and quickly sank by
the stern in position 45º17.6' N, 081º37.2' W (see Appendix A).
1.2.5 Abandonment
From the time the vessel started to ship water, the rapidity of the
sinking was such that the master did not have time to give out lifejackets
or prepare his passengers for abandoning the vessel. Some passengers were
swept clear by the water. Others swam to the surface after abandoning the
vessel by way of the bridge front doorway or the port, starboard and rear
openings in the superstructure.
As the vessel heeled and sank, two orange rigid floats--called buoyant
apparatus--located on the top of the superstructure floated free. The
master reboarded the sinking vessel and stood on top of the
superstructure, which was awash, but he was unable to reach the
already-submerged inflatable liferaft, which remained secured to its
cradle. Of the 20 persons on board, the master and 5 passengers clung to
one buoyant apparatus, 12 passengers clung to the other. The buoyant
apparatus, pushed by the 30-knot winds and 1.5 m waves, drifted separately
onto Flowerpot Island. A head count of the passengers was not possible
until after the two buoyant apparatus reached the shore. When it was found
that two children were missing, a shoreline search was initiated.
The two schoolchildren who were missing were among the last to be seen
on board the vessel. Their egress may have been hindered by various
floating debris such as bench seats, the shuffle board, wooden panels and
camping equipment trapped inside the superstructure as the vessel sank. In
the week following the sinking, the team of professional divers engaged to
clear the wreck confirmed that most of this debris was still trapped and
floating in the superstructure.
1.2.6 Alerting
There was no distress call or any emergency radio communication
transmitted by the "TRUE NORTH II" before it sank.
At 1045 the pleasure craft "PICKING DAISIES", en route to Tobermory,
sighted the two apparatus with people in the water around them. The
location was reported to the nearby Canadian Coast Guard (CCG) Search and
Rescue (SAR) Station in Tobermory at 1049. Because of the shallow water
near Flowerpot Island, the operator of the pleasure craft felt he could
not approach the buoyant apparatus in the prevailing sea and wind
conditions.
At about 1100, after reaching the shore, one child, accompanied by the
master's dog, ran to the lighthouse to alert the Friends of Fathom Five
volunteers of the sinking of the vessel. Realizing that the dog belonged
to the owner of the "TRUE NORTH II", one volunteer, using a portable
telephone, alerted the CCG Station that the "TRUE NORTH II" had sunk. By
that time, the 12 persons with the second buoyant apparatus had reached
the shore. The passengers, who had spent up to 50 minutes in 1.5 m waves
and 10C water, were in various stages of hypothermia and shock. The park
warden station near Beachy Cove was closed and, regardless, did not have
any means of communication to alert the Park Warden.
1.2.7 Search and Rescue Operations
At 1050 the CCG Station in Tobermory informed the Rescue Co-ordination
Centre (RCC), in Trenton, Ontario, that the "TRUE NORTH II" had sunk and
the local SAR unit, "CCG 733" had been dispatched. At 1104 the "CCG 733"
arrived at Beachy Cove to provide assistance to the survivors. Parks
Canada staff also joined the rescuers to provide assistance. The "CCG
SHARK", a small Department of Fisheries and Oceans research vessel,
arrived on-scene to participate in the search, and at 1125 the coxswain of
the "CCG TOBERMORY" became the on-scene commander.
Floating debris and a patch of oil leaking from the "TRUE NORTH II"
helped to locate the vessel on the lake bottom in about 15 metres of water
in position 45º17.8' N, 081º36.9' W. At 1128, following a head count and a
shoreline search, it was confirmed that two children were missing. The
on-scene commander requested additional resources including an Ontario
Provincial Police (OPP) helicopter to assist with the search for the two
missing children.
At 1205, RCC Trenton established the first search pattern, which was
completed at 1355. Further search patterns were undertaken throughout the
day. At 2253, the search was suspended because of darkness. The area was
searched by two Coast Guard cutters, an OPP helicopter, two Parks Canada
vessels, and six private boats. During the afternoon, the survivors were
evacuated from the island by two air ambulance helicopters and taken to
Tobermory for medical examination.
On the morning of June 17, the OPP Underwater Search and Recovery Unit
conducted an examination of the sunken "TRUE NORTH II" and located the
bodies of the two missing children on the lake bottom near the vessel. The
bodies were subsequently examined by the Coroner, who determined that the
cause of death was drowning.
1.3 Injuries to Persons
|
Crew |
Passengers |
Others |
Total |
Fatal |
- |
2 |
- |
2 |
Missing |
- |
- |
- |
- |
Serious |
- |
- |
- |
- |
Minor/None |
1 |
17 |
- |
18 |
Total |
1 |
19 |
- |
20 |
1.4 Vessel History
1.4.1 Construction History
The vessel was built in 1948 as a steel-hulled, flush-decked small
fishing boat of closed construction, with a wooden deckhouse bolted to a
200 mm high steel watertight coaming fitted on the main deck around the
boundary of the main engine casing. A steel hatch with a clear opening of
610 mm by 610 mm, bounded by a 75 mm high steel watertight coaming, was
fitted at the after end of the main deck in way of the underdeck steering
gear quadrant.
The underdeck space was a common compartment throughout the length of
the hull and was not fitted with any watertight transverse bulkheads. Such
subdivision was not required by the Small Fishing Vessel Inspection
Regulations.
A steel bulwark around the perimeter of the main deck, some 350 mm
high, was fitted with four freeing ports. Two freeing ports, each with
clear openings 125 mm high and 380 mm long, were installed in each of the
port and starboard side bulwarks and fitted with outboard-swinging hinged
steel flaps. The foremost pair of freeing ports was near midships, and the
after pair was 2.4 m forward of the transom.
1.4.2 Vessel Conversion History
The vessel was extensively modified and was renamed "CAPTAIN AHAB"; it
entered service in 1972 as a passenger vessel. As part of the
modification, the original deckhouse and all fishing-related gear were
removed, the height of the steel bulwarks was raised to 585 mm, and an
open wood-framed plywood superstructure was erected over the main deck to
provide shelter for deck passengers.
Hull Construction Regulations (HCR) requirements applicable to
passenger vessels call for subdivision of the hull by the incorporation of
at least three transverse watertight bulkheads in order to retard the loss
of stability and buoyancy in the event of flooding. This requirement is
not applicable to passenger vessels with a gross tonnage of less than 75.
Consequently, as a passenger vessel with a gross tonnage of 5.67, the hull
of the "TRUE NORTH II" was not required to be subdivided, and was
comprised of one common compartment.
The size of the opening in the main deck in way of the original
deckhouse and engine casing was reduced, and the 200 mm high steel
watertight coaming around its perimeter was removed. The engine casing was
replaced with a semi-portable wood-framed plywood structure located inside
the superstructure.
To ease access to the main engine, the lower plywood panels of the new
casing were secured to the wooden framing with simple turn-button and slip
bolt fastenings and were not attached to the main deck plating. The after
end of the new casing was 405 mm forward of the original casing opening in
the main deck, and this space was fitted with recessed flush-fitting
wooden covers with no means of securing and no watertight gaskets.
The original steel hatch cover and its 75 mm high watertight coaming at
the after end of the main deck were removed and replaced with a wooden
hatch cover recessed into the deck, providing an unobstructed level
surface in the passenger sitting area. The flush-fitting wooden cover was
not fitted with a securing device or a watertight gasket.
An access hatch with a clear opening of 510 mm by 405 mm bounded by a
25 mm high steel coaming was installed in the main deck forward of the new
superstructure. The hinged steel hatch cover was not fitted with a
watertight gasket.
Two 32 mm diameter main deck drainage scuppers were fitted in the
outboard corners of the transom bulwark, and a 75 mm long by 25 mm high
scupper opening was fitted at its centre.
Scuppers were installed in the port and starboard bulwark plating to
provide drainage from the foredeck, with openings in the plating 140 mm
long by 63 mm high. The outboard side of each scupper was fitted with a
venturi type semicircular cowling made from 75 mm diameter steel pipe, and
closed at its forward end.
After these modifications, the First Inspection Report was completed
and a Safety Inspection Certificate (SIC 16) was issued 6 June 1972, by
the (then) Canadian Steamship Inspection (CSI) branch of the Department of
Transport (DOT).
1.4.3 Structural Modifications History
At various times during service as a passenger vessel, since 1972,
structural and mechanical modifications and additions were made, the most
significant of which were:
- the installation, in 1984, of a watertight steel trunk which
encloses transparent panels in the bottom shell plating for underwater
viewing;
- the fitting of hinged doors in the port and starboard side steel
bulwarks to provide easy boarding and disembarking of passengers with a
disability on to the main deck;
- the installation of a 430 mm by 680 mm access hatch in the main deck
abaft the engine casing, which is fitted with a flush-fitting wooden
cover with no securing device or watertight gasket;
- the hinged steel flaps of the main deck freeing ports__in
the port and starboard side bulwarks near midships__were
welded shut;
- the replacement, in the spring of 2000, of the original Cummins 63
kW main engine with one rated at 120 kW.
Sketches and further details of items 1 and 2 were forwarded to CSI,
DOT, prior to their incorporation in the vessel, and item 5 was completed
before the routine annual safety inspection in the spring of 2000.
There is no record of when items 3 or 4 were installed, or if they were
formally accepted. These modifications and the main deck non-watertight
flush fitting hatches were present and accepted at each subsequent annual
safety inspection where an SIC 16 was issued.
1.4.4 Vessel Structural Condition
The watertight integrity of the hull shell plating below main deck
level was intact and leak free when examined while the vessel was afloat
after her recovery. Localized pitting found on the internal surface of the
shell plating was insignificant, and the extent and depth of any existing
external pitting was such that it did not compromise the watertight
integrity of the underwater hull at the time of the occurrence.
Neither the access hatches nor the main engine casing boundary in the
main deck were fitted with watertight gaskets or securing devices. Any
water shipped and retained on the main deck was thus allowed to freely
enter the underdeck compartment (see photographs 2 and 3).
Photo 2 - Aft end of main deck showing intact
steel bulwark and hatch opening in main deck with no sealing
gasket or means of securing flush wooden
cover. |
Photo 3 - Hatch opening in main deck with no
sealing gasket or means of securing flush wooden
cover. |
Main deck plating was extensively corroded around the boundary of an
irregularly shaped opening that provided access to the main engine
control, steering gear and electrical cables inside the wooden console at
the steering position. This opening allowed any water shipped and retained
on the main deck to freely enter the underdeck compartment.
The lower edges of the 75 mm by 100 mm open ventilators at the port and
starboard sides of the engine-room were approximately 165 mm above main
deck level, and were not fitted with a means of closing. These openings
allowed water shipped and retained on the main deck to freely enter the
underdeck compartment as the vessel rolled or heeled to either side.
