TRANSPORTATION SAFETY M A R I N E

Transportation Safety Board Bureau de la sécurité des transports

of Canada du Canada







TRANSPORTATION SAFETY









Issue 22 – July 2005



M A R I N E









The Lady Duck

The Toughness of Steel

The Bridge and the Windoc

Contents

The Lady Duck . . . . . . . . . . . . . . . 2



A Lesson in Firefighting . . . . . . . . 9



The Toughness of Steel . . . . . . . 12



The Bridge and the Windoc . . . . 16



The Harsh Arctic . . . . . . . . . . . . 20



Statistics . . . . . . . . . . . . . . . . . . . 24



Summaries . . . . . . . . . . . . . . . . . 25



Investigations. . . . . . . . . . . . . . . 30



Final Reports . . . . . . . . . . . . . . . 32









2 12 16

The Lady Duck The Toughness The Bridge and

of Steel the Windoc









www.tsb.gc.ca Reflexions is a safety Pass it on! The articles in this issue of

For information on digest providing feed- To increase the value Reflexions have been compiled

the TSB and its work, back to the transporta- of the safety material from official text of TSB reports.

including published tion community on presented in Reflexions,

reports, statistics, and safety lessons learned, readers are encouraged

other communications based on the circum- to copy or reprint, in Également disponible

products, please see stances of occurrences part or in whole, for en français

the TSB Web site. This and the results of TSB further distribution but

issue of Reflexions is also investigations. should acknowledge ISSN 1499-2469

posted on the Web site. the source.

Being Safety Conscious

Risk does not discriminate. Large bulk carriers, cruise ships, tankers, fishing vessels, tug

boats and small passenger vessels are susceptible to it, whether at sea or in harbour. The

Transportation Safety Board of Canada investigates a wide spectrum of marine occurrences

each year; some result in tragedy, some do not, and some have international repercussions.



This issue of Reflexions offers an interesting cross-section. Each may stem from different circum-

stances, but all highlight the uniqueness and complex nature of an accident. Rarely is there one

single event responsible for an occurrence. Instead, investigators must sift through a series of

underlying causes and contributing factors.



This presents significant challenges for investigators. These challenges are compounded by

the need to remain current with shipping and operational practices of all vessel types.

As a result, it is more and more complex to identify and verify safety deficiencies in

order to advance transportation safety.



The reductions in risk are no accident. They have resulted from actions taken by all partners,

often based onthe results of our investigations. Reported marine accidents and vessel losses are

at a 30-year low. However, this encouraging statistic does not diminish the importance of the

findings of our investigations: personal injuries caused by accidents, for example, have not

followed the same trend.



Lessons learned about what happened, why it happened and how we can avoid a recurrence

will continue to offer critical insight and information for each and every one of us.



Risk may not discriminate, but we can avoid being its target. This starts by being safety

conscious, and continues with a relentless commitment to minimize unsound policies and

practices. We trust that the following pages will help readers appreciate the severity of what

might happen and to reflect on the possible consequences.









Charles H. Simpson

Acting Chairperson









REFLEXIONS Issue 22 – July 2005 1

Lady Duck after

recovery at the

Hull Marina









The Lady Duck

What began as a land-sea cruise on the Ottawa River, Ontario, on 23 June 2002, ended with the sinking of

the amphibious vehicle Lady Duck. Of the 12 people on board, 6 passengers, the driver, and the tour guide

escaped from the vehicle and were recovered by private craft on the scene at the time of the sinking. Four

passengers, trapped within the sunken vehicle, drowned. — Report No. M02C0030



The vehicle was based on the Passenger Cabin A fabric awning provided pro-

conversion of a Ford F-350 truck A passenger boarding ramp, tection from inclement weather.

chassis. The original gasoline located at the rear left corner Roll-down transparent weather

engine was used for on-road of the vehicle, hinged up to a screens were arranged on each

operation. A gasoline-powered steel sill and a flexible gasket to side of the passenger area for

Mercruiser inboard/outboard ensure the watertight boundary additional protection.

(I/O) at the rear was used of the passenger deck. The ramp

for water-borne propulsion. was lifted to the closed position Approved lifejackets were stowed

by an electrically driven winch in lockers under each of the

The bottom of the chassis and secured with hasps on each passenger seats and, at the time

was enclosed with welded and side of the ramp. of the occurrence, three children’s

bolted steel plating and the lifejackets were located at the

sides were extended upward Eleven single-passenger seats after end of the vehicle. Twelve

to enclose a buoyant structure. were arranged along the sides additional adult-approved per-

The original truck wheels and of the open passenger deck, sonal flotation devices (PFDs),

suspension were fitted outside with five on the port side and located adjacent to the seats in

the watertight hull. The effec- six on the starboard side. There the passenger area, were readily

tive breadth of the chassis was were two seats in the vehicle available.

increased by the addition of cab: the left one for the driver

extensions (sponsons) on each and the right one for the tour A steel visor plate was fitted at

side. These sponsons were par- guide. In the event of a full pay- the front of the forward engine

tially filled with rigid foam load, the tour guide’s seat acted compartment and was intended

plastic to enhance transverse as the 12th passenger seat; the to prevent the entry of water at

stability and buoyancy and to guide would assume a standing the front end of the vehicle when

ensure appropriate forward and or crouching position in the water-borne and under way.

after trim when water-borne. middle of the cabin aisle.









2 REFLEXIONS Issue 22 – July 2005

Cruise too small, or incorrectly worn, forward of the bilge wells, were

The Lady Duck started the the wearer can be at risk of sus- also activated to discharge the

amphibious tour—its second taining personal injury and/or accumulation of floodwater.

of the day—at about 1500. At drowning. In this occurrence, Water was then seen discharg-

the beginning of the tour, the the PFDs worn by two of the ing intermittently from outlets

guide briefed the passengers, victims were too large for their on both sides of the vehicle

in French and English, on safety body size. near midships.

procedures related to the on-

land part of the tour. Before the Although passengers were The weather was fine and clear

vehicle entered the water at the informed that the rear exit and with little wind. The river was

Hull, Quebec, marina ramp at side windows were emergency relatively calm, with waves

approximately 1540, the tour exits, no instructions were given caused by wakes from boats

guide provided a safety briefing about what to do in the event and other watercraft in the tour

to the passengers for the water- of an abandonment. For exam- area. On occasion, the vehicle

borne portion of the tour. ple, passengers were not told encountered some waves that

how to open the windows if they

The tour guide had no formal were zipped closed. Passengers

training or written instructions were not instructed to look

on suitable pre-departure safety around to determine their The tour guide had no formal

briefings. Consequently, only nearest exit and they were not

incomplete verbal instructions cautioned that it may not be training or written instructions

were given, and passengers were the same one used to enter

on suitable pre-departure safety

not advised of the location and the vehicle.

use of all safety equipment. briefings.

When the vehicle entered the

In addition, passengers did not water, the main bilge pumps

receive a demonstration on how were switched on to clear the

to correctly don their lifejackets. hull of any shipped water. washed over the hood and up

The size of a lifejacket or a PFD Because no water was seen to to the windshield. Some spray

must be appropriate to the be discharging from the five also came in through the opened

body size of the wearer to per- drainage points near midships, windows in way of the driver

form as designed. If the life- the two emergency bilge pumps, and tour guide seats.

saving appliance is too large, located in the hull, slightly

Taking on Water

Toward the end of the tour, at

about 1608, while returning

to the Hull Marina at approxi-

12 Passengers A1 A2 mately 8 km/h, the driver noted

Driver

that the front end of the vehicle

I/O Engine N.W.T. Floor Top of Sponson was floating lower than normal

P4 Road Engine V4

L/J L/J L/J L/J L/J L/J and that water was being con-

P1 P2

M.P.

P3 tinuously discharged from both

G.L. G.L.

sides of the vehicle near mid-

V1 B1

W.T. Hull

V2 V3

ships. The driver then ordered

the four foremost passengers

G.L. Ground Level V1 2 Bilge Drain Valves (19 mm dia)

I/O Inboard/Outboard V2 2 Bilge Drain Valves (19 mm dia) and the tour guide to move to

L/J Lifejacket V3 1 Bilge Drain Valve (12 mm dia) the back of the vehicle to try

W.T. Watertight V4 Fixed W.T. Visor

N.W.T. Non-Watertight P2 2 Emergency Bilge Pumps in Hull to decrease the forward trim.

P1 2 Main Bilge Pumps in Wells P3 Bilge Pump in Road Engine Compartment

P4 Bilge Pump in I/O Engine Compartment A1 2 Ventilation Openings in Hood Top

B1 Drive Shaft Bearing A2 2 Cowl Ventilators in Hood Top The driver confirmed that the

M.P. Manual Bilge Pump

emergency bilge pumps were

discharging water. However, the

Construction profile outline









REFLEXIONS Issue 22 – July 2005 3

However, the Canadian Coast the guide used the top of the

The two main bilge pumps Guard Marine Communications awning to help pull out from

and Traffic Services (MCTS) do under the water. The passenger

were inoperable. not provide marine very high also reported experiencing diffi-

frequency (VHF) coverage in the culty exiting through that side

Ottawa area and bystanders with window.

cellular telephones called 911.

combined discharge capacity The passengers who exited

of these two pumps did not At about 1610, the situation through the rear exit encoun-

stem the increasing ingress of deteriorated rapidly as more tered difficulties because of

water overflowing the forward floodwater accumulated in the the need to climb up to the

visor and the vehicle trimmed forward end of the vehicle. The opening at the top of the raised

progressively by the bow. These driver then called on the pas- boarding ramp and because of

pumps were the only opera- sengers to abandon the vehicle. the small opening provided by

tional pumps whose discharges The driver left the steering posi- that exit. Minor injuries were

could be observed from the tion, made his way aft and, received when passing through

driver’s position. The two main with seven other persons, man- the opening.

bilge pumps were inoperable. aged to get free of the sinking

vehicle. The remaining four pas-

The bilge pumps were not

sengers became trapped under

installed in accordance with Of the six electrically driven

the fabric awning and sank with

manufacturer instructions.

the vehicle in 8 m of water.