The lower edge of the portable plywood panel forming the after end of
the engine casing structure did not extend down to the main deck level,
leaving an opening 15 cm by 1.05 m wide across the bottom of the casing
end. This opening was provided to enhance ventilation and air supply to
the main engine. However, its location at deck level also allowed free
entry into the underdeck compartment of any water shipped and retained on
the main deck (see photographs 4 and 5).
Photo 4 - Opening in main deck with no steel
coaming in way of portable plywood panels of engine
casing. |
Photo 5 - Engine casing with portable plywood
panels in place showing opening at aft end for engine
ventilation. |
The drainage scupper at the centre of the transom bulwark was found to
be effectively sealed shut by a large decal, bearing the vessel's name,
that was fixed to the outside of the transom.
This obstruction, in conjunction with the welding-shut of the two
freeing ports near midships, reduced the vessel's ability to clear any
water shipped on the main deck (see photographs 6 and 7).
Photo 6 - Main deck freeing port in hinged
open position. |
Photo 7 - Main deck freeing port welded shut
- Starboard side is similar. |
The effective height of the port and starboard side bulwarks within the
superstructure was 0.91 m, while that in way of the chain rails at the
open after end of the main deck was 660 mm.
Visual, probing and mallet pounding examinations of the wooden
superstructure in general, and the bridge front and its door and door
frame in particular, showed areas of significant deterioration due to
advanced and incipient rot (see photograph 8).
The wooden framing of the bridge front, console and door frame was
discoloured and softened by decay, and the lower ends were partially
disintegrated (see photograph 9).
Photo 8 - Disintegration due to dry rot of
plywood bridge front in way of front door
frame. |
Photo 9 - Disintegration due to dry rot of
door frame and console base, and corrosion in way of irregularly
shaped hole in main deck. |
The deteriorated condition of the inboard edge of the wooden frame in
way of two of the three hinges of the bridge front door was such that the
holding power of the 25 mm long screw fastenings was markedly reduced. The
timber and wood packing in way of the hinge screw holes was decayed such
that the screws were pulled clear with the door. The third and lowest door
hinge remained attached to the door frame, and its screw fastenings were
pulled clear from the door itself.
The 20 mm by 20 mm wooden door stop and its nail fastenings to the
framing at the door's outboard edge (which were found to have been bent
backwards through 90 degrees), extended down from the top of the door
frame to within some 350 mm of the deck and consequently did not provide
any support to the lower area of the door.
The 63 mm by 63 mm thick wooden door stop, forming a sill across the
bottom of the door, had been unbolted and removed for repair the day
before the occurrence. The sill had been replaced without its bolted
connection, which reduced support to the lower area of the bridge front
door (see photographs 10 and 11).
Photo 10 - Disintegration due to dry rot of
inboard base of bridge front door frame (outboard base
similar). |
Photo 11 - Opening in bridge front with
stove-in door forced inside superstructure and unpainted, corroded
foot print on main deck of missing door sill. |
Reinorcement or repairs to the bridge front included the fitting of an
additional layer of plywood over the original structure installed when the
vessel was converted to passenger service. The inner layer of plywood was
in a deteriorated condition due to dampness and rot, and several voids had
developed between the layers where the inner layer had disintegrated.
The lower area of the outer layer was found to be soft when lightly
probed and the unpainted edges of both layers of plywood exposed in way of
the damaged hinges were discoloured and the wood fibres loose and brittle.
Over a period of time, the accumulation of standing water due to the
loss of weathertightness of the lower bridge front structure would have
led to the corrosion of the main deck plating inside the steering console
and contributed to the decay and disintegration of the lower wooden
framing.
The nature of the fractures and the colour of the exposed damaged
surfaces of the wooden beams and plywood awning__in the area
damaged from impact with the bottom__are consistent with the
onset of decay and incipient rot in that area of the superstructure.
1.5 Vessel Condition on Recovery
Underwater video recordings showed the bow of the sunken vessel was
pointing toward Flowerpot Island, that the hull was nearly level fore and
aft, and resting on the port side bottom shell and bilge.
On June 24 the sunken vessel was raised to the surface;
occurrence-related items noted during the subsequent inspections included
the following:
- The steel hull up to main deck level was undamaged and structurally
intact, with the bilges remaining dry after the recovered vessel was
pumped clear of all flood water.
- All through-hull fittings of the main engine keel cooling and bilge
pumping systems and the inboard glands of propeller and rudder shafts
were undamaged and leak free.
- The after starboard quarter of the superstructure top was damaged
and several wooden beams broken as a result of impact with the lake
bottom.
- The wooden door on the starboard side of the bridge front was torn
from its hinges, forced through its frame and retained inside the
superstructure.
- The wood door stop and all securing bolts at the bottom of the
bridge front door opening were missing, and the retaining stop at the
outboard side of the door frame was bent aft through 90 degrees.
- The frame of the bridge front window forward of the steering
position was stove in some 100 mm.
- The semi-portable lower side and after end panels of the plywood
casing in way of the main engine were displaced and scattered inside the
superstructure.
- The hinged upper plywood panels on the port and starboard sides of
the engine casing lockers were open, and the lifejacket contents,
pyrotechnics and firefighting gear exposed.
- All of the wooden flush-fitting hatch covers in the main deck were
displaced.
- The inflatable liferaft on top of the superstructure was lashed
secure in its cradle and one lifebuoy with safety light remained in its
stowed position, while the other, with its heaving line, was on deck,
having remained within the superstructure during the sinking.
- Unsecured passenger seating initially found by divers to have been
displaced, was recovered or removed prior to the raising of the vessel,
and the broken backrest of one passenger seat at the after port side of
the main deck remained attached to the wooden framing of the
superstructure.
- The passenger boarding doors in the port and starboard bulwarks at
the forward end of the superstructure were secured in the shut position,
and all bulwark safety chains around the after deck were in place.
- Passenger camping equipment was found stowed inside the steel trunk
of the viewing well, and personal baggage, camping gear and the vessel's
tool boxes, spares and other sundry gear were scattered on the main
deck.
- The main engine control lever was found engaged in the forward drive
position and the throttle was at the normal service speed setting.
- Starting and service batteries adjacent to the main engine were
unsecured and had been displaced, probably as a result of impact with
the lake bottom when the vessel sank.
- The outfit of electronic communications equipment was water damaged,
the radar scanner dome fractured, and the vessel's funnel, found on the
lake bottom near the sunken vessel, was recovered separately.
1.6 Vessel Stability
When the vessel was built as a small fishing vessel in 1948, there was
no regulatory requirement for the preparation and submission of stability
data for approval purposes. The original builder is no longer in business,
and there are no records of any hydrostatic particulars or stability data
having been prepared.
On completion of her conversion for operation as a passenger vessel,
and as part of the inspection and certification process, an estimate of
the vessel's initial intact transverse stability was made in 1972.
At that time, and in the absence of more comprehensive hull design
data, a rolling period test was carried out by the then CSI, DOT. The
rolling period test showed the unloaded vessel had a transverse
metacentric height (GM)[4]
of 0.677 m, and was accepted as a reasonable indication of satisfactory
transverse stability characteristics.
After the "TRUE NORTH II" was raised to the surface, a rolling period
test and a more comprehensive inclining experiment was carried out by the
TSB at the Parks Canada wharf in Tobermory. The inclining experiment and
rolling period test results were consistent, and indicated the as-inclined
GM to be 0.704 m and 0.674 m, respectively.[5]
Based on the lightship weight and the longitudinal and vertical centres
of gravity derived from the inclining experiment, together with additional
hydrostatics data generated by the TSB, a review was made of the vessel's
trim and intact transverse stability characteristics for the various
loaded conditions at the time of the occurrence.
Calculations show that on departure from Beachy Cove with all
passengers, camping and personal equipment stowed on board, and with five
persons located on the foredeck, the vessel was trimmed slightly by the
bow. However, due to the after rake of the keel, the actual forward and
after static draughts were 0.90 m and 1.0 m, respectively.
When approximately 0.3 m of water was shipped and retained on the
foredeck, and passengers from the foredeck had just moved inside the
superstructure, the forward trim increased slightly and the actual forward
and after static draughts were 0.95 m and 1.0 m, respectively.
While passengers were making their way aft on the instruction of the
master, and the water shipped and retained on the foredeck was level with
the top of the bulwarks, the forward trim increased and the forward and
after static draughts were 1.1 m and 0.93 m, respectively.
On departure, the GM was approximately 0.57 m and as water was shipped
and retained on the foredeck, the GM and the vessel's intact initial
transverse stability gradually reduced. When the water retained on the
foredeck reached the top of the bulwark, the GM was some 0.41 m, and the
vessel still retained positive initial intact transverse stability.
The retention of a positive range of transverse stability was dependent
on the vessel maintaining its intact watertight integrity; however, this
integrity was compromised by the non-watertight condition of virtually all
of the access hatches and other openings in the main deck.
The longitudinal and transverse stability of the vessel were markedly
reduced by the weight and free-surface effects of the large volume of
water shipped through the port side openings in the superstructure.
The clearing of shipped water from the main deck inside the open
superstructure was retarded, as two of the four original freeing ports had
been welded shut. The shipped water, which was retained on the after end
of the main deck, caused the vessel to trim by the stern and also
downflooded through non-watertight openings and accumulated in the
underdeck compartment.
The additional weight of the water suddenly shipped when the bridge
front door was stove in further reduced the transverse stability as it
surged aft along the port side alleyway and also caused the vessel to trim
rapidly by the stern. The vessel initially heeled severely to port, as
transverse stability was virtually eliminated due to the increasing
free-surface effects of water shipped and retained above the main deck and
the accumulated downflooding water inside the hull.
The action of the relatively high waves on the vessel caused a
transitory rolling motion to starboard, and as the wave actions continued,
the vessel variously heeled or was rolled to port and starboard as she
settled deeper in the water.
Downflooding into the underdeck compartment became continuous, and
water accumulated until the vessel lost all reserve buoyancy and sank by
the stern.
The extent and rapidity of the downflooding, which caused the sudden
heeling to port and stern-first sinking of the "TRUE NORTH II", together
with the obstructions caused by unsecured passenger seats, personal
baggage, and camping equipment that became buoyant as the vessel settled,
all contributed to the difficulties encountered by the passengers in
abandoning the inside of the superstructure.
1.7 Downflooding and Sinking Sequence
The loss of reserve buoyancy was brought about by the accumulation of
water inside the hull resulting from the rapid and progressive
downflooding of shipped water through non-watertight hatch covers and
other openings in the main deck of the vessel.
Rolling and heeling effects, imparted by wave motions while the vessel
was trimmed by the stern and sinking, preclude a precise determination of
the many trimmed attitudes the vessel could have taken. However, based on
the reported sequence of events, the chronology of the
occurrence__from the initial shipping of water over the bow to
the subsequent sinking__can be determined, and is illustrated
in Figure 2.