Specifically, the wiring con- bilge pumps, the two that were

nections to the pumps were After ordering the evacuation,

not watertight or adequately effectively operable did not stem

and as he was moving aft to

secured, and the main pumps help the passengers don their

were over-fused. Debris in the the ingress of water.

PFDs, the driver was swept out

impellers stalled the pumps of one of the window exits. To

and, as the fuses were too evacuate, all other occupants

large, induced the failure of turned to the rear exit that had Once passengers were at the top

the pump motors. Of the six been their entrance point. of the retractable stairs, there

electrically driven bilge pumps, was no platform to step on to

the two that were effectively Exit Bottleneck facilitate egress into the water.

operable did not stem the The guide and one passenger, Passengers had to find a posture

ingress of water. recognizing that there was a to jump without any support

“bottleneck” at that exit, evacu- structure to aid them in that

The forward trim continued to

ated through the window exit movement, while ensuring

increase and, realizing that the

beside the aftermost seat on that they cleared the hazard

safety of the passengers was at

the port side. Reportedly, the presented by the exterior stairs

risk, the driver instructed the

vehicle was almost vertical and and the I/O motor.

tour guide to tell the passengers

to don PFDs. At this time, he During the evacuation, one

diverted the vehicle toward the survivor held onto a PFD. Two

nearest point on the Quebec others wore PFDs when they

shore. The driver then broadcast exited, neither of which was fas-

a MAYDAY on emergency tened. One of the survivors was

channel 16, identifying the given a lifejacket before exiting,

Lady Duck, giving its position but it was a child’s lifejacket

and the number of passengers and was too small to allow the

on board. head to pass through. Another

Lady Duck approximately passenger, on surfacing, also

five minutes before sinking. used a child’s lifejacket that was

Reproduced with permission.









4 REFLEXIONS Issue 22 – July 2005

ineffective as a flotation device

for that person. The driver and

one of the passengers had not

donned PFDs; the driver

because he was swept overboard

as he was moving to the rear

of the vehicle, and the other

person because he had moved

to the rear of the vehicle at the

driver’s request and was no

longer within reach of the PFD

at his seat. The driver was able

to link his arm around a float-

ing PFD after he was ejected

from the vehicle.



In order for the passengers

to retrieve the lifejackets from

their storage location beneath

each passenger seat, it would

have caused congestion in the

narrow centre aisle. During

vehicle inspection after the

occurrence, removing a lifejacket Lifejacket under the seat with booster cables on top

without tearing it on the edges

of the metal storage box was a including fire extinguishers, dis- Post-Accident Tests

challenge for investigators, let tress equipment and, in the case After the accident, the vehicle

alone passengers who, in a of the company’s larger vehicles, was the subject of structural,

time-critical situation, could the liferafts. mechanical, pumping and

have jeopardized the integrity other safety-related equipment

of the jacket. Further, other Although the side window exits inspections and tests. A series

items that were stored on top were larger than the rear exit of speed, freeboard, trim, wave-

of the lifejackets would have and were available as a means making and flooding trials was

presented a challenge to their of escape, 11 of the occupants also completed to determine

quick removal. initially turned to the rear exit the operational characteristics

to evacuate. For a few, this may and physical condition of the

No Formal have been due to the driver’s Lady Duck. Review and analysis

Evacuation Policies earlier request to move to the of these inspections, tests and

The company had no formal rear of the vehicle. The others trials showed that the safe oper-

evacuation policies, procedures may have been reacting in a ation of the vehicle was at risk

or training that addressed the manner that has been seen in due to the following:

possibility of a vehicle evacua- other evacuations, where people

tion. Although the driver had tend to exit through their point • The condition of the vehicle

received abandonment instruc- of entry. Only two occupants meant that watertight integri-

tions, no specific training or recognized that there was a ty could not be maintained.

drills were conducted on com- “bottleneck” there and chose Watertight integrity was

pany vehicles, including the a side window as their point compromised by fractures,

Lady Duck, to put that training of egress. the absence of effective

into practice. Further, none of the watertight glands and seals,

tour guides received hands-on and water siphoning action

training on the safety equipment, through bilge piping.









REFLEXIONS Issue 22 – July 2005 5

• The non-watertight con-

Effective struction of the hood and

F/B of 381 mm Speed = 5 km/h; Forward F/B = 470 mm; the installation of 75 mm-

Bow wave height = 89 mm; Aft trim = 254 mm.

Hull and shaft bearing leakage starts to diameter (3-inch) cowl ven-

accumulate. Port and starboard main bilge

pumps activated (port-side pump inoperative).

tilators at its forward end,

after the completion of

Effective

Transport Canada’s inspec-

F/B of 343 mm Speed = 5 km/h; Forward F/B = 432 mm; tion, allowed the ingress

Bow wave height = 89 mm; Aft trim = 216 mm.

Hull and shaft bearing leakage continues.

of water when the forward

Starboard main bilge pump is fouled with freeboard was reduced and

solid debris. Syphonic flooding starts. Both

emergency bilge pumps activated.

waves were encountered.

Effective

F/B of 203 mm Speed = 5 km/h; Forward F/B = 292 mm; • The design and construction

Bow wave height = 89 mm; Aft trim = 38 mm. of the vehicle were such that

Hull, shaft bearing and syphonic flooding

continue. Emergency bilge pumps continue all bilge and floodwater

in operation.

initially accumulated in the

forward half of the hull and

Effective Vehicle returning to the marina. caused a forward trimming

F/B of 25 mm Speed = 8 km/h; Forward F/B = 292 mm;

Bow wave height = 267 mm; Aft trim = 38 mm. moment and a reduction of

Hull, shaft bearing and syphonic flooding effective forward freeboard.

continue. Bow wave starts to overflow visor

and downflooding of forward end begins. This reduction of forward

Emergency bilge pumps continue in operation. freeboard made the vehicle

Effective

MAYDAY broadcast while the vehicle is headed

more vulnerable to shipping

F/B lost

for shore at approximately 8 km/h. water at speeds lower than

Bow wave height = 267 mm. Hull, shaft bearing

and syphonic flooding continue. Downflooding

when completely free of

accumulates as bow wave overflows visor and floodwater.

enters cowl vents, hood sides and air vents.

Forward trim increases as vehicle settles

and reserve buoyancy is reduced (see photo • Launching trials at the Hull

on page 4).

Sinking Marina showed that, when

condition Downflooding becomes general with a sudden

increase in forward trim as reserve buoyancy is the visor was submerged

lost and vehicle sinks rapidly by the bow. before the front of the vehi-

cle became fully buoyant,

water was shipped and accu-

mulated in a well specifically

served by the forward bilge

The most likely sequence of events

pump. Malfunction of this

pump would result in flood-

• When operating in water water being retained on

• When operating in calm disturbed by the wakes of board, causing a reduction

water conditions, the other craft, the Lady Duck of the effective forward free-

Lady Duck was vulnerable was highly vulnerable to board at the start of each

to shipping water over the shipping water when water-borne tour.

bow, because of low initial relatively moderate waves

static forward freeboard and were encountered. In the event of pump malfunc-

of proportional loss of effec- tion or failure, any accumula-

tive forward freeboard due • The effective static forward tion, including floodwater due

to the bow wave created by freeboard in the loaded con- to hull leakage, could not be

the speed of the vehicle. dition, when reduced by the detected by the driver. The com-

progressive accumulation bined weight of the shipped

of floodwater in the hull, water and floodwater from

was insufficient to prevent drive shaft bearing leakage and

the entry of water from bow bilge piping siphon effects

waves generated at service would reduce the forward free-

speed. board. This would render the





6 REFLEXIONS Issue 22 – July 2005

vehicle more vulnerable to requirements that address the

shipping water over the visor hull, machinery, electrical sys- The current regulatory framework

as speed was increased and tems, fire protection equip-

its own bow wave and the ment, life-saving equipment, does not address all aspects

wakes of other vessels were and stability, thus affording a

encountered. greater level of passenger safety. of small passenger vessel



Inadequate Regulations As a consequence, the effective- operations.

The regulatory framework that ness of the regulatory frame-

applied to the Lady Duck did work is compromised in that

not adequately address the risk the complexity of regulations, As a result of this investigation,

involved in the vehicle’s opera- standards, and programs that action was taken to improve

tion. Although the Lady Duck, apply to small passenger vessels safety briefings, improve bilge

with a gross tonnage of less may not be readily understood pumping operations, establish

than 5 and carrying not more by the owners, operators, and life-saving equipment carriage

than 12 passengers, had a first inspectors who must apply requirements, address inconsis-

inspection, it was not subject them. Furthermore, the current tencies regarding lifejackets,

to construction requirements, regulatory framework does require the carriage of radio

did not require a qualified not address all aspects of small equipment, and develop risk

operator, and the company was passenger vessel operations. indices to help select vessels for

not required to have a safety Consequently, vessels that may random and targeted compli-

management structure in place. not be fully fit for their intended ance monitoring inspections.