1.8 Vessel Inspection and Certification
1.8.1 Passenger Vessel Inspection
Pursuant to the Canada Shipping Act (CSA), the inspection of
passenger vessels is carried out by Transport Canada, Marine Safety
(TCMS), in accordance with the Hull Inspection Regulations, to
ensure compliance with the appropriate regulatory requirements, including
the HCR.
On satisfactory completion of an annual inspection by TCMS, a SIC 16 is
issued, and the vessel's current structural and other safety-related data
are recorded in the Ship Inspection Reporting System (SIRS).
Each annual inspection is intended to be comprehensive, and includes
examination of the hull, machinery, shafting, steering, pumping,
electrical, life-saving, firefighting, navigation and communications
outfits. Internal and external inspections also address the general
structural condition of the vessel, including hatchways, ventilators,
casings and other deck openings, together with their closing and securing
appliances. Crew numbers, certification status, qualifications and
operating limitations are also reviewed at this time.
"Standards for the Construction and Inspection of Small Passenger
Vessels" (TP 11717) was published by the (then) Ship Safety Branch of the
CCG in June 1994. The standards address a range of small passenger vessels
including those (similar to the "TRUE NORTH II") with gross tonnages less
than 15 and which carry more than 12 passengers. The standards include
requirements addressing stability, subdivision, hull and deck watertight
integrity, minimum freeing ports area and passenger deck railing heights.
However, the standards are only applicable to new vessels and, because her
conversion to passenger service took place in 1972, before TP 11717 came
into effect, the "TRUE NORTH II" was not subject to this standard.
It is the responsibility of the operator to inform the inspector or
bring to the attention of TCMS any structural, mechanical, or safety
equipment additions or changes introduced since the previous inspection.
Any deficiencies recorded by TCMS during the annual inspections are
brought to the attention of the operator in order that remedial action can
be taken.
In addition to regulatory requirements, two construction standards and
a compliance program addressing the safety of passenger and other small
vessels have been compiled, published and implemented by TC. These
incorporate safety requirements, including hull subdivision for small
vessels and charter vessels, which are more stringent than the regulations
applicable to passenger vessels under 75 gross tons.
1.8.2 "TRUE NORTH II" Inspection
Since entry into service as a passenger vessel in 1972, regulations
made pursuant to the CSA required that the "TRUE NORTH II" be inspected
every year by TCMS.
Following modifications to the vessel in 1978, the "TRUE NORTH II" was
re-measured by TCMS and assigned a gross tonnage of 5.67. Consequently,
TCMS determined that the vessel became subject to the requirements of
Class V of the Life Saving Equipment (LSE) Regulations, in
lieu of her previous Class VII rating. Class V required a lifeboat with
means of launching and one or more inflatable liferafts to accommodate 75
per cent of the passenger and crew complement.
The then owner requested that the life-saving equipment on board the
vessel at that time be accepted because of the impracticability of
carrying a lifeboat, due to the small size of the vessel. In November 1978
the Board of Steamship Inspection granted an exemption from the
requirement to carry a Class I lifeboat (Board Meeting 3470), subject to
the following conditions:
- buoyant apparatus capable of supporting 100 per cent of the
complement to be carried;
- voyages to be limited to fine and clear weather only between May
1st and October 15th of each year on Inland Waters
Class II Voyages on the waters of Georgian Bay bound by straight lines
drawn from Tobermory Harbour to Lat. 45º15'24" N, Long. 081º36'12" W,
thence to Gigs Point, Cove Island and Turning Island to Tobermory
Harbour;
- the vessel to be manned by two crew members in accordance with the
Safe Manning Regulations; and
- compliance with all other requirements of the LSE Regulations
for a Class V ship.
The Board of Steamship Inspection's exemption reiterated the
requirement in the existing Safe Manning Regulations for the "TRUE
NORTH II" to have two crew members and this requirement was continued in
what are now known as the Crewing Regulations.
From 1978 to 1985, conditions 2, 3 and 4 were not recorded on the SIC
16s issued by TC after each routine annual inspection and TCMS did not
ensure compliance with these conditions prior to the issuance of the SIC
16s.
Following the sale of the vessel in 1981, the current owner of the
"TRUE NORTH II" operated the vessel alone every year until the time of the
sinking. SIC 16s issued from 1986 to 2000 included a voyage limitation
condition but contained no mention of the vessel having to be manned by
two crew members. During this period, condition number 3 was not met and
TCMS neither recorded the discrepancy nor required the operator to meet
this condition.
In 1997, a 20-person inflatable liferaft was added on board the vessel
and the total number of passengers and crew indicated on the SIC 16 was
lowered from 21 to 20 persons to reflect the liferaft's maximum carrying
capacity.
The inspection certificate issued on 22 May 2000 was valid for Inland
Waters Class II voyages until 21 May 2001.[6]
The vessel was equipped with one inflatable liferaft capable of
accommodating 20 persons, two 10-person capacity buoyant apparatus, 2
lifebuoys, 23 adults' lifejackets and 3 children's lifejackets. The vessel
was certified for the carriage of 20 passengers and one crew member, for a
total of 21 persons, which exceeded the rated capacity of the inflatable
liferaft.
It was reported that, between 1996 and 2000, there were instances when
the school had sent a group of 25 children and 4 adults, a number of
passengers that exceeded the limit of 20 indicated on the vessel
certificates.
The May 2000 certificate also contained the following notation
regarding voyage limitation:
Tobermory to Flowerpot Island & Cove Island, in fine clear
weather only at master's discretion. Between May 15th and
September 30th.
This notation is at variance with the 1978 decision of the Board of
Steamship Inspection. The notation also assigns a discretionary role to
the master which was not a part of the Board's decision.
1.9 Parks Canada Operators' Permits
To operate within Fathom Five National Marine Park, commercial tour
operators are required to submit an "Application for Commercial Operators
Permits" and to enter into a "Commercial Vessel Operating Agreement" with
Parks Canada. The application for the permit states that the applicant
agrees to conform to the provisions of the "Commercial Vessel Operating
Agreement" as well as to applicable federal and provincial laws. At the
time of the occurrence, Parks Canada had signed the agreement but the
master of the "TRUE NORTH II" had not. Neither the permit nor the
Agreement contained a weather-limiting clause.
1.10 Master's Qualifications and Certification
In 1979 the master of the "TRUE NORTH II" worked a total of 100 hours
as a crew member on the vessel when it was registered as the "CAPTAIN
AHAB". When he purchased the vessel in 1981, he applied for a Master of a
Small Craft (CSC) Certificate. A local Transport Canada examiner conducted
an oral examination and issued him his first CSC certificate. The
Automated Certification and Examination System shows that, until 1997, the
master of the "TRUE NORTH II" held a CSC certificate issued by TCMS.
In November 1983, the master of the "TRUE NORTH II" completed a first
Marine Emergency Duties (MED) Level 1 course at Georgian College, Owen
Sound, Ontario. The 30-hour course covered the syllabus for the MED 1
training.
In 1998, with the passing of the new Crewing Regulations, TCMS
issued a Master, Limited (CL), certificate on the basis that the master of
the "TRUE NORTH II" held a CSC certificate. This new certificate allowed
him to work as master on his vessel when operating out of Tobermory in the
marine park, not more than two miles off shore. The new CL certificate was
issued for a five-year period and was valid until May 2003. Upon
examination, TCMS also issued him a Restricted Engineer's Certificate,
Motor Ship, valid for Inland Waters Class II voyages.
In April 2000 the master completed a second MED course at the Georgian
College MED Centre in Port Colborne, Ontario. A total of 64 hours of
instruction was given covering all sections of the approved syllabus for
the MED B1 (survival craft) and MED B2 (marine firefighting) courses.
Between 1980 and 2000 the master gained operational experience on his
vessel in the marine park. At no time, however, did he attend a marine
college to gain more formal education and training in the five main areas
covered in the Master, Limited, syllabus.
1.11 Weather Conditions
Marine Communications and Traffic Services (MCTS) Thunder Bay, Ontario,
provides the continuous marine broadcast of Environment Canada's marine
synopsis, forecasts and warnings for the Tobermory area on channels 21B
and 83B. The regular forecasts are issued three times a day at 0300, 1030
and 1830. On June 16 the 0300 marine forecast for Lake Huron and Georgian
Bay stated the following:
small craft wind warning[7]
in effect [. . .] small craft thunderstorm advisory[8]
in effect [. . .] winds southerly 10 to 20 knots increasing to 15 to 25
this morning [. . .] waves 1 metre or less, building to 1 to 2 metres
this morning.
The advisory also stated that:
winds are for mid lake [. . .] wave heights are for offshore and are
forecast from trough to crest [. . .] near shore winds and waves may
vary considerably due to shoreline effects.
Between 0926 and 1126 that morning, Environment Canada's remote weather
station at Cove Island, which is about 4 nautical miles west of Flowerpot
Island, recorded southerly winds of 15 knots gusting to 29 knots. At 1000
the master of the "TRUE NORTH II" estimated that the wind was from the
south to southwest, gusting up to 25 knots. At 1110 the "CCG SHARK", which
was in the area where the "TRUE NORTH II" sank, recorded southwesterly
winds gusting at 30 to 40 knots and seas 1.3 m high with whitecaps and
foam.
1.12 Navigation Aids and Instruments
Two small buoys maintained by Parks Canada are located near the end of
the breakwater at Beachy Cove. The buoys mark the narrow and shallow
channel leading to the tour boat dock inside of the breakwater.
The "TRUE NORTH II" was equipped with a magnetic compass and a small
radar. Navigation was conducted by sight in daylight hours.
1.13 Communications
1.13.1 Radio Communications
The "TRUE NORTH II" was equipped with two very high frequency (VHF)
radiotelephones and had a Radio Inspection Certificate (Great Lakes) valid
until 12 May 2001. Radio communications were heard between two other
stations during the transit to Flowerpot Island but the master did not use
the radio during the return voyage from Flowerpot Island. There was no
emergency (portable) VHF radio on board and there is no standard requiring
such equipment.
MCTS Thunder Bay provides radio communication services for Lake Huron
and Georgian Bay. This includes monitoring channel 16 for vessel distress
communications, providing weather forecasts and advisories, and facilitate
ship-to-shore communications. Vessel movements may also be monitored by
MCTS Thunder Bay. The "TRUE NORTH II" was not required to report to MCTS
Thunder Bay nor was MCTS Thunder Bay aware of its movements.
1.13.2 Distress Alerting Equipment
There was no automatic or manual distress radiotelephone alerting
system such as digital selective calling (DSC) or an emergency
position-indicating radio beacon (EPIRB) on the vessel to alert the SAR
authorities of a distress situation as well as the position of the vessel
in case of emergency. At the time, no such equipment was required by
regulations for this class of vessel.
1.14 Passenger Safety
1.14.1 Life-saving Equipment Plan
A life-saving equipment plan that details the location and use of
safety equipment for the benefit of the crew and passengers is a safety
and regulatory requirement. The "TRUE NORTH II" did not have one. During
the annual inspection and certification of the vessel, TCMS overlooked the
requirement for such a plan and did not ensure one was displayed on board.
Except for a small sign above the lifejacket compartment, there were no
other signs indicating the location and use of life-saving equipment.
1.14.2 Crewing Level and Safety Briefing
The Board of Steamship Inspection (Meeting 3470) required a second crew
member for the vessel. However, since 1979, each ship inspection
certificate stated that only one crew member was required. After the
accident, in June 2000, TCMS determined "that it had incorrectly certified
the vessel with respect to the number of crew required to be on board
during operations."[9]
During the trips to and from the island, there was no pre-departure
safety briefing regarding the availability, location, and instructions for
the use of life-saving equipment such as lifejackets, liferafts, and
buoyant apparatus, and none of the 19 passengers were made aware of
emergency procedures. A safety briefing, although important, is not
required by regulations and the master did not include such a procedure in
his departure routine.
1.14.3 Lifejackets
The inspection certificate issued for the vessel listed 23 adults' and
3 children's lifejackets. Found on board after the sinking were 22 adults'
lifejackets, and 2 children's lifejackets. Also found in the lifejacket
locker was a personal flotation device for a child.
Minimum safety requirements contained in the LSE Regulations
require the carriage of a sufficient number of lifejackets for the
ship's entire complement of passengers and crew. The regulations require
passenger vessels (Classes IV through VII), where the vessel regularly
carries a known number of children as passengers, to carry enough
lifejackets suitable for every child.
There are two sizes of standard lifejacket approved for use:
- for a body mass more than 40 kg, and
- for a body mass 40 kg and under.
Since one of the three required children's lifejackets was a personal
flotation device, not a certified lifejacket, the vessel was not equipped
with the required number of children's lifejackets as shown on the
vessel's certificate.
None of the lifejackets on board the vessel was fitted with a personal
locator light. Furthermore, none of the lifejackets were retrofitted with
a personal locator light as per TCMS record of Board Decision No. 6220 of
31 October 1996.
The passengers did not know where the lifejackets were stowed (see
photograph 12).
The lifejackets were stored in a compartment above the main engine
along the port side passageway. The upper half of the compartment has a
door that is hinged along the bottom and is secured closed by a barrel
bolt latch located at each end along the top of the door. To access the
lifejackets, both barrel bolt latches must be opened to allow the door to
swing out and down into the passageway. A small sign with the word
"LIFEJACKETS" painted in red on a white background, in 19 mm high
lettering, was fitted close to the deckhead, above and inboard of the door
top panel. The outer face of the compartment door had several posters of
interest attached to it. There was no poster on the vessel illustrating
how to don a lifejacket.
Individual lifejackets were not readily accessible to passengers, in
that each lifejacket was stowed in a tied plastic garbage bag. Removing
the lifejackets from the tied plastic bags would have been time-consuming.
The plastic bags were used to protect the lifejackets from water,
ultraviolet rays and the fumes from the exhaust of the engine.
Photo 12 - Lifejacket locker in engine casing with door in
closed position showing LIFEJACKETS sign (arrow) and posters on
door.
1.14.4 Buoyant Apparatus
Since its conversion in 1972, the "TRUE NORTH II" was equipped with two
buoyant apparatus. They were located on top of the superstructure and
forward of the funnel. They were not lashed and floated free from the
sinking vessel, as they were designed to do. Each buoyant apparatus was
manufactured in 1971 and was approved for 10 persons. When the vessel
sank, the master and passengers clung to the two buoyant apparatus. After
being immersed in 10ºC water for up to 50 minutes, survivors suffered
varying degrees of hypothermia.
1.14.5 Inflatable Liferaft
On 22 May 2000 the "TRUE NORTH II" was certified for service and
received an inspection certificate that listed one inflatable liferaft
capable of accommodating 20 persons and two buoyant apparatus capable of
accommodating a total of 20 persons. The inspection certificate and the
liferaft inspection certificate were valid until May 2001.
In 1997, following discussions with TCMS inspectors, the vessel was
equipped with an inflatable liferaft. A 20-person Dunlop-Beaufort liferaft
was installed in a cradle located on top and at the after end of the
wooden superstructure. It was secured by a nylon lashing, which was
attached to the cradle by a shackle at one end of the lashing and by a
Senhouse slip at the other end. Such a securing arrangement requires human
intervention for the launching. The master did not have ready access to
the liferaft, as there was no means, such as a ladder, to climb atop the
superstructure where it was stowed. Its installation on the vessel was
accepted by TCMS inspectors (see photograph 13).
|
Photo 13 - Manual release Senhouse slip securing inflatable
liferaft in cradle on superstructure top. |
After being washed out of the vessel, the master swam on top of the
superstructure but did not reach the inflatable liferaft in time to
release it before it sank with the vessel. Since 1978, safety requirements
provide for either deep chocks or a hydrostatic release unit to allow the
liferaft to float free. Without the benefit of a liferaft, passengers were
immersed in the cold water for up to 50 minutes as they clung to the
buoyant apparatus; this increased their risk of hypothermia and drowning.
1.14.6 Lifebuoys
There were two lifebuoys on board, one fitted with a float-activated
light, the other with a buoyant lifeline. Each lifebuoy was held in place
by two U -shaped brackets attached to the inside of the viewing well
coaming.
The lifebuoys were accessible to the master and the passengers, but
they were stowed in the viewing well, which also contained carry-on
baggage that partially covered the lifebuoys. Neither of the lifebuoys
floated clear of the vessel when she sank; there was no regulatory
requirement for them to do so.
2.0 Analysis
2.1 Decision to Sail
On the morning of the occurrence, the master twice made conscious
decisions to transit between Little Tub Harbour and Flowerpot Island. The
first decision was to transit to Flowerpot Island in the face of the small
craft warning and the thunderstorm advisory issued by Environment Canada.
On arrival at Flowerpot Island, the master had an opportunity to remain
alongside at Beachy Cove until the sea conditions improved. While he had
just made the crossing in near gale-force winds and fielded concerns about
the weather conditions, the master elected to proceed with the return
voyage. The master's decisions to sail to and from Flowerpot Island were
shaped by his perception of the risks associated with the transit.
2.1.1 Perception of Risk
The master was aware that a small craft warning and a thunderstorm
advisory were in effect but he believed that the crossings could be made.
The master's perception of risk was tempered by his previous exposure
to similar and worse conditions in over twenty years of operating this
vessel in this area. Upon departing Little Tub Harbour, the "TRUE NORTH
II" was in the lee of the Bruce Peninsula; the waves there were smaller
than on the more exposed, windward side of Flowerpot Island, where
confused seas prevailed due to the shoreline effect. Also, while some
operators decided not to sail to Flowerpot Island that day, the master
knew that the shallow draught of the "TRUE NORTH II" allowed him to enter
Beachy Cove where other, larger vessels could not proceed.
The vessel's inspection certificate did not clearly state the
operational limitations on the vessel, as it allowed the master to proceed
"in fine clear weather only at master's discretion." The first part of the
limitation is open to interpretation but the second part, "at master's
discretion," allowed the master to base his decision to sail upon his own
judgement of the risk associated with the weather.
The master understood neither the serious shortcomings of the vessel's
condition (with regard to watertight integrity) nor the effect that the
southwest wind would have on his vessel; he overestimated the ability of
his vessel to withstand the head-on encounter with the waves, and
underestimated the result of shipping water.
2.1.2 Pressure to Sail
While specific arrangements had been made to pick up the group at 1000
the following day, no contingency plans were discussed and no alternative
plans or telephone communications were made on the morning of June 16 to
cancel or postpone the trip due to poor weather. As a result, the master
would have felt a personal commitment to proceed to Flowerpot Island to
rendezvous with the school group.
2.2 Master Certification and Training
The master's certification met the minimum requirements of the
Crewing Regulations to operate the "TRUE NORTH II" in the trade in
which she was engaged.
From 1981 to 1997 the master held a CSC certificate, renewable annually
at the beginning of the navigation season. In 1998 he was issued, without
examination, a CL certificate on the basis of holding a CSC certificate.
The new CL certificate simply reflected the criteria previously stated on
the CSC certificate. The CL certificate is a certificate of competency
which has to be renewed every five years. Even though every applicant for
a CL certificate must pass an oral, practical and written examination, the
TCMS examiner may renew the CL certificate without examination if he or
she is satisfied that the holder has continued to operate in the same
capacity for the last five years.
When examining a new applicant for a CL certificate, the TCMS examiner
determines whether the person is competent to operate a specific vessel in
a designated area where certain constraints, such as weather, can be
expected. To assess a candidate, the TCMS examiner is guided by the
general requirements for the CL certificate. The examination is based on a
syllabus that encompasses various aspects of vessel operation such as
navigation safety, engineering knowledge, general seamanship, ship
management, and chart work and pilotage.
The examination and certification practices for the CSC or CL
certificates are left to the discretion of the local TCMS examiner. The
local examiner determines which part of the syllabus is appropriate to the
operation, type of craft and equipment carried on board and conducts oral
examinations which, in rare cases, may be supplemented by written papers.
The knowledge required to understand local weather forecasts or to
recognize shortcomings with a vessel's watertight integrity is not part of
the syllabus for this certificate. Since 1993, an instruction to TCMS
examiners covered the preparation and evaluation of oral examinations, the
latest version of which was issued on 30 June 2000. The instruction states
that special care should be taken to document responses that are
unsatisfactory or where the candidate is borderline.
The master was last given an oral exam in 1983. As there is no
documentation as to how the examination was conducted, it is not possible
to determine how the TCMS examiner assessed the master's competence in
operating the "TRUE NORTH II".
In April 2000 the master took MED Level 2 training at Georgian College.
The master continued to stow the lifejackets and the liferaft in the same
manner as before and he did not institute a passenger safety briefing or
conduct an emergency drill or exercise.
2.3 Crewing Level
In December 1978, at the request of the previous owner, the vessel was
re-measured by TC and a gross tonnage of 5.67 was assigned. The Board of
Steamship Inspection then required, among other things, that the vessel
carry two crew members for the safety of passengers. In 1979 the present
owner was hired as a second crew member. Since 1981, when the vessel
changed ownership, the new owner operated the vessel single-handedly.
The TCMS inspectors did not ensure that the operator had engaged a
second crew member to meet the requirement for a crew of two, prior to the
issue, each year, of the SIC 16. The certificates made no reference to
this requirement. This meant that an additional crew member trained in
emergency and survival procedures was not available to assist the master
during the sinking. An additional crew member, if properly trained, might
have been able to assist in the handing out of lifejackets to passengers
or in the launching of the inflatable liferaft located on the top of the
superstructure.
2.4 Meaning of "Fine Clear Weather only at Master's Discretion"
Passenger vessel inspection certificates issued by TCMS contain
limitations with regard to voyage and weather. The intent of the
limitations is to reduce risks to passengers on small vessels.