In contrast, when more than purpose may operate, placing

12 passengers are carried, ves- passengers at risk. TSB Recommendations

sels are subject to additional Recognizing that the Interna-

tional Safety Management Code

for the Safe Operation of Ships

and for Pollution Prevention

(ISM Code) may be beyond the

scope of most small operators,

a system tailored to the needs

of small passenger vessels,

which incorporates principles

of effective safety management,

would assist small vessel opera-

tors to help ensure that the

company, the vessel, and its

crew are fit for their intended

purpose. Given the benefits

associated with preventing

accidents, and the need for a

structured approach for opera-

tors to effectively manage the

risks associated with their oper-

ation on an ongoing basis, the

TSB recommended that:

Vehicle launched at 8 km/h, visor submerged by approximately 25 mm

The Department of Transport take

steps to ensure that small passen-

ger vessel enterprises must have

a safety management system.

M04-01









REFLEXIONS Issue 22 – July 2005 7

The TSB acknowledged the or carrying more than 12 pas- Given NSS’s leadership role

initiatives by Transport Canada sengers. However, there are no to work directly with federal,

to reform the current regulatory statutory requirements for small provincial and local authorities,

framework to make it more passenger vessels, such as the and other organizations, to

streamlined, applicable, and Lady Duck, to be ergonomically develop and standardize the

effective. However, given the designed to afford passengers quality of SAR services, and

planned time frame of 2006 for and crew the best possible mitigate risks associated with

completion of this reform, and opportunity to safely evacuate an improperly coordinated

the large number of small pas- in the event of an emergency. SAR system, the TSB recom-

senger vessels that have yet to mended that:

be identified, the TSB recom- The TSB is aware of proposed

mended that: amendments to incorporate The National Search and Rescue

by reference the Construction Secretariat, in collaboration with

The Department of Transport Standards for Small Vessels local authorities and organizations,

expedite the development of a (TP 1332). However, review promote the establishment of a sys-

regulatory framework that is easily indicates that small commercial tem to monitor distress calls and to

understood and applicable to all vessels in excess of 6 m, such as effectively coordinate Search and

small passenger vessels and their the Lady Duck, are not required Rescue responses to vessel emergency

operation. to incorporate sufficient inher- situations on the Ottawa River

M04-02 ent buoyancy to prevent sink- between Ottawa and Carillon.

ing, and there are no provisions M04-04

Small passenger vessels are rarely for the timely and unimpeded

of standardized design and, evacuation of passengers in the REFLEXION

consequently, the arrangements event of an emergency. The TSB, Whether cruising on a large pas-

for boarding, accommodating, therefore, recommended that: senger vessel in the Caribbean

and disembarking passengers or a small vessel on a river or a

vary greatly, particularly in ves- The Department of Transport lake, we should all be aware of

sels of novel construction such ensure that small passenger vessels safety requirements and keep a

as the Lady Duck. incorporate sufficient inherent weather eye on the operational

buoyancy and/or other design and environmental aspects

Transport Canada has standards features to permit safe, timely involved.

for commercial passenger vehi- and unimpeded evacuation of

cles, such as buses, trains and passengers and crew in the

aircraft, and, to a lesser extent, event of an emergency.

for small passenger vessels with M04-03

a gross tonnage greater than 15

The National Search and Rescue

Secretariat (NSS), an independ-

ent government agency reporting

There are no statutory to the Minister of National

Defence, has responsibility for

requirements for small passenger

promoting the national Search

vessels, such as the Lady Duck, and Rescue (SAR) program.

The program is a collection

to be ergonomically designed of SAR services provided by

all agencies and individuals in

to afford passengers and crew Canada, regardless of the type

of activity or jurisdiction.

the best possible opportunity



to safely evacuate in the event



of an emergency.









8 REFLEXIONS Issue 22 – July 2005

The Katsheshuk









A Lesson in Firefighting

On the afternoon of 17 March 2002, while it was stopped in ice and waiting for a change in the weather, a

fire broke out in the bow of the large fishing vessel Katsheshuk. After an unsuccessful attempt at fighting the

fire, the decision was made to abandon ship. Several days later, the tug Atlantic Maple took the vessel into

tow and steamed towards St. John’s, Newfoundland and Labrador. The tug and tow encountered adverse

weather and were forced to seek refuge in Trinity Bay, Newfoundland and Labrador. When the weather

finally moderated, the tow resumed. On the morning of 30 March 2002, while approximately six nautical

miles northwest of Cape. St. Francis, Newfoundland and Labrador, the Katsheshuk listed and sank. —

Report No. M02N0007



The fire was discovered when vessels by very high frequency Fighting the Fire

two crew members working on radio, the Newfoundland Otter, Two fire parties on the port and

the deck saw smoke coming the Arctic Endurance and the starboard sides of the vessel

from door “G” in the trawl Ocean Pride, which were fishing attempted to extinguish the fire

superstructure providing access in the area, and informed them of internally but were unsuccessful.

to the lobby. One crew member the fire on board the Katsheshuk The first fire party lead opened

immediately went to inform and requested their assistance. door “D” and entered a small

the officer of the watch (OOW) The master did not immediately foyer where he was met by a

while the other entered the inform the Canadian Coast wall of smoke. Upon opening

lower accommodation to Guard of the vessel’s situation. either door “E” or “F” he was

warn the crew. met with heat and flame. The

An initial inspection determined second fire party lead made

The OOW, on being informed that the smoke was emanating it to door “D” and when he

of the situation, immediately from the bow area of the vessel opened it, he was met by a

activated the fire alarm, but it and, as a precaution, the sliding white flame that shot out over

failed to sound. He was soon watertight doors were remotely his head and hit the deckhead.

relieved by the master and pro- closed. While the master moni- Door “D” provided access to

ceeded to his muster station. tored the situation from the the compartment that housed

The master then made an wheelhouse, in the ‘tween deck the spurling pipes and door “F”

announcement on the public accommodation three decks provided access to the forward

address system and activated the below, preparations were being stores. This would suggest

general alarm, which did sound. made to locate and fight the fire. that the fire originated either

The master then contacted three



REFLEXIONS Issue 22 – July 2005 9

in the compartment housing clamp. A second fire hose was In this instance, the fact that

the spurling pipes or in the set up on the trawl deck and no mock scenarios were used

forward stores. directed at the transverse bulk- during the fire drills meant

head at the forward end of the that, when faced with a real life

The housekeeping practices in trawl deck. Meanwhile, the situation, the crew, although

the forward stores were poor. master contacted other vessels trained in Marine Emergency

The supplies were stored on in the area and requested addi- Duties, was not completely

deck or on shelving and were tional firefighting equipment. familiar/comfortable with the

not secured. As such, they Some hoses and self-contained duties at hand. As a result, the

were prone to being dislodged breathing apparatuses (SCBAs) crew was ill-prepared to put

from their position due to the were transferred to the Katsheshuk forward a cohesive and coordi-

movement of the vessel in the from other vessels; however, nated firefighting response.

50-knot winds and 4 m swell. the hose connections were

Further, materials stored in the incompatible and an adapter The TSB is concerned that,

locker included flammable had to be made for one of despite efforts to improve the

material such as barbecue the Katsheshuk hydrants. familiarity with equipment and

lighter fluid, chemicals and competence of fishing vessel

cleaning materials that have Incomplete Fire Drills crew members in emergency

the potential to generate toxic Boat and fire drills carried out situations, accidents like that

fumes in enclosed places, and on a regular basis, in accordance on the Katsheshuk continue to

combustible materials such as with the regulations, familiarize put vessels and their crews at

paper products. All these mate- the crew in dealing with emer- risk. The TSB will continue to

rials provided a source of fuel gency situations. In accordance monitor these issues and will

to the fire. As the vessel ulti- with the intent of the Boat and determine whether further

mately sank, the cause of the Fire Drill Regulations, drills on safety action is required.

fire could not be determined; board vessels like the Katsheshuk

however, it is highly likely that are to be carried out monthly, Poorly Executed Response

the fire originated in the stores and the crew is to be familiar- The firefighting effort, while well

compartment. ized and instructed with respect intentioned, was ill-advised and

to the facilities of the vessel and poorly executed. A review of the

their duties. Each crew member Fire Drill Muster List indicated

is to demonstrate such familia- that the crew did not proceed

There was no indication that any to the designated emergency

rity. Such drills include, inter

fire hoses were ever run out, alia, the running out, examina- stations. Instead, crew members

tion and pressurization of fire reacted to the emergency situa-

inspected and pressurized. hoses, and examination of tion individually and took

smoke helmets, breathing appa- upon themselves different roles,

ratus and associated firefighting leading to an uncoordinated

equipment. response. This culminated in

The crew then started to set up

boundary cooling on the exterior The vessel was a recent acquisi-

of the vessel. To cool the deck- tion in late 2001 and boat and

head of the forecastle storage fire drills were carried out on a

locker, a fire hose was fed regular basis. However, due to

through the wheelhouse, onto the short period the crew was

the foredeck, and then lowered on board this vessel (three to

through a rope scuttle (an open- four months), relatively few

ing through which mooring drills had been performed.

ropes are passed) to the forward However, in spite of regulatory

mooring station. Shortly after requirements, there was no

charging the line, a hose clamp indication that any fire hoses

securing the hose to the fitting were ever run out, inspected

let go, requiring the line to be and pressurized. The rescue boat

shut down to reattach the





10 REFLEXIONS Issue 22 – July 2005

the Katsheshuk as well as boats Given that the success of a

Between the time the fire dispatched from the nearby ves- Search and Rescue (SAR)

sels. During the initial evacua- mission is dependent on the

was detected and the time a tion, 24 crew members were prompt and efficient dispatch

transferred to other vessels; of SAR resources, it is essential

notification was made, almost two more crew members were that the authorities be notified

evacuated a short time later. as soon as an emergency situa-

3 hours 40 minutes had elapsed.

tion arises. This permits the SAR

Eventually, the wheelhouse authorities to identify, prepare

began to fill with smoke, and and dispatch appropriate units

neither of the fire party leads the decision was made by the and equipment in a timely

(port and starboard) being master for the remaining crew manner in the event the situa-

properly attired with SCBA and members to leave the vessel. tion escalates and/or SAR assis-

protective fireman’s outfit to tance is required/requested.

fight the fire and both had to Between the time the fire was

retreat from the fire scene. In detected at 1545, and the time By not notifying SAR, the vessel

this instance, a fireman’s outfit an initial notification was made as well as the shipboard person-

was at hand for use by the port to Marine Communications nel are placed in a vulnerable

fire hose party but none was and Traffic Services (MCTS), situation. In the event that the

readily available for the star- almost 3 hours 40 minutes had emergency is brought under

board party. The vessel was elapsed. The master indicated control and assistance from the

outfitted with two complete that he did not think it neces- authorities is no longer required,

sets of SCBAs and fireman’s sary to contact MCTS as there the resources could then be

outfit and one fireman’s outfit were three other vessels in the stood down.

was not available for use. The area. He was also very busy in

non-availability of one of the the wheelhouse with his own

fireman’s outfits may be attrib- emergency duties.

utable, in part, to personnel not

adhering to the designated fire

stations, culminating in it being

moved to a different location

during firefighting activity.



Roughly 45 minutes after the

fire was discovered, the master

decided to evacuate all non-

essential personnel to the other

fishing vessels in the area. An

attempt was made to raise the

vessel’s rescue boat (RB) using

the port davit, but the crew

could not get it to operate. As

a result, they used the cargo

crane on the starboard side.



The crew evacuated using the

vessel’s own RB by boarding the

RB on the forecastle deck and

then being lowered to the water.

After several lifts, it was decided

to deploy the pilot ladder and

have the crew climb down the Post fire

ladder and board the RB from







REFLEXIONS Issue 22 – July 2005 11

The Lake Carling

stopped in ice,

22 March 2002

(assisting tug, the

Ryan Leet, seen

on the port side)









The Toughness of Steel

On 18 March 2002, the bulk carrier Lake Carling, with 24 654 metric tons (mt) of iron ore pellets in hold

numbers 1, 3 and 5, departed Sept-Îles, Quebec, bound for Point Lisas, Trinidad. According to the loading

instrument, the greatest seagoing Still Water Bending Moments (SWBMs) were located at frame 85 in

the No. 4 hold (90 per cent of approved maximum) and at frame 154 in the No. 2 hold (86 per cent of

approved maximum). The next morning, during scheduled rounds, it was discovered that the No. 4 hold

was taking on water. Further inspection revealed that a six-metre fracture had developed on the port side

shell. Sea ice thwarted attempts to keep a collision mat in place to stem water ingress and the bilge pumps

were unable to keep up. — Report No. M02L0021



The ship’s position at this and the Lake Carling eventually 94 (K strake) in the No. 4 upper

time was 48°16’48” N and proceeded to Québec, Quebec, water ballast tank, which was

061°21’30” W, approximately to undergo permanent repairs. empty at the time. The shell

38 nautical miles north of the On 28 March 2002, the vessel fracture divided at the juncture

Îles de la Madeleine in the tied up at Québec and offloaded of the ballast tank sloping plate:

Gulf of St. Lawrence. Winds a portion of its cargo. Floating one branch continuing for

were from the north at 20 knots, repairs were carried out accord- 45 cm on the ballast tank slop-

air temperature was -6°C and ing to Det Norske Veritas (DNV) ing plate at approximately 90°

water temperature was near classification specifications and, from the juncture point, and

0°C. Sea state was not docu- on 04 April 2002, the vessel the other branch on the ship’s

mented by the crew but, by all was cleared to sail by port state side continuing up and forward

accounts, was unexceptional. inspectors and the DNV surveyor. for approximately 40 cm past the

Calculations and historical juncture point. Visual inspection

data support a wave height Side Shell Fracture and laboratory analysis indicates

of between 1.5 and 2.5 m The principal fracture was on that the principal fracture origi-

and a wave length of approxi- the port side frame at frame 91, nated at the base of frame 91

mately 56 m. extending upwards and forward (at the toe of the weld). The

from the toe of the weld at the fracture origin was located

With assistance from a Canadian base of the side shell frame. The 1.3 m below the neutral axis

Coast Guard vessel and a salvage fracture traversed frames 92 and of the vessel’s midships section

tug, temporary repairs were made 93 through the H and J strakes, modulus.

terminating just short of frame



12 REFLEXIONS Issue 22 – July 2005

In the No. 2 hold, four crack voyage to Montréal, Quebec,

Five similar crack manifestations locations were also found: on are possible causes of the crack

the starboard side at frames initiation. The loading printout

were found in the No. 4 hold. 1711/2 and 1721/2, and on the (harbour condition) for this

port side at frames 144 and loading indicates an actual

145. In contrast to the cracks bending moment (BM) of

in No. 4 hold, all the cracks in 78 055 tonne-metres (t-m)

The principal fracture was the No. 2 hold had been covered occurring at frame 86. This is

forward half of a crack manifes- with superficial weld repairs. 79 per cent of the permissible

tation that presented itself on The weld repairs had penetrated harbour BM of 99 375 t-m, but

either side of the base of the only a few millimetres into the 103 per cent of the seagoing limit

frame. Five similar crack mani- thickness of the hull plate. It of 75 900 t-m at this location.

festations were found in the was not determined when, or No loading instrument print-

No. 4 hold: on the port side, by whom, these repairs were out for the seagoing condition

at frames 89 and 93, and on undertaken, nor is there any was available. The Lake Carling

the starboard side, at frames 85, record held by DNV of these sailed from Thunder Bay in this

91 and 96. All crack manifesta- cracks or the repairs. In contrast condition, with draughts of

tions appeared to originate near to the crack manifestations in 7.99 m forward and 8 m aft.

the base of the frame at the toe No. 4 hold, not all these cracks

of the weld, and giving rise to were present both fore and aft For the deballasting scenario,

two cracks, one forward and of the frame, such as at frame the SWBM imposed on the hull

one aft of the frame, each some 1711/2, where the crack was only girder at frame 91 would have

75 mm in length and generally forward of the frame. been 107 per cent of the approved

in a characteristic “V” forma- maximum permissible. For the

tion. All of these cracks were How the Cracks Started loading scenario, the SWBM at

rusted and appeared to have Several sources could have been frame 86 was 103 per cent of

been present for some time. responsible for the cracks in the approved seagoing allow-

the No. 4 hold. Deballasting in able limit. Being farthest from

unprotected waters and/or an the neutral axis, stresses would

improper loading at Thunder have been experienced in the

Bay, Ontario, four months prior deck and bottom shell. However,

to the hull fracture before a the combination of all global

and localized stresses would

still have been significant at the

bottom of the side shell frames.

The vessel sailed in this condi-

tion for five days, from Thunder

Bay to Montréal, in water close

to 5°C. After leaving Montréal,

the vessel encountered very

heavy weather in the North

Atlantic. Had small cracks

developed due to improper

loading and cold water condi-

tions between Thunder Bay

and Montréal, they could have

grown under such dynamic

loading.









Principal fracture Frame 1711/2, starboard





REFLEXIONS Issue 22 – July 2005 13

The restrained nature of the Lack of Specifications by all the major classification

welded connections at the lower The grade A steel used in the societies for many years by pro-

ends of the side shell frames construction of the side shell viding a qualitative estimate

made this area susceptible to of the Lake Carling was “within of material toughness. There

the retention of residual stress- specifications” insofar as tensile are, however, no requirements

es. The coincidence of several strength is concerned, but as to use steel of a given CVN

stress concentration factors cre- for minimum Charpy V-notch energy at low operating tem-

ated the conditions necessary, (CVN) impact test, no speci- peratures in way of the ship’s

when subjected to high stresses fications actually exist. The sides (which are usually grade A

and cold ambient temperatures, extremely low fracture tough- steel). Nonetheless, cargo vessels

to cause small cracks to form ness of the side shell plate may often trade in zones where

at the base of the side shell when exposed to temperatures ambient temperatures are close

frames between frames 85 and near 0°C allowed the forward to, or below, 0°C and these low

96 in the No. 4 hold. These crack at frame 91 (port) to grow temperatures generally tend to

factors are: to failure at a load well below reduce the ability of the steel

the ultimate tensile strength of to resist crack growth.