The master had worked on this vessel in the area of the marine park
since 1980. During this period he had experienced a range of weather and
sea conditions. When he sailed the morning of June 16, he had listened to
the weather broadcast and was aware of the weather, the small craft
warning, and the thunderstorm advisory.
The Ship Inspection Certificate restricted the vessel to sail in "fine
clear weather only at master's discretion." This notation is imprecise and
does not define any physical wind and sea limitations useful for small
vessel operators. The master considered that the operating restriction did
not prevent him from proceeding to Flowerpot Island, nor from returning to
Tobermory, in the prevailing weather and sea conditions.
The Board of Steamship Inspection exemption permitted the vessel to
sail in "fine and clear weather only . . . ." The Ship Inspection
certificates were different, in that the vessel was permitted to sail in
"fine clear weather only at master's discretion." This element of
discretion, which made the limitation less restrictive, was not contained
in the original exemption.
Definitions of "in fine weather" vary from one official publication to
another. For example, Transport Canada's Recommended Code of Nautical
Procedures and Practices (TP 1018), states that "the officer of the
watch should pay particular attention to the state of the weather and
sea." This would suggest that "weather" is distinct from "seas". The
Home-Trade, Inland and Minor Waters Voyages Regulations also refer
to voyages "in fine weather," but without any definitions. The Interim
Guidelines to the Interim Passenger Vessel Compliance Program also
introduce voyage limitations and provide an expanded definition of voyages
"in fair weather only" as "fine, clear settled weather, with a sea state
such as to cause only moderate rolling and/or pitching."
The lack of a clear definition of "in fine weather," and industry-wide
understanding of its derivations, leaves the interpretation of the
limitation up to individual masters and would be dependent on the size and
design of their vessels. Some may take it to mean atmospheric and sea
conditions, while others may take it to mean atmospheric conditions only.
The use of the qualifier "at master's discretion", which is often appended
to the limitation, further calls into question the effectiveness of such a
limitation.
2.5 Vessel Condition After Recovery
Inspection of the recovered vessel showed that the shell plating and
underwater fittings of the "TRUE NORTH II" were intact and effective in
preventing the entry of flood water into the hull. However, the lack of
watertight integrity of the main deck--due to the non-watertight condition
of three access hatches, the main engine casing and ventilators--made the
vessel highly vulnerable to downflooding in the event of water being
shipped on board. Since the non-watertight openings were distributed
throughout the length of the main deck and water downflooded through all
of them, transverse watertight subdivision would not have provided
protection against progressive flooding.
In order to ensure adequate drainage of shipped water from exposed
decks, the HCR require that vessels of all classes and tonnage be fitted
with bulwark freeing ports as set out in the Load Line Rules. The
actual freeing port area in the steel bulwarks on each side of the "TRUE
NORTH II" was approximately 10 percent of the minimum requirement and,
consequently, the rate at which shipped water could be cleared from the
main deck was severely limited. That two of the four freeing ports with
which the vessel was originally fitted were welded shut exacerbated the
situation and led to the rapid accumulation of shipped water on deck and
the subsequent downflooding of the underdeck compartment.
The total effective area of the foredeck scuppers was equivalent to one
75 mm internal diameter pipe, and any increase in their efficiency due to
the venturi (suction) effect of their external cowlings was only effective
when they were fully immersed and the vessel was making significant
forward progress. The water which was shipped over the bow and retained up
to the level of the bulwark top rail amounted to some 1.3 tonnes. While
this was draining through the scuppers and also flowing aft through the
gap at the bottom of the bridge front door, the vessel remained trimmed by
the bow. While so trimmed, the vessel was vulnerable to shipping more
water over the bow and the bridge front was also exposed to further wave
impacts.
The wood-framed plywood superstructure was open on each side and at its
after end, and was intended to provide some shelter from the sun, wind and
inclement weather for passengers carried on the main deck. Because of its
greater exposure to headwinds and bow spray, the bridge front was
constructed with two layers of 12 mm thick plywood, while the remainder of
the superstructure sides and the bridge front door were made from a single
layer. While the bridge front structure was more robust than the remainder
of the superstructure, the forward facing window and its frame was of less
than fully weathertight construction and unsuitable to withstand the loads
and impacts imposed by "solid" water. The single layer plywood
construction and insubstantial securing devices and hinges of the bridge
front door made it more vulnerable in the event of waves being shipped
over the bow.
The deteriorated condition of the bridge front and its wooden framing
in way of the door and window frames and the reduced support in the lower
area of the door were such that, in the event, the bridge front door and
window were unable to withstand the forces imposed on them.
The effective height__in way of the ship side guard chains
across the transom and at the after end of the open
superstructure__of 0.670 m was less than the 1.0 m minimum
safety requirement. While this condition was not a factor in the vessel's
sinking, it presented an unnecessary risk to passengers, especially on a
vessel that routinely carries groups of children.
2.6 Vessel Inspection
The operators of small passenger vessels may not always be conversant
with all safety requirements and may rely on the annual inspection as a
means of ensuring compliance with all of the various government regulatory
requirements. From the time of her entry into service as a passenger
vessel in 1972, until 2000, the "TRUE NORTH II" was inspected annually in
accordance with the Hull Inspection Regulations to ensure
compliance with HCR, LSE and other regulatory requirements. Throughout
this 28-year period various modifications and additions to the structure,
propelling machinery and safety equipment were carried out, which were
inspected and accepted by the (then) CSI, and latterly by TCMS.
The details of past annual inspections recorded in SIRS, together with
copies of the previous SIC 16, were routinely used as the basis upon which
subsequent annual inspections were conducted. However, the continual
reliance upon previously recorded data and approvals as a means of quickly
assessing the current status of the vessel did not achieve the fundamental
intent of the annual inspection, which was to provide an accurate safety
audit of the vessel's current condition. This practice led to the repeated
acceptance of unsafe features, including non-watertight unsecured hatches
and openings in the main deck, inadequate main deck freeing port and
drainage arrangements, and insufficient crewing.
The conduct of annual inspections of similar vessels in the above
manner became the established normal practice of TCMS, and developed into
what may be termed "a routine annual inspection syndrome" in which the
previously accepted structural features and information were not
questioned or subjected to renewed scrutiny. Consequently, safety audits
related to each of the annual inspections of the "TRUE NORTH II" were
based on initially inaccurate assessments of the watertight integrity and
the water-freeing capability of the main deck. As a result, the safety
audit defences, which should have been integral to each inspection, were
lost.
The scheduling of inspections of small passenger vessels in the
Tobermory area is dictated to a large extent by the seasonal nature of the
tourist industry, and most operators seek to have their vessels inspected
just prior to the start of each summer season. In practice, to cope with
the resultant congestion, several annual inspections were routinely
conducted on the same day by whichever TCMS inspector was currently
available. The inspectors so employed over the years had knowledge and
experience in the various available fields of expertise, including
nautical, marine engineering, hull, and small vessels.
Since the annual inspections were carried out on the "TRUE NORTH II" by
individual inspectors with specialized knowledge in certain fields and
limited cross-training in others, this led to a reluctance to question
previously accepted features that were outside an inspector's particular
field of expertise. Such inspection procedures contributed to the
continued acceptance of shortcomings in the vessel's condition.
The perennial continuation of such oversights was the result (in part)
of inadequate quality assurance procedures in relation to the
administration and monitoring of the annual ship inspection program by
TCMS District and Regional offices.
2.7 Passenger Safety Briefings
The operator of the "TRUE NORTH II" did not provide a safety briefing
to his passengers. Although such a briefing is not a regulatory
requirement, TCMS has issued Ship Safety Bulletin No. 4/95 (SSB)
recommending the practice. The passengers were not aware of the location
of the lifejackets, or the use of the buoyant apparatus and the liferaft
on the vessel. The teachers who had been on the vessel on several previous
occasions were unaware of the location of the lifejackets. Once in the
water, some of the passengers tried to open the buoyant apparatus
believing the lifejackets were inside.
In order to prepare for emergency situations, passengers must be well
informed of any safety precautions and emergency actions, including the
location of emergency equipment available on board. Safety briefings
provide critical information to passengers and prepare them for successful
evacuation in the event of an emergency. Previous TSB recommendations
(M94-04 and M96-05) identified this deficiency, but it continues to be
identified in spite of action taken by the authorities.
2.8 Life-saving Equipment
It is important that crew members have access to life-saving and
emergency equipment to distribute to the passengers to increase their
survivability when a vessel is being abandoned.
2.8.1 Carriage and Stowage of Lifejackets
The inspection certificates showed that, from 1980 to 2000, the number
of adults' lifejackets carried on board the "TRUE NORTH II" varied between
21 and 25; the number of children's lifejackets varied between 2 and 6.
None of the surviving passengers knew where the lifejackets were
stowed. Information submitted to TCMS in the spring of 1984 indicates the
lifejackets were to be stowed in the benches located on the afterdeck.
However, the lifejackets found on the "TRUE NORTH II" were stowed in a
compartment located along the port side passageway directly above the main
engine. An opening in the deckhead for the smoke stack and air intake
exposed the lifejackets to rain, smoke and ultraviolet light. Rather than
modify the compartment, the owner had wrapped the lifejackets in opaque
plastic bags to protect them. This practice, routinely accepted by TCMS
inspectors who inspected the "TRUE NORTH II", made the lifejackets less
conspicuous.
This situation was not improved by the lifejacket signage. The
placement of the sign and the size of the lettering were not sufficient to
effectively advise passengers of the location of the lifejackets. In
addition, the posting of tourist-related information on the compartment
door below the lifejacket sign competed for the viewer's attention. The
inadequacy of the signage could have been overcome through a pre-departure
safety briefing alerting the passengers to the location of the
lifejackets.
A lifejacket is designed to provide buoyancy and to keep an unconscious
wearer's head face-up above the surface when in the water. For the
lifejacket to perform as designed, the size of the lifejacket must be
appropriate to the body size of the wearer. If the lifejacket is too big
or too small, or is worn incorrectly, the wearer can be at risk of
drowning.
Current regulations require passenger vessels, similar to the "TRUE
NORTH II", to carry enough lifejackets for the number of adults authorized
to be carried under the inspection certificate issued for the vessel.
However, only 10 percent of that number must be lifejackets "suitable for
children." Only when the vessel "regularly" carries a known number of
children as passengers, is the vessel required to have one lifejacket for
each child. In the event of an emergency, it is critical to the safety of
all passengers that they each have a suitable lifejacket.
2.8.2 Buoyant Apparatus and Lifebuoys
The LSE Regulations permit a vessel to carry buoyant apparatus
instead of a liferaft, provided certain safety requirements are met. In
this occurrence, since the vessel sank without the liferaft being
deployed, the buoyant apparatus were critical to the master and passengers
reaching shore successfully. However, as the buoyant apparatus offered
only a small surface area, the master and the passengers were immersed in
10ºC water. Consequently, they found it difficult to cling to the
apparatus and were at severe risk of hypothermia. It should be noted that
the vessel sank some 200 m directly upwind of Flowerpot Island, and the
waves pushed the apparatus directly towards the island.