• the discontinuities caused the material. The length of the

by a scallop (cut-out) in the crack at the time it became criti-

side frame; cal was not determined, but cal-

• the proximity of the frames’ Without actual standards,

culations have shown it could

lower ends to the shell plate have been as short as 10 cm. expectations are not always

seam (possibly exacerbated

when the frames were Under the International enough to ensure adequate

renewed in the drydock Association of Classification

at Gdansk, Poland, a year Societies’ (IACS) Unified Rules, fracture toughness and damage

previously); grade A steel less than 50 mm

• the change in plate thick- tolerance.

thick (and grade B, 25 mm or

ness at the shell plate less in thickness) does not have

seam weld; and to demonstrate a minimum

• the presence of residual CVN. Under these rules, this A recent Lloyd’s initiative to

stresses. steel can be used for a ship’s qualify the toughness of grade A

side shell. Some testing has steel may appear to be an

shown that the average CVN improvement on existing stan-

The extremely low fracture tough- of grade A steel available world- dards; however, the required

wide is often quite high and the 27 Joules at 20°C is less than that

ness of the side shell plate when grain size relatively small. This, demonstrated by the Lake Carling,

in effect, sets a de facto standard and 20°C is certainly well above

exposed to temperatures near —ship owners, ship constructors, the temperature most vessels

and classification societies all may expect to encounter at one

0 ° C allowed the forward crack at time or another. Additionally,

expect and depend upon grade A

frame 91 (port) to grow to failure steel having a fracture tough- Lloyd’s leaves it up to the man-

ness that is sufficient for all ufacturer to report that the steel

at a load well below the ultimate conditions. However, without meets the requirement by way of

actual standards, expectations “in house” checks. This measure,

tensile strength of the material. are not always enough to ensure although well intentioned, is less

adequate fracture toughness a tool for quality control than it

and damage tolerance. is an indication that the tough-

The intervening four months ness of grade A steel has been

of operation prior to the occur- Although the relationship and continues to be a cause for

rence is a reasonable time between CVN energy and frac- concern. It has been suggested

frame in which these cracks ture toughness is not necessarily that a fracture appearance tran-

could grow imperceptibly straightforward, the system has sition temperature (FATT) below

under the dynamic loading been used with relative success 0°C is necessary to ensure suffi-

of the hull girder. cient fracture toughness for





14 REFLEXIONS Issue 22 – July 2005

ships’ hulls. In the Lloyd’s study Risks Continue

of the fracture properties of All ships, especially bulk carri- Some grade A and B steels that

grade A steel, 5 of 39 samples ers, operating in cold waters

(nearly 13 per cent) demon- and having their side shell of are not suitable in all conditions

strated a FATT above 0°C, while metal with characteristics simi-

another 4 samples (10 per cent) lar to those of the Lake Carling are still being produced and used

were at -6°C or above. For the are at risk. The damage tolerance

Lake Carling, the FATT was in ships’ hulls.

could be less than adequate and

determined to be 32°C. In cracks could remain unnoticed

other industries, such as electric or discounted as insignificant,

power generation, risks due yet they would still pose a Even vessels without ice strength-

to brittle fracture are reduced significant risk when exposed ening are regularly called upon

by ensuring that operating to low temperatures. Given the to trade in waters with sea tem-

pressures are only permitted uncertainties and variability peratures at or near 0°C. By

at component temperatures of fracture toughness for some limiting any possible modifi-

approaching or exceeding the grade A and B steels, it would cations of the IACS Unified

component’s FATT. appear that residual risks for Rule S6 (Use of steel grades for

unstable brittle fracture are still various hull members) to ice-

A recent study found a signifi- present in hulls constructed of strengthened vessels, other ves-

cant variability in the fracture these steels, especially when sels will continue to be exposed

initiation toughness of grade A operating in colder climates. to unacceptable residual risks.

plates after a review of the avail-

able data. Other studies have The TSB is encouraged by the REFLEXION

found similar results and have intention of the IACS to carry In any language, “grade A”

advocated the use of a prescribed out critical crack length calcu- would mean something that

minimum toughness standard lations. Based on the results is top of the line. In the case

for all metals and welds used in of this analysis, the IACS will of ship’s steel, it is not neces-

ships’ hulls. In fact, 40 Joules at apparently consider whether sarily so.

-40°C has been the standard to introduce a screening of

for Canadian ships of war for the material properties of

over 40 years, while 100 Joules shell plating in way of the

at -20°C has also been sug- single skin areas of the cargo

gested as a minimum to ensure and machinery region in ships

adequate damage tolerance and with ice strengthening. The

protection against brittle frac- TSB is also encouraged by

ture. In a major review of a vast the work of the International

amount of available literature Marine Organization involving

concerning the fracture proper- restrictions on alternate hold

ties of grade A ship plate, it was loading and its proposal for

concluded that “... the crack “Goal-based new ship con-

arrest ability of grade A plate is struction standards.”

poor and probably inadequate

for most ship applications.” The TSB is concerned, however,

Nonetheless, it would appear that, even if a standard is agreed

that, notwithstanding the aver- upon, too low a standard would

age high toughness and quality cause unwanted and unnecessary

of most steels, some grade A constraints with a questionable

and B steels that are not suit- safety benefit. Furthermore,

able in all conditions are still until such time that restrictions

being produced and used in or regulations are put into effect,

ships’ hulls. existing bulk carriers and their

crews continue to be at risk.









REFLEXIONS Issue 22 – July 2005 15

The bulk

carrier Windoc

(photograph

provided by

Boatnerd.com)









The Bridge and the Windoc

The bulk carrier Windoc was transiting the Welland Canal at Allanburg, Ontario, on 11 August 2001, when

it was struck by Bridge 11’s vertical lift span, which was lowered before the vessel had passed clear of the

bridge structure. The vessel’s wheelhouse and funnel were destroyed. The Windoc drifted downstream,

caught fire, and grounded approximately 800 m from the bridge. — Report No. M01C0054



The wheelhouse team had the vessel was approximately Control Centre (TCC) on very

observed the flashing amber 0.75 to 0.5 nautical miles from high frequency (VHF) radio

approach light, located 925 m the bridge, the signal lights about the lowering of the

from the bridge on the west changed to solid green and the bridge. The master quickly

side of the canal, which indicated lift span was in the fully raised stopped the engines and ordered

that the bridge operator was position. With the Windoc’s an evacuation of the wheelhouse.

aware of the approaching vessel. centre line lined up with the

The Windoc’s speed was reported bridge signal lights, the vessel The bridge operator did not

to be approximately five knots. proceeded under the bridge. respond to either the VHF radio

As the vessel neared the bridge, call or the ship’s whistle

the signal lights on the bridge The Lights Turned to Red blasts. It is unlikely that the

were flashing red and the lift When the vessel was approxi- operator could have heard the

span was being raised. When mately halfway under the VHF radio transmission, given

bridge, the third the noise level in the bridge

officer observed control room when the bridge

that the bridge sig- is in operation. However, given

nal lights were solid the proximity of the whistle to

red and the lift span the bridge, and the high pitch

was descending. The and decibel level of the whistle,

master sounded a the operator should have been

few blasts on the able to hear the ship’s whistle.

ship’s whistle. Then, Residents upstream of the

without identifying bridge reported coming out

himself or the bridge of their homes to investigate

Bridge 11 striking vessel in way of wheelhouse in question, the mas- the reasons for the repeated

front windows. Reproduced with permission. ter called the Traffic whistle blasts.



16 REFLEXIONS Issue 22 – July 2005

Operator Impairment deteriorated between the time

The Windoc was clearly visible Earlier that morning, the bridge he came on duty at 1830 on

operator took two Darvon-N the day of the accident and the

through the south windows pain relief tablets to relieve period immediately preceding

back pain, and consumed the accident, which occurred

of the control room when about two to four glasses at approximately 2054.

the operator began lowering

of wine around lunch time.

Between 1300 and 1400, As revealed by the recorded

the bridge. he received a telephone call communication, in the period

from a St. Lawrence Seaway surrounding the accident, the

Management Corporation operator’s confusion, slurred

(SLSMC) team leader, who speech, impaired memory, and

Nevertheless, the bridge opera- asked the operator if he would lack of appreciation for the

tor described having seen the work an overtime shift that seriousness of the event are

stern of the vessel through the evening on Bridge 11. The oper- consistent with substance

north windows of the control ator agreed. Reportedly, he did and/or alcohol intoxication.

room where the door is located. not consume any additional Comments made by TCC con-

If this were the case, the Windoc alcohol or take any medication trollers following their conver-

would have been clear of the after accepting to work the sation with the bridge operator

bridge at the time the span was overtime shift. indicate that they might have

lowered. Analysis of the ship’s entertained this possibility.

position before and at the time On behalf of the TSB, the United Therefore, it is likely that the

of impact shows that the super- States National Transportation operator’s performance was

structure of the Windoc was Safety Board conducted an impaired while the bridge span

clearly visible through the south analysis of the bridge operator’s was lowered onto the Windoc.

windows of the control room speech and noted that intelli-

when the operator began lower- gibility of the operator’s speech Following the collision, a fire

ing the bridge. broke out in way of the main

engine casing and spread to the

Figure 1 Bridge Operator’s Control Room accommodation structure as the

vessel drifted downbound from

44 m

Bridge 11. The starboard anchor

P

was dropped; however, the ves-

Water Line

286 m

sel’s starboard bow struck the

504 m east bank of the canal. The

Windoc then drifted to the west

side of the canal and went

Diagram of a bridge operator’s field of view when the bow of the vessel is

under the operator’s control room. Bridge is in the fully raised position.

aground.