Because the lifebuoys were stowed inside the viewing well, they were
contained within the superstructure and did not float clear of the vessel
as she sank.
2.8.3 Inflatable Liferaft Securing and Deployment
In 1996 the owner added an inflatable liferaft to the life-saving
equipment on board the vessel. The lashing that secured the liferaft in
the cradle was fitted with a Senhouse slip that required manual operation
in order to deploy the liferaft. The liferaft was not readily accessible,
as there was no provision for easy access to the top of the
superstructure. Although launching the inflatable liferaft is considered a
two-person operation, the vessel was operated single-handedly, and prior
to departure the master did not brief any of the passengers to assist him
in this task in the event of an emergency. After swimming to the top of
the superstructure, the master could not reach the already immersed
liferaft in time to manually release the Senhouse slip. As a result, the
liferaft sank with the vessel.
The liferaft was required to be fitted with either a hydrostatic
release unit or to be stowed in deep chocks (without lashings). The
absence of either of these devices had not been identified by TCMS
inspectors in 1996 when the liferaft was installed, and none was fitted
thereafter. As a result, the lashing that secured the liferaft to its
cradle was not fitted with a hydrostatic release device or other means to
allow the liferaft to float free when the vessel sank.
2.9 Emergency Communications
Due to rapidly moving events, the situation became difficult to manage,
and after the bridge front door was stove in, the master could not
transmit a Mayday or distress signal nor make any request for assistance
on the VHF radio. Except for that radio, the vessel had no other means of
alerting the CCG station or the parks warden that the vessel was in
distress. Like most small passenger vessels, the "TRUE NORTH II" was not
required to carry an automatic distress alerting system such as an EPIRB
to alert SAR authorities in the event of a distress situation. At present,
passenger vessels under 20 m in length are not required to carry an EPIRB.
As there was no sailing plan with a pre-determined time of departure
and arrival, no one in Tobermory was aware that the vessel had been lost.
Consequently, SAR authorities were not aware of the distress situation
until a passing pleasure craft observed the two buoyant apparatus and
notified the local Coast Guard radio station.
3.0 Conclusions
3.1 Findings as to Causes and Contributing Factors
- The master sailed to Flowerpot Island in near gale-force winds,
while a small craft wind warning and thunderstorm advisory were in
effect.
- On the return voyage, successive waves stove in the vessel's bridge
front door and window, and shipped water rapidly flooded the main deck
through the front and port side openings of the superstructure.
- Ineffective scuppers and insufficient freeing port area caused the
shipped water to be retained on deck and quickly downflood the underdeck
compartment through non-watertight hatches and deck openings. As a
result, the vessel lost reserve buoyancy and sank rapidly by the
stern.
- Modifications to the vessel had compromised its watertight
integrity.
- The absence of a pre-departure safety briefing, the inconspicuous
lifejacket sign, and the lack of an emergency equipment plan resulted in
the passengers being unaware of the location and use of life-saving
appliances on board the vessel.
- At the time of the sinking, the master was in sole charge of the
vessel, with no other crew member available to guide or render
assistance to the passengers during and after the abandonment.
- The inflatable liferaft stowed on the top of the superstructure was
not readily accessible and required human intervention for its
deployment. The liferaft sank with the vessel because it was neither
placed in deep chocks without lashings nor fitted with a hydrostatic
release unit.
3.2 Findings as to Risk
- Since 1972, unsafe structural features were improperly assessed
during the vessel's annual inspections by TCMS, and remedial action was
not taken to address these risks.
- In the event of underwater damage, the risk of loss of stability and
sinking is greatly increased by the absence of transverse watertight
bulkheads.
- The continuous acceptance of structural shortcomings was the result
of, in part, inadequate quality assurance procedures in relation to the
administration and monitoring of the annual ship inspection program by
TCMS.
- The voyage limitation on the Ship Inspection Certificate restricted
the vessel to sail "in fine clear weather only at the master's
discretion." Such wording is imprecise and does not adequately define
wind and sea parameters.
- The vessel was required to be crewed by two persons, but this
requirement was not implemented and subsequent Ship Inspection
Certificates made no reference to the requirement for an additional crew
member.
- Due to the rapidity of the sinking, the master did not transmit a
distress call on the VHF radio. The vessel was not required to be
equipped with an automatic distress alerting system such as an EPIRB,
and there was a delay in alerting the SAR station, which increased the
on-scene response time.
- Unsecured debris floating inside the vessel's superstructure may
have posed an increased risk to passengers trying to escape the sinking
vessel.
3.3 Other Findings
- The master and 17 passengers, who were not wearing lifejackets,
escaped the sinking vessel and swam to two buoyant apparatus which
drifted to Flowerpot Island in the onshore wind.
- TCMS examination and certification procedures did not require
examiners to file a report on their assessment of a candidate for oral
examination. It is not possible to determine how the examiner assessed
the master's competence in operating the "TRUE NORTH II".
- The syllabus for Master, Limited, does not cover ship construction
or meteorology, two subject areas that might have helped the master to
recognize the vessel's vulnerability.
4.0 Safety Action
4.1 Action Taken
4.1.1 Advisory on Liferaft Release Mechanism
In October 2000 and January 2001 the TSB sent a Marine Safety Advisory
(MSA 00-09) to Transport Canada indicating serious shortcomings with the
inspection of life-saving equipment and the lack of a float-free
arrangement for liferafts on many small passenger vessels operating in
Canadian waters.
In response, TCMS has indicated that an amendment to the LSE
Regulations has been prepared and will require vessels under 25 m in
length to have liferafts, if fitted, that will "float free" if the vessel
sinks. In the interim, TCMS has drafted a Ship Safety Bulletin to address
the stowage and float-free arrangements for liferafts.
4.1.2 Review of Passenger Vessel Inspection and Certification
As a result of this occurrence, TCMS initiated a review of its
inspection and certification processes and procedures for passenger
vessels in the Ontario Region. As a result of this internal review, TCMS
made recommendations in four key areas:
Regulatory Review and Audit
- to review a sample of small passenger vessels' files in different
regional offices to detect non-conformities;
- to institute a formal process of monitoring inspectors' reports on
inspections;
- to avoid the use of "fair or fine weather" and to define a set of
parameters such as sea states;
- to review regional directives; and
- to initiate a National Marine Safety Circular from headquarters to
the regional offices, and to clients.
Operations and Inspections
- to update notices to surveyors;
- to review inputs and extraction of SIRS information and preparation
of inspection certificates;
- to inform inspectors of the required information that is to be
placed on a ship file as a result of an inspection;
- to discuss regulatory and policy changes at regular intervals;
- to make reference to water temperature in SIRS and on the
certificate when the number of persons on board a vessel and the
provision of life-saving equipment is based on water temperature; and
- to provide instructions on the use of special passenger complement
allowances shown on the inspection certificates.
Information Management
- to develop procedures for provision and distribution of electronic
information;
- to highlight regulatory amendments and changes of policy to marine
inspectors;
- to introduce and ensure availability of a controlled electronic
version of all documents;
- to transmit full text of board decisions;
- to develop procedures to control the sources of information provided
to inspectors; and
- to provide instruction on the use of forms when new or modified
forms are implemented.
Training and Performance Assessment of Inspectors
- to develop procedures to assess marine inspectors' core competencies
and regulatory effectiveness;
- to provide training courses and policies for the proper use of the
SIRS II;
- to locate clients;
- to institute a training program for new inspectors for early
introductory training prior to formal appointments, and to introduce a
mentoring program; and
- to review the appointment of inspectors.
Subsequent to the above review, TCMS has advised the TSB of various
actions that have been taken, or are planned, to address the four key
areas. For details see Appendix
C.
4.1.3 Weather Limitation
Subsequent to this occurrence, and the above-noted review, TCMS found
that the use of "fair or fine" weather as a voyage limitation is ambiguous
and that its use should be discontinued.
4.2 Action Required
4.2.1 Adequacy of TCMS Inspection Regime and Safety Culture
Vessels such as "TRUE NORTH II" are required to be inspected annually
to ensure that the structural condition of the hull, the condition of the
machinery, electrical, life-saving, navigation and communication equipment
continue to be fit for safe operation. The inspection also includes a
process to make sure that not only the vessel and its equipment are fit
but that crews are competent to safely operate their vessels.
The operators of passenger vessels such as "TRUE NORTH II", small
vessels and small fishing vessels alike, may not always have comprehensive
knowledge of safe operating practices and the safety requirements of their
vessels. As such, the safety of passengers can become dependent upon
safety inspections as a means of ensuring that the condition of these
vessels is safe for the intended operation, that adequate safety
appliances are carried and that all safety requirements are met.
This investigation has found procedural, performance and management
deficiencies associated with the safety inspection regime of the safety
inspection program. These deficiencies included the following:
- the inspections did not identify modifications that negatively
affected the watertight integrity and overall safety of the vessel;
- TC Board of Steamship Inspection Meeting (3470) placed a voyage
limitation and listed crewing and life-saving requirements for the
vessel. These requirements were never transmitted to the vessel's owner;
- the existing TCMS inspection regime did not ensure that the TC Board
of Steamship Inspection decisions were implemented or monitored;
- the inspections did not identify that the lifejackets and the
liferaft were not readily accessible in the event of an emergency;
- the safety implications of the above shortcomings were not
recognized by the inspectors and the annual inspection certificate (SIC
16) was routinely issued;
- there was no quality control or audit function that might have
identified performance deficiencies and non-conformities to alert
management to the need for corrective action.
The deficiencies in the TCMS ship inspection regime, found in this
investigation, are not limited to this vessel, or this region. Since 1990
the TSB has conducted several investigations into marine accidents in
which deficiencies related to the ship inspection regime have been noted:
|
M90L3033 |
"LE BOUT DE LIGNE" |
M90L3034 |
"NADINE" |
M92W1081 |
"BARGE LC 15" |
M93M0007 |
"THE PAMELA & JENELLE L" |
M93W1015 |
"ATOMIC II" |
M93W1050 |
"ARCTIC TAGLU" |
M98F0009 |
"TWIN J." |
M98L0149 |
"BRIER MIST" |
M98W0239 |
"HARKEN No. 5" and barge "BARNSTON ISLAND No. 3" |
M99W0133 |
"SUNBOY" |
M00H0008 |
"AVATAQ" |
For example, in the investigation into the 1998 swamping and sinking of
the scallop dragger "BRIER MIST" (M98L0149), off Rimouski, Québec, where
five fishermen lost their lives, the Board found that despite the vessel
having been inspected five times by TCMS inspectors, the hatch covers had
not been modified to comply with safety standards. On the basis of the
information gathered during the inquest into the "BRIER MIST", the coroner
also recommended that the existing regulations, with respect to such
openings, be enforced by TCMS inspectors.