Ineffective Firefighting

The arrival of the Thorold,

Figure 2 Bridge Operator’s Control Room

Ontario, Fire Department

on scene at 2105 was timely;

44 m

P however, crews were confronted

Water Line with a situation for which con-

286 m

504 m

ventional shore-based firefight-

ing had not prepared them.

Due to the watertight integrity

Diagram of a bridge operator’s field of view when the vessel is amidships of the accommodation structure,

under the operator’s control room. Bridge is in the fully raised position. water applied to the vessel from

the shore-side aerial ladder

Legend for figures 1 and 2:

truck had little effect on the fire,

The area within the straight lines (i.e.–––) represents the lower limit when the operator

is seated at the control panel. beyond its use as peripheral

The area within the dotted lines (i.e.-----) represents the lower limit when the operator boundary cooling. Once on

is standing at the control panel.







REFLEXIONS Issue 22 – July 2005 17

board, the shore-based firefight- Inadequate and communications between

ing team was reluctant to enter Contingency Plan vessels and structures.

the burning accommodation. The SLSMC contingency plans

The team did not appreciate that in place for responding to Given the limited opportunities

the fire was partly contained by vessel-related emergencies under the Canadian Human Rights

sealed dampers and watertight within the canal were inade- Code for the SLSMC to identify

doors. Based on their training quate and outdated. They were employees who may be experi-

and experience, opening water- neither used at the time of the encing personal problems that

tight doors to ventilate smoke accident nor made available to could affect their fitness for duty,

from the vessel may have seemed personnel, some of whom were it is determined that the SLSMC

an appropriate tactic; in fact, not aware of their existence. should review its supervision

such actions allowed fresh air and monitoring with respect to

to reach the smouldering fire In essence, SLSMC’s overall fitness for duty to the full extent

and superstructure. The fire response to the accident was permissible under human rights

department’s lack of training conducted in an ad hoc manner, legislation. The TSB therefore

and experience for fighting hampering coordination and recommended that:

shipboard fires and the unavail- deployment of response

ability of equipment to access personnel and equipment. The St. Lawrence Seaway

the vessel hindered firefighting Management Corporation reassess

response. Safety Action and and clearly identify safety-sensitive

Recommendations positions in their organization in

The TSB acknowledged that the which incapacity due to impairment

SLSMC has expressed positive could result in direct and signifi-

The fire department’s lack of cant risk of injury to the employee,

intentions in response to safety

deficiencies raised throughout others or the environment;

training and experience for

the investigation. The SLSMC M02-01

fighting shipboard fires and outlined a number of steps,

including identifying safety- and that:

the unavailability of equipment sensitive positions, drafting

a new policy on alcohol and The St. Lawrence Seaway

to access the vessel hindered Management Corporation establish

drug testing, and updating

attendance and sick leave programs and policies which are

firefighting response.

procedures. It increased the pro-active and promote early detec-

number of supervisory posi- tion of impairment and safety risk

tions, and implemented new of employees occupying safety-

The Thorold Fire Department, procedures for shift handover sensitive positions by management,

in which jurisdiction the acci-

dent occurred, was the only fire

department in the canal area

that did not have shipboard

firefighting experience or train-

ing. Other than a request for

boats, no assistance was request-

ed of nearby, more experienced

fire departments. As a result,

available firefighting resources

in the canal area were not effec-

tively used to contain and extin-

guish the fire in time to prevent

the vessel’s accommodation

from being destroyed.





Aerial view of aft section of vessel with fire department vehicle on site

(photograph by Harry Rosettani)



18 REFLEXIONS Issue 22 – July 2005

supervisors or peers and which emergencies. The TSB therefore

promote an effective mechanism recommended that:

for remedial action.

M02-02 The Department of Transport

ensure that overall preparedness

In response, the SLSMC said is appropriate for responding to

that it has a new Drug and vessel-related emergencies within

Alcohol Abuse Policy, and that the Seaway.

supervision of employees at iso- M02-04

lated sites has been enhanced.

As a result, Transport Canada

During the 1999-2000 naviga- indicated that, following

tion season, there were 3141 discussions with the SLMC, an

vessel transits through the amendment will be made to

Welland Canal, including petro- the Management, Operation and

leum and chemical product Maintenance Agreement that will

carriers. However, no major require the SLMC to have in Aerial view looking north at the

vessel-related emergency response place an up-to-date emergency bridge and vessel after the striking

exercise involving other agencies response plan. Exercises will be (photograph by Harry Rosettani)

has been conducted within the required annually and a valida-

canal. Given that the risks asso- tion of the plan will be conducted detectors were to be installed

ciated with an improperly coor- by an independent party every at other Seaway bridges.

dinated response were higher five years. A validation report will

than those associated with a fully be sent to both Transport Canada The TSB noted that the Windoc’s

coordinated response, the TSB and the SLMC. fire plan was stowed in the

therefore recommended that: wheelhouse and was inaccessible

The TSB was encouraged by the because of the fire. The TSB

The St. Lawrence Seaway measures taken by the SLSMC was concerned that, without a

Management Corporation conduct, towards correcting identified requirement for such plans to

in collaboration with the other procedural and supervisory be stored in a location outside

appropriate authorities and organi- deficiencies. The TSB noted, the deckhouse on Canadian non-

zations, exercises to respond to however, that, in the absence convention vessels, inaccessibility

vessel-related emergencies which of effective backup monitoring of the plans may continue to hin-

may be encountered within the systems, the competence of the der the firefighting capability of

Seaway, including the Welland bridge operator continued to be municipal fire departments, there-

Canal, in order to evaluate the the sole line of defence against by increasing the risk of personal

preparedness for responding to a the inadvertent lowering of the injury and damage to property.

major vessel-related emergency. span onto a vessel. The TSB

M02-03 therefore recommended that: Examination of the sprinkler

system on the Windoc indicated

The SLSMC said that two inter- The St. Lawrence Seaway that the pipework had been

nal table-top exercises were con- Management Corporation ensure secured to wooden structures.

ducted in each SLSMC region, that physical and administrative Once the fire destroyed the

the results of which were inte- defences are in place to ensure wooden components, the

grated into the contingency plan. that Seaway bridges are prevented unsupported sprinkler pipework

Annual exercises were being from coming into contact with collapsed, rendering it unser-

conducted, and arrangements to transiting vessels. viceable. The TSB was therefore

conduct an inter-agency exercise M02-05 concerned that such other older

were ongoing. vessels may have retrofitted

The SLSMC responded that sprinkler systems attached to

Transport Canada retains regu- two vessel detectors had been combustible internal structures,

latory authority over the Seaway installed at Bridge 11 and were in a manner similar to the

and is responsible to ensure to be integrated into the opera- Windoc, and that exposure

that arrangements are in place tion of the bridge for the next of such systems to fires may

for dealing with vessel-related navigation season. Similar negate their effectiveness.



REFLEXIONS Issue 22 – July 2005 19

Photo of the

Avataq in 1990

(provided by

Transport Canada)









The Harsh Arctic

At approximately 2330 on 24 August 2000, the captain of the small fishing vessel Avataq, in Hudson Bay,

in gale force winds, initiated a series of radio calls on citizen’s band (CB) radio channel 14, advising a

relative that the crew was on deck re-securing cargo that had come loose and that they expected to arrive

in Arviat, Nunavut, at 0200 the next morning. Another radio call at 0030, 25 August 2000, indicated that

the vessel was in a position 10 nautical miles south of Arviat, that the bilge pumps were not working

properly, and that the vessel was taking on water. A final radio transmission was heard from the vessel at

0130 advising that the Avataq was taking water over the bow and stern and was sinking. Despite attempts

from shore to contact the vessel, no further transmissions were heard. The vessel foundered, and all

four crew members perished. — Report No. M00H0008



When communications could and to identify local Search and residents at 0255 and immedi-

not be established with the Rescue (SAR) forces. A telephone ately called NES Iqaluit, NES

Avataq, a group of residents call was made to the Canadian Iqaluit did not inform RCC

proceeded south along the Coast Guard (CCG) in Iqaluit, Trenton until 2.5 hours later.

shoreline on all-terrain vehicles Nunavut, seeking information

in an attempt to locate the on what vessels were in the Emergency position-indicating

vessel. At 0255, the searchers vicinity of the occurrence. radio beacons (EPIRBs), which

called the head of the local However, the nature of the operate on 406 MHz, provide

Emergency Measures Organi- emergency was not communi- an immediate distress signal

zation (EMO) in Arviat and cated to the CCG, which in turn and have become common;

informed him that the Avataq did not inform RCC Trenton, however, the Avataq was not

was missing and might have Ontario, that the Avataq might equipped with one and was

sunk. have foundered. While local not required to be so equipped.

authorities may wish to react, Had the vessel carried a float-

No procedures were in place an efficient SAR operation free EPIRB or had the emergency

to ensure that the appropriate requires that the appropriate been immediately communi-

Rescue Coordination Centre RCC be notified as soon as cated to NES Iqaluit, RCC Trenton

(RCC) was notified. Nunavut possible. Resources may then would have become aware

Emergency Services (NES), be dispatched expeditiously sooner of the vessel’s sinking.

when contacted at 0257, pro- to the area. In this occurrence, Given earlier notice, a Hercules

ceeded to assess whether the although the Arviat EMO was aircraft that was operating

Avataq had indeed foundered informed of the distress by area north of the area—and that

was re-tasked to search for the









20 REFLEXIONS Issue 22 – July 2005

operators are more familiar with for the crew to cover the after-

At present, there are no statutory and tend to use PFD coveralls, deck with a plastic tarpaulin

which provide protection against attached to the gunwale to

requirements for life-saving equip- hypothermia for a shorter period reduce the amount of water

of time than a full immersion shipped.

ment to be carried on board small suit.

fishing vessels such as the Avataq.

At present, there are no statu-

tory requirements for life-saving Safety equipment carriage

equipment such as liferafts, deep

Avataq—could have arrived on standards, appropriate for vessels

chocks or hydrostatic releases,

scene within the estimated sur- and immersion suits to be car- operating in southern Canada,

vival time of those persons in ried on board small fishing ves-

the water who were wearing sels such as the Avataq. Given do not provide protection for

personal flotation device (PFD) that operating conditions vary

coveralls. The two victims from location to location across the crews of vessels operating

whose bodies were found died Canada, safety equipment

of hypothermia. carriage standards, appropriate in the isolated Arctic marine

for vessels operating in south- transportation environment.

The Avataq was equipped with ern Canada, do not provide

a four-person Beaufort liferaft protection for the crews of ves-

secured by a pelican hook to sels operating in the isolated

a cradle on top of the wheel- Arctic marine transportation On one previous voyage, the

house. A hydrostatic release environment. Avataq nearly capsized after

and deep chocks were not fitted taking on a large angle of heel.

to the liferaft, nor were they Information provided by cargo In that instance, the cargo was

required to be so fitted. There consignors and gathered from lost overboard and the vessel

is evidence that the Avataq the examination of salvaged righted itself. A small fishing

foundered quickly and the crew cargo indicated that the Avataq vessel that is not engaged in

had little time to don survival was carrying an estimated fishing herring or capelin is not

equipment and manually launch 15 823 kg of cargo made up required by regulation to have

the liferaft. A liferaft sitting in of 3727 kg of propane and approved stability information.

deep chocks or equipped with 12 096 kg of building materials. However, at the time of the

a suitable release mechanism occurrence, the vessel was

such as a hydrostatic release is The precise on-board disposi- operating as a cargo carrier.

likely to deploy and be avail- tion of the cargo cannot be

able to the crew in the water. ascertained. In the past, the Meeting the

During the extensive air search, vessel had been loaded with Demand for Cargo

neither the liferaft nor its canis- steel pipe “space frames,” wood Although a well-established

ter was spotted in the debris construction materials, and marine transportation system

field, suggesting that they sank large propane bottles stored on exists to facilitate the summer

with the vessel. deck. Smaller propane bottles re-supply of Canada’s northern

were stowed in the hold on territories, the system’s complex

Limited Survival Time either side of the engine room. scheduling is not always flexible

Once the crew members found On departure from the Port of enough to provide for the short-

themselves in the water of 8°C Churchill, the vessel’s freeboard term needs of northern commu-

to 10°C without a liferaft, their was estimated to have been nities. As a result, a demand has

survival time was limited in approximately 40 cm. To pre- developed for smaller vessels

part by the amount of thermal vent water ingress onto the such as the Avataq that can oper-

protection they were wearing. afterdeck, the scuppers were ate on a more flexible schedule.

Full immersion suits are not plugged with threaded barrel Economically, it is more advan-

comfortable to work in; conse- plugs. Because of the low free- tageous for a northern vessel

quently, most small vessel board, it was common practice operator to purchase an existing







REFLEXIONS Issue 22 – July 2005 21

vessel in southern Canada than Untrained Crew

to construct a purpose-built The use of small fishing vessels No assessment was made to

vessel. Therefore, small fishing carrying heavy cargoes on off-

vessels such as the Avataq, which shore voyages has engendered determine whether the vessel’s

may be unsuitable to carry cargo, new hazards for northern sea-

have become commonplace in farers. Special technical skills cargo was properly loaded or if it

the North. and knowledge are required to

was seaworthy as a cargo vessel.

ensure safe and efficient vessel

Transport Canada Marine Safety operations. Although such

(TCMS) does not maintain a knowledge can be acquired

resident surveyor in the Port on the job, formal courses and reminding vessel owners of the

of Churchill, nor would it be training, coupled with seagoing importance of having life-saving

reasonable to expect it to do experience, provide an enhanced equipment visible and accessi-

so. The Canada Shipping Act, awareness of safe operational ble. TCMS, with the assistance

however, does provide a statu- practices. The crew of the Avataq of industry groups, was also

tory mechanism for the inspec- had no such training, and with- examining certification and

tion of any vessel by a port out that guidance, the crew did training requirements for small

warden or other competent not have the required knowl- commercial and fishing vessels,

person. In a small port such edge of cargo loading, stability, with a goal of designing manda-

as Churchill, with relatively few and the deleterious effect of tory operator training and

ship movements, the identifica- free-surface water to recognize qualifications.

tion of vessels loading cargo in the risks associated with operat-

an unsafe manner is not diffi- ing the vessel under conditions Amendments to the Ship Station

cult, particularly if a trained that could be expected during (Radio) Regulations and the

and competent port warden is the voyage. Ship Station (Radio) Technical

already present and directed Regulations are being phased in

to act as the eyes and ears of Safety Action over the next few years. As of

TCMS. After this occurrence, TCMS met 01 April 2002, small commer-

with the Government of Nunavut cial vessels more than 8 m long

There was an awareness that the and agreed to translate the Ship (which includes the Avataq)

Avataq and other similar fishing Registration Guide into Inuktitut. operating more than 20 miles

vessels were engaged in the from shore are required to

loading of cargo at the Port of Amendments to the Life Saving carry an EPIRB.

Churchill for delivery to com- Equipment Regulations came into

munities on the western shore force on 14 March 2002 and Since the occurrence, TCMS

of Hudson Bay since the vessel require all vessels under 25 m has reorganized the Prairie

began operating out of Rankin that are equipped with liferafts to and Northern Region Branch

Inlet in 1995. During this time, have provision for the liferafts and moved its headquarters

concerns for the safety of the to float free in the event of to Winnipeg, Manitoba, from

vessel’s loading practices had a sinking. TCMS issued Ship Ottawa, Ontario.

not been identified and passed Safety Bulletin (SSB) 03/2001

on to the appropriate authori- recommending that all vessels, With the support of Department

ties. As a result, no assessment irrespective of their size, have of National Defence Search and

was made to determine whether float-free arrangements for Rescue New Initiatives funding

the vessel’s cargo was properly liferafts. TCMS also proposed for three years, Marine Commu-

loaded or if it was seaworthy amendments to the Life Saving nications and Traffic Services

as a cargo vessel. Cargo vessels Equipment Regulations to require (MCTS) Iqaluit implemented an

are required to have load-line that liferafts be stowed in readi- Inuktitut-language marine radio

markings and to have a stability ly accessible locations. In the safety service during the 2001

book to assist the master in interim, SSB 07/2001 was issued operating season. The service

safely loading the vessel. is based in Iqaluit and provides









22 REFLEXIONS Issue 22 – July 2005

coverage 20 hours per day, master was uncertified, it would Given the continuing delays in

7 days per week, during July, not be reasonable to expect that notifying the appropriate RCC,

August, and September. Regularly he possessed the skills required the TSB is concerned that the

scheduled broadcasts focus on to determine whether he should agreements made between the

weather and tide information, have been operating the Avataq key agencies have not been

as well as hazards to navigation. given the loaded condition and effectively implemented, result-

Although the system is intended the area of operation. By not ing in a continued risk to sea-

to cover the waters of Frobisher defining the operational param- farers and others in peril in

Bay, the coverage area in fact eters of the vessel and the capa- the area. The TSB will continue

extends beyond and in other bilities of its crew through the to monitor and assess these

directions as well. A listening certification process, a master’s types of occurrences with a

watch is also kept on the ability to assess risks is poten- view to determining the need

medium-frequency “hunters” tially compromised. The fact for further safety action.

favoured by Inuit hunters and that the master may not per-

seafarers. ceive the risk in time to take REFLEXION

corrective action increases the Just because a vessel has oper-

TSB Concerns probability and the adverse ated without an accident for a

The TSB continues to be con- consequences of an accident. certain period of time does not

cerned that any shortcomings indicate that it is safe to continue

with the monitoring of small After this occurrence, personnel to do so. Furthermore, in north-

commercial vessels, particularly from key agencies involved in ern climates, the SAR organiza-

in remote areas, may result in SAR operations in the Arctic tion should be rapidly informed

vessels being used for carrying and representatives of local as a prime priority.

cargo beyond their capabilities. authorities met to review man-

The Avataq had been operating dates and to discuss procedures

as a cargo vessel for at least five relating to SAR operations. It was

years before this occurrence but agreed that RCC Trenton or RCC

was not inspected for this type Halifax must be immediately

of operation. As a result, neither notified of marine accidents.

an inspector nor the master had

participated in an assessment At the time of the Avataq

of the capabilities of the vessel occurrence, there was a delay

to carry cargo according to the of 2.5 hours before NES Iqaluit

applicable regulations. The informed RCC Trenton of the

determination of the appropri- occurrence. This delay held up

ate operating parameters for the tasking of a SAR Hercules

this type of voyage was left to that was already in the area and

the knowledge and the experi- reduced the efficacy of the SAR

ence of the crew. Because the response.