In 1994, following its investigation into the 1990 sinking of the small
fishing vessel "LE BOUT DE LIGNE" (M90L3033) in the Gulf of St. Lawrence,
the Board found that there were no procedures in the ship inspection
regime for systematically accounting for modifications adversely affecting
vessel safety. If TCMS is not notified of such modifications by the
owners, inspectors often do not account for the modifications in their
routine safety inspections.
The Board recommended that TCMS explore means to ensure that added
weight and structural modifications are recorded and accounted for in
reassessing vessel safety (M94-32, issued December 1994). In response to
this recommendation, TCMS indicated that it is the responsibility of the
owners/operators to notify it of such modifications and that regulations
already exist that require owners/operators to do so. In other words, if
the regulations are followed, modifications will be identified and
incorporated into the inspection process. This approach to safety does not
address this deficiency in the ship inspection regime.
Modifications to the "TRUE NORTH II", such as the addition of
equipment, the welding-shut of the freeing ports and the non-watertight
integrity of the deck, went unnoticed and therefore were unaccounted for
by inspectors during their routine inspections.
As a result of this accident, TCMS, Ontario Region, is conducting its
own review of the inspection and certification process in regard to the
"TRUE NORTH II" and similar vessels. The Board understands that the review
and audit will not be restricted to this vessel or this region alone and
will extend throughout the TCMS organization. The Board is encouraged and
hopes that this will lead to the timely identification of safety
deficiencies and to effective risk mitigation. The Board also notes that
although some actions, recommended by this "review" may have been
completed, many issues have not yet been addressed and several are
currently in the planning stage. In view of the fact that quality safety
inspections and timely identification of unsafe practices and conditions
are critical to the safety of crews and passengers, particularly those
carried on small vessels, the Board recommends that:
The Department of Transport establish a timetable to expedite the
review of the deficiencies in the inspection and certification process,
and that it make interim progress reports to the public demonstrating
the extent to which these deficiencies have been resolved.
M01-01
Furthermore, the Board believes that for the TCMS ship inspection
regime to achieve its safety objectives, current systemic deficiencies
need to be addressed in a broader context. TCMS bases its safety
philosophy on a foundation of compliance with rules. At the same time,
however, extensive grandfathering of vessels takes place, and this
permits vessels that have actual or potential safety deficiencies to
operate outside appropriate rules. While the Board believes that
compliance with rules is necessary, rule compliance alone is not
sufficient. A "rule-book" approach can produce too narrow a focus where
safety inspectors routinely do not recognize those safety deficiencies not
covered by regulations and, as a consequence, the deficiencies are not
addressed.
The most rigorous set of rules will not cover every aspect of a safety
system. The interpretation and judgement of safety inspectors is necessary
to evaluate unsafe conditions both inside and outside the regulatory
framework. The Board believes that, with appropriate management support
and guidance, TCMS ship inspectors are capable of recognizing and
addressing unsafe practices and conditions not proscribed by regulations.
Therefore the Board recommends that:
The Department of Transport, Marine Safety, instill within its
organization an approach to safety that would enable management and
safety inspectors to identify and address all unsafe practices and
conditions and not limit inspection only to compliance with rules.
M01-02
4.2.2 Emergency Preparedness and Survivability
In rapidly developing distress situations, such as those encountered by
the "TRUE NORTH II", it is critical that life-saving equipment be readily
available and accessible for use by crews and passengers.
Pre-departure safety briefing
Previous accidents have convinced the Board that pre-departure safety
instructions can increase the chances for survival in an emergency
situation. Since there was no life-saving equipment plan or pre-departure
safety briefing, the passengers were unprepared for an emergency and did
not know the location of the lifejackets or the other emergency equipment
and life-saving appliances. The use of this equipment was not demonstrated
before departure; such a demonstration is not a common practice among
small passenger vessel operations. Such pre-departure safety briefings,
and the demonstration of safety equipment, have been the norm on large
passenger vessels and in the aviation industry for many years, where they
have enhanced passenger safety, and saved lives.
In 1996, the Board also recommended to Transport Canada that it
"require the operators of small sight-seeing boats to provide
pre-departure safety instructions to the passengers for normal operating
conditions and for emergency situations" (M96-05). To date, while
operators have been encouraged by Transport Canada to do so, there is no
requirement for the operators of small passenger vessels to provide
pre-departure safety briefings to passengers.
Life-saving equipment
It has also been learned that the ready availability of life-saving
equipment is crucial to its deployment and use in an emergency situation.
Although lifejackets were carried aboard the vessel, they were stowed in
such a way that they were not readily available. Two lifebuoys were also
carried in such a way that they were not readily available to the
passengers in distress. All this life-saving equipment was intended to be
used by passengers in an emergency situation, but it was not used.
In 1994 the Board issued two recommendations to Transport Canada, that
it "initiate research and development into ways of ensuring the
accessibility of all emergency equipment, including in a capsizing
situation" (M94-05); and "conduct a formal evaluation of current practices
for the stowage of life preservers and immersion suits on fishing vessels
with a view to ensuring immediate accessibility" (M94-08). Action has been
taken by Transport Canada in respect of the accessibility of life-saving
equipment on board fishing vessels. However, the Board is concerned with
current practices on board small passenger vessels which continue to
compromise accessibility of all emergency equipment.
Liferaft
The inflatable liferaft on "TRUE NORTH II" was not fitted with a
hydrostatic release unit, nor was it able to float free; it required human
intervention to deploy. In addition, it was secured on top of the
superstructure, to which there was no means of easy access. Consequently,
it sank with the vessel.
After the accident, the TSB conducted an impromptu survey of 25 vessels
in the Toronto and Tobermory areas to examine the securing arrangements of
liferafts and buoyant apparatus. The survey found that many liferafts on
board passenger vessels were installed and secured in such a way that they
would not deploy as intended and thus would likely not be of assistance in
a distress situation. Subsequently, the TSB apprised TCMS of these unsafe
conditions (MSA 09/00).
Since 1995, five TSB marine investigation reports found that
difficulties were encountered in deploying liferafts due to inappropriate
securing arrangements and in which there was a subsequent loss of life.[10]
In one instance, involving the sinking of the scallop dragger "CAPE ASPY",
the Board identified the same deficiency and subsequently TCMS issued a
related SSB (No. 9/93) on this subject.
Again, as a result of the investigation into the sinking of "BRIER
MIST", the TSB forwarded another MSA (No. 09/00) to TCMS on the same
subject.
The Board notes that, as a result of the MSA 09/00, TCMS is preparing
an amendment to the LSE Regulations that will require all vessels
under 25 m in length to have liferafts arranged for float-free operation.
However, these requirements will not apply to fishing vessels and vessels
under 5 tons which carry fewer than 12 passengers. The deficiency will
continue to exist on fishing vessels, which account for approximately 50
per cent of all accidents.
Emergency communications
It is essential that shore-based facilities be able to respond to
emergency situations without delay. Time gained in the initial stages of
an occurrence can be crucial to the saving of life. In this instance, the
rapidity with which the "TRUE NORTH II" sank precluded a Mayday
transmission. The rescue effort began once search and rescue authorities
were informed of the accident by a vessel which happened to pass by and
noticed the people in the water.
There are a number of means, available on the market, of alerting
others of an emergency situation, other than calling on a marine VHF
radiotelephone. These include emergency position-indicating radio beacons
(EPIRBs) and search and rescue transponders (SARTs).
In 1994, as a result of the accident involving a small open charter
boat (M92W1031), the Board issued a recommendation that Transport Canada
"encourage all charter vessel operators to equip their vessels with
life-saving and emergency communication and/or signalling equipment
suitable for the type of operation" (M94-03). While EPIRBs and SARTs are
required to be carried on vessels, they are not required on small vessels
such as the "TRUE NORTH II" in her area of operation.
Despite identification of these safety deficiencies relating to
emergency preparedness and survivability, the Board's recommendations and
Transport Canada's subsequent action taken, the Board's investigations
continue to demonstrate that these safety deficiencies remain unresolved.
The Board therefore recommends that:
The Department of Transport require small passenger vessels to
provide pre-departure briefings, and to be equipped with a liferaft that
is readily deployable, life-saving equipment that is easily accessible,
and the means to immediately alert others of an emergency situation.
M01-03
4.3 Safety Concern
4.3.1 Crew Competency Evaluation and Certification Process
TCMS issued the operator of the "TRUE NORTH II" a CSC certificate in
1980 after an oral examination. As a result of a regulatory change, the
certification was exchanged for a CL certificate in 1997, without
examination.
The CL certificate is a certificate of competency that has to be
renewed every five years. The certificate requires oral, written and
practical examination on subject matter appropriate to the area of
operation and the type of vessel to which the certificate applies.
However, TCMS examiners may renew certificates, without an examination, if
they are satisfied that holders have continued to and will operate in the
same certificated capacity. In a previous occurrence, involving the tanker
"PETROLAB" (M97N0099), TCMS was apprised of a similar safety issue: the
issuance of a tanker endorsement based upon previous experience, without
an examination.
The assessment of the competence of the operator of the "TRUE NORTH II"
was based on his possession of an existing certificate and on his
experience working in the Tobermory area for a long time. However,
throughout this time he had operated his vessel with a number of
unrecognized unsafe conditions and practices that compromised safety.
The investigation found that the following unsafe conditions and
practices had become the norm over a period of several years:
- the lifebuoys and the liferaft were stowed or fitted in a manner
that made them not readily available for deployment, and they sank with
the vessel;
- the lifejackets were wrapped in plastic bags and were stowed in a
compartment that was neither easily accessible nor readily identifiable;
- two freeing ports had been welded shut, which prevented water
shipped on deck from draining overboard;
- the vessel was operated without a means of closing the openings in
the main deck;
- the vessel was operated with insufficient freeing-port area, such
that shipped water was entrapped, to the detriment of vessel freeboard
and stability; and,
- a ventilation opening in the engine-room casing compromised the
watertight integrity of the hull.
Individually, these deficiencies might not have resulted in the sinking
of the vessel and the loss of life, but together they did. For an operator
to take the measures necessary to minimize risk, the operator must be
aware of safety deficiencies. This awareness depends on an operator having
sufficient knowledge to understand how the deficiencies present a risk to
safety.
The master of "TRUE NORTH II" was initially examined, and his
certificate renewed, several times by TCMS. Given the above unsafe
conditions and practices, the basis on which the certificate was granted
and renewed is questionable. However, since documentation of the
evaluation process for the issuance of the certificates was not kept, the
Board was unable to identify specific shortcomings in the process.
In the past decade, the TSB has identified deficiencies in training,
knowledge and certification requirements for operators in several of its
investigations into accidents involving small passenger vessels, work
boats, and small fishing vessels.
In its report on the swamping of the "CROWN FOREST 72-68" (TSB Report
No. M93W0005), the Board noted that trained personnel with a knowledge of
the vessel's stability and of free-surface effect would have been able to
recognize the risks associated with operating the craft under the
conditions that led to the sinking of the vessel. In its report on the
capsizing of the fishing vessel "FLYING FISHER", the Board expressed
concern that inadequately trained personnel on fishing vessels were
contributing to the frequency and the severity of such marine occurrences
(TSB Report No. M91W1075).
As a result of the investigation into the accident involving the small
sight-seeing vessel "TAN 1" (TSB Report No. M93L0003), the Board noted
that the lack of adequate knowledge of safety measures can have serious
consequences in emergency situations. Consequently, the Board recommended
that:
The Department of Transport develop training standards and
certification requirements for the operators of small sight-seeing boats
that carry fare-paying passengers. (M96-01, issued March 1996)
The aforementioned findings and recommendations underline the critical
importance of the knowledge, skill, and competency of masters and officers
to the safety of persons on board. TCMS's initial certification and
renewal process is to confirm that operators possess__and
continue to possess__the knowledge and competence necessary for
the safe operation of the vessel and for the safety of the people it
carries.
The Board is concerned that any shortcoming in the evaluation and
certification process may result in allowing operators with inadequate
competency to maintain and operate vessels, thereby inadvertently placing
crews and passengers at undue risk in emergency situations. The Board will
be monitoring the situation to determine if appropriate remedial action is
being taken and will assess the need for further action on this issue.
This report concludes the Transportation Safety Board's
investigation into this occurrence. Consequently, the Board authorized the
release of this report on 26 April 2001.
Appendix A - Sketch of the Occurrence Area
Appendix B - List of Additional Information
The following reports have been prepared in connection with the
occurrence:
Underwriters Laboratory Test of Lifejackets
TSB Inclining Experiment and Rolling Period Test Report
Appendix C - Transport Canada Proposed Actions
Regulatory Review Audit
- to review a sample of small passenger vessels' files in different
regional offices to detect non-conformities:
All passenger vessel files in Ontario Region and a sample of
passenger vessel files nationally will be reviewed in the respective
TC, Marine Safety Regional Offices. If any non-conformities are noted,
action will be taken immediately to rectify by means of letter to the
owner or operator and the SIRS record updated to note the deficiency.
In particular, crewing and life-saving equipment are to be examined.
This sample of the files will be expanded in size if non-conformities
are found.
- to institute a formal process of monitoring inspectors' reports on
inspections:
TC, Marine Safety has developed guidelines to ensure control and
harmonization of inspection reports on a national basis.
TC, Marine Safety has revised the feedback procedures to ensure
that inspection report deficiencies are properly reported to the
respective Marine Safety Regional Director.
TC, Marine Safety has prepared instructions to inspectors
addressing compulsory information that is to be included in inspection
reports.
- to avoid the use of "fair or fine weather" and to define a set of
parameters such as sea states:
TC, Marine Safety is in the process of developing a guide for
correct terms to be used in describing weather restrictions on
certificates.
- to review regional directives:
TC, Marine Safety Headquarters has instructed all Regions to
provide them with copies of all "regional directives" issued in order
that the directives can be reviewed.
- to initiate a National Marine Safety Circular from headquarters to
the regional offices and clients:
TC, Marine Safety is developing a format and process for advising
stakeholders of policy decisions and changes in Marine Safety.
Operations and Inspections
- to update notices to surveyors:
TC, Marine Safety has started to revise the "Notices to
Inspectors". Those parts of the Notices which reference small vessel
inspections are being given priority in the process.
- to review inputs and extraction of SIRS information and preparation
of inspection certificates:
TC, Marine Safety is in the process of developing a new ship
inspection system. This new system will enable the inspector to issue
a certificate taking into consideration information stored in the
system's database. The system will not accept input unless all the
information required has been entered into the report.
- to inform inspectors of the required information that is placed on a
ship file as a result of an inspection:
TC, Marine Safety has prepared instructions to inspectors
addressing compulsory information that is to be included in inspection
reports. The new SIRS system, which is in the process of being
developed, will be configured to reject incomplete files and to notify
the administrator of all such rejections for immediate follow-up.
- to discuss regulatory change and policy changes at regular
intervals:
The Chairman of the Board of Steamship Inspection sent a letter to
all members of the Marine Safety National Management Committee (MSNMC)
in August 2000, regarding the importance of regular staff meetings to
discuss regulatory and policy changes. MSNMC, which includes TC
Headquarters and Regional Marine Safety Directors, holds monthly
meetings as well as short weekly telephone conferences.
- to make reference to water temperature in SIRS and on the
certificate when the number of persons on board a vessel and the
provision of life-saving equipment is based on water temperature:
TC, Marine Safety has prepared instructions regarding the
information on both the certificate and the Ship Inspection System
(SIRS) when the permitted numbers of persons on board and the
provisions of life-saving equipment is based on the ambient water
temperature that the vessel is operating in. The revised Notices to
Inspectors will also provide further instructions to the inspector.
- to provide instructions on the use of special passenger complement
allowances shown on the inspection certificate:
Instructions concerning the use of special passenger complement
allowances are shown on the inspection certificate (SIC 16).
Information Management
- to develop procedures for provision and distribution of electronic
information:
TC, Marine Safety is developing an Information
Management/Information Technology (IM/IT) Policy and Procedures Manual
which will include a national process for the dissemination of
information to TC, Marine Safety personnel. The process will include
audit procedures.
- to highlight regulatory amendments and changes to policy to marine
inspectors:
In addition to the previously mentioned directive by the Chairman
of the Board of Steamship Inspection to the MSNMC regarding the
importance of regular staff meetings to discuss regulatory and policy
changes, the Intranet and Internet is the main medium for highlighting
regulatory amendments and policy changes. The TC, Marine Safety Review
newsletter will also report any new regulatory amendments and policy
changes.
- to introduce and ensure availability of a controlled electronic
version of all documents:
A system is being developed to ensure that documentation used by
TC, Marine Inspectors is current and that changes are transmitted in a
timely manner. Part of this system includes development of a new
on-line Transport Publication database, a Board Decision application
and an on-line IM/IT Policy and Procedures Manual.
TC, Marine Safety has also developed a controlled Electronic
Library containing master copies of Ship Safety Bulletins, Transport
Publications (TP's) and Board Decisions.
- to transmit full text of Board Decisions:
The full text of Board Decisions, dating back to 1986, is currently
available to all TC, Marine Safety staff via a computer based system
together with a small database which allows limited search
capabilities, as well as a copy of final Board Decisions will be
provided to the appropriate shipowner.
TC, Marine Safety is in the process of creating an improved Board
Decisions application for the Transport Canada Intranet which
incorporates the full text of Board Decisions from 1960 to present and
also allows advanced search capabilities. Data previous to 1960 will
be incorporated into the database at a later date.
- to develop procedures to control the sources of information provided
to inspectors:
As stated previously, a system is being developed to ensure that
documentation used by TC, Marine Inspectors is current and that
changes are transmitted in a timely manner.
- to provide instruction on the use of forms when new or modified
forms are implemented:
TC, Marine Safety has already put in place a policy whereby new
forms are not introduced until instructions on the use and method of
completion of the form are available. Furthermore, Regional Marine
Safety Directors have been instructed that any new forms are not to be
developed and used without prior approval from TC, Marine Safety
Headquarters.
Training and Performance Assessment of Inspectors
- to develop procedures to assess Marine Inspectors' core competencies
and regulatory effectiveness:
TC, Marine Safety is currently conducting a needs assessment survey
with marine inspectors to identify training requirements. These
requirements will establish the training priorities in line with
operational and national programs and regulatory requirements.
- to provide training courses and policies for the proper use of the
SIRS II:[11]
TC, Marine Safety will review and revise existing SIRS training
programs and ensure that they are available to all Regional staff.
This will ensure that the SIRS system is properly used.
- to locate clients:
TC, Marine Safety is aware that in order to effectively address the
issues concerning small passenger vessels, accurate information has to
be gathered on the size of the industry and the client population.
Marine Safety has let a contract to gather such information. This
information will be assembled into a database which can then be
analysed and used to make policy and regulatory decisions regarding
small passenger vessels. A publicity campaign will be launched in the
summer of 2001 which will include handouts, pamphlets and the presence
of a kiosk at various marine conferences. Transport Canada will
introduce, on their web-site, a specific area dealing with small
vessels.
- to institute a training program for new inspectors for early
introductory training prior to formal appointments and introduction of a
mentoring program:
Currently, TC, Marine Safety is offering specific technical courses
required in order to appoint inspectors under delegated authorities.
Additionally, on-the-job-training scenarios are highly utilized with
newly recruited Port Wardens and Examiners, as well as a combination
of on-line inspector handbooks and orientation manuals. Training is
currently under development, or at the pilot stage, for Quality
Assurance, Introduction to Examination, Ship Certification and
Orientation to New Inspectors.
A mentoring program is in the preparatory stage of development and
will be tested on a specific program area. This mentoring approach
will be monitored throughout its adoption to determine effectiveness,
applicability and adoption for use in other program areas.
- to review the appointment of inspectors:
The appointment process was initially instituted upon the
consolidation of the appointment process function in 1998/99. Based on
an existing requirement deriving from the Privy Council Office and the
Minister's Office, the process is a step-by-step process requiring
consultation and decision by several levels. The process has been
reviewed, to simplify it, and implemented by Marine Safety in January
2001.
Appendix D - Glossary
A |
|
aft |
C |
|
Celsius |
CCG |
|
Canadian Coast Guard |
CCGS |
|
Canadian Coast Guard Ship |
CL |
|
Master, Limited (certificate) |
cm |
|
centimetre |
CSA |
|
Canada Shipping Act |
CSC |
|
Master, Small Craft (certificate) |
CSI |
|
Canadian Steamship Inspection |
DOT |
|
Department of Transport |
DSC |
|
digital selective calling |
EDT |
|
eastern daylight time |
EPIRB |
|
emergency position-indicating radio
beacon |
GM |
|
transverse metacentric height |
HCR |
|
Hull Construction
Regulations |
kg |
|
kilogram |
km/h |
|
kilometre per hour |
kW |
|
kilowatt |
LSE |
|
Life Saving Equipment
[Regulations] |
m |
|
metre |
M |
|
nautical mile |
MCTS |
|
Marine Communications and Traffic
Services |
MED |
|
marine emergency duties |
mm |
|
millimetre |
MSA |
|
Marine Safety Advisory |
N |
|
north |
RCC |
|
Rescue Coordination Centre |
SAR |
|
search and rescue |
SART |
|
search and rescue transponder |
SIC |
|
Ship Inspection Certificate |
SIRS |
|
Ship Inspection Reporting System |
SSB |
|
Ship Safety Bulletin |
TC |
|
Transport Canada |
TCMS |
|
Transport Canada Marine Safety |
TSB |
|
Transportation Safety Board of
Canada |
UTC |
|
coordinated universal time |
VHF |
|
very high frequency |
VTS |
|
Vessel Traffic Services |
W |
|
west |
º |
|
degree |
' |
|
minute |
|