REFLEXIONS Issue 22 – July 2005 23

Marine Occurrence Statistics

2004 2003 1999–2003

Average

Total Marine Accidents 490 547 536

Shipping Accidents 440 481 475

Collision 12 24 19

Capsizing 18 11 10

Foundering/Sinking 17 30 33

Fire/Explosion 51 65 67

Grounding 108 118 126

Striking 81 76 78

Ice Damage 17 28 10

Propeller/Rudder/Structural Damage 37 39 34

Flooding 63 49 57

Other 36 41 40

Accidents Aboard Ship 50 66 61

Vessels Involved in Shipping Accidents 469 527 518

Cargo 21 18 25

Bulk Carrier/OBO 52 48 59

Tanker 7 16 13

Tug 32 34 34

Barge 34 31 31

Ferry 20 25 24

Passenger 28 41 25

Fishing 227 260 252

Service Vessel 25 27 26

Non-Commercial 10 14 16

Other 13 13 13

By Vessel Flag 469 527 518

Canadian (Non-Fishing) 193 216 201

Canadian (Fishing) 223 253 243

Foreign 53 58 74

Vessels Lost (By Gross Tonnage) 21 38 41

1600 grt and over 0 2 1

150 to 1599 grt 0 2 2

60 to 149 grt 4 8 6

15 to 59 grt 7 12 11

Less than 15 grt 3 12 16

Unknown Tonnage 7 2 5

Fatalities 28 17 28

Shipping Accidents 22 9 15

Accidents Aboard Ship 6 8 13

Injuries 82 95 84

Shipping Accidents 37 35 28

Accidents Aboard Ship 45 60 56

Reportable Incidents (Mandatory) 246 223 212

Close-quarters Situation 67 60 48

Engine/Rudder/Propeller 105 83 84

Cargo Trouble 1 3 4

Personal Incidents 9 14 8

Other 64 63 69

All five-year averages have been rounded.

Occurrence data do not include pleasure craft except when the latter are involved in an occurrence with a commercial vessel.

The majority of vessels listed under “unknown tonnage” are suspected of being less than 15 grt.

(2004 figures are preliminary as of 11 February 2005 and subject to change.)

Source: Transportation Safety Board of Canada



24 REFLEXIONS Issue 22 – July 2005

MARINE Occurrence

Summaries

The following summaries highlight pertinent safety information from

TSB reports on these investigations.



BILGE PUMP FAILURE LED TO FLOODING AND CAPSIZING

The log salvage vessel Bruce Brown took on water and capsized when a makeshift

bilge pump repair failed. The vessel took on water and capsized at Artevida Reef,

Mamaspina Strait, British Columbia, sometime during the night of 11 June 2002.

The vessel owner and his son were later found some distance from the tug; one had

died from hypothermia and the other, from drowning. — Report No. M02W0089



The bilge pump hose in the engine compartment parted where two lengths of

hose of the same diameter had been joined with a metal connector. Examination

of the connector revealed that, in place of a straight connector, a reducer had

been used. One end of this reducer

matched the 28.5 mm diameter of

the rubber hose, while the other end

was 25.4 mm in diameter. This smaller

diameter had been built up to match

the 28.5 mm inside diameter of the

hose with plastic electrician tape. Two

hose clamps had then been secured

over each hose end at the reducer.



The raw cooling water, its temperature

raised by the heat from the engine,

warmed the electrician tape and softened

its adhesive. The wire reinforcing within

the rubber hose limited the ability of the

hose clamps to compress the hose against

the reducer. The pressure of the cooling

water, as supplied by the circulating pump,

was sufficient to elongate the warmed

adhesive until the connection failed and

the hose parted.



Bruce Brown in 1987







REFLEXIONS Issue 22 – July 2005 25

Because the hose failure occurred during darkness, it is unlikely that the opera-

tor would have been able to observe that the cooling water discharge was now

reduced to a single stream. The accumulation of water in the bilges would

have served to trim the Bruce Brown by the stern. A vessel change of trim can

often be detected when referenced to the horizon; however, this would be

more difficult to detect during darkness.



It was calculated that the bilge would have filled in

50 minutes. However, because of the low freeboard of

Without corrective action, the vessel, it can be estimated that the addition of approx-

the vessel would capsize. imately 1.8 metric tons of seawater would cause the stern

to become submerged to the point where seawater would

downflood into the vessel after well deck and eventually

flow forward over the partial transverse bulkhead into the

accommodation space. Without corrective action, the vessel

would capsize. By calculation, this sequence would take approximately

25 minutes from the time of the hose failure.



Although both crew members were experienced, neither had received formal

marine-related instruction, nor had either obtained a Transport Canada marine

certificate. At the time of the accident, the crew of vessels with a gross tonnage

under 15, not carrying passengers, did not require Transport Canada certifica-

tion. The crew members had not taken two new Marine Emergency Duties

(MED) courses, nor was there a requirement for such training.



Transport Canada was working with approved safety training providers

and industry associations to enhance awareness among mariners about

MED training, which is now required, and to make the training available

in remote areas.



Mariners who had not yet had training available in their area of operation

were required to demonstrate, before 30 July 2003, or within a reasonable

period after the training became available in their area, that they had regis-

tered to take the appropriate MED course. Transport Canada will enforce

the requirement without exception after 01 April 2007.



REFLEXION

If a system is worth repairing, it is worth repairing properly. The jury is

still out on “jury-rigs.”









26 REFLEXIONS Issue 22 – July 2005

OVERBOARD IN THE RAPIDS

Jet boating in the boiling rapids of the Niagara River below Niagara Falls

can be an exhilarating experience. One trip turned out to be frightening for

two passengers, who were swept overboard on 02 September 2001. The passengers

were rescued within a few seconds and suffered only cuts and abrasions to

their legs. — Report No. M01C0063



The Saute Moutons 14 set out from Niagara-on-the-Lake, Ontario, at about

1730 that day with 43 passengers. Before departure, the passengers received a

mandatory safety briefing, including a safety lecture and reference to posted

signs highlighting the inherent risk of the activity. The pre-boarding briefing

also included instruction of the importance of using the support bar to

assist passengers to remain seated during the whitewater ride.



The trip was uneventful until 1814,

when the trip from the Niagara

Gorge Whirlpool near Devil’s Hole

began. Just before entering the

Devil’s Hole rapids, the passengers

were asked if they wished to proceed

sideways into the rapids. Proceeding

sideways into the rapids means that

the vessel encounters large waves at

an oblique angle and side slips into

the trough. The result of this is that

the volume of water shipped into

the starboard and port forward pas-

senger seating areas is substantially

increased.



As the trip progressed, an on-board

video camera, operated by a crew

member, recorded a deluge of water Passenger water

increasing in frequency and volume being shipped over the bow and wind- jet boats

shield. The passengers were waist and chest deep in water. In addition, due

to the constant spray, there was very little opportunity for the forward three

or four rows of passengers to catch their breath.



About three-quarters of the way through the rapids, the

passenger area remained full with water and the vessel

approached a large trough and subsequent wave in quick The passengers were waist

succession. The vessel proceeded into the trough and wave and chest deep in water.

with no let-up in speed. The forward section of the wind-

shield of the Saute Moutons 14 and the forward half of the

passenger compartment disappeared from view, after having

passed through the wave. These passengers were completely submerged for

approximately four to five seconds beyond the wave before the forward half

of the vessel rose to the surface.



Immediately before the occurrence, the time between wave encounters did

not allow the vessel to evacuate the water and re-acquire its normal operating

draught. Thus, when the vessel bow dipped down into the next wave trough,

it did not rise with the next approaching wave but rather ploughed into it.

The availability of the high engine horsepower (1620 HP) applied to the water





REFLEXIONS Issue 22 – July 2005 27

jets allowed the operator to continue to move the vessel with the passenger

compartment in a flooded condition. The manner in which the operator was

manoeuvring the vessel for a brief moment before the occurrence indicates

that he was not sufficiently cognizant or aware of the danger to which the

passengers were exposed.



As the bow of the vessel was under water and rising to the surface, the outflow

of water carried the outboard of the two passengers over the side. The inboard

passenger attempted to keep the outboard passenger on board but was carried

or pulled overboard. At this time, the operator had reduced power, which

slowed the vessel and at the same time he noticed the second passenger going

over the starboard side. Both were successfully recovered and taken to the dock

for treatment.



Niagara Gorge Whirlpool Jet Boats Ltd. advised that, at the end of the 2001

season, the bailing ducts, which evacuate water from the passenger area, were

expanded in size and re-designed. The previous design incorporated a 90-degree

turn in the duct. The new design and larger construction allows the same

volume of water to be evacuated in a straight line direction aft and thus shed

water faster from the passenger area. The weight of the water exiting in the

reconstructed tubes helps to raise the bow and drop the stern, further helping

to trim the boat.



REFLEXION

The force and effect of moving water should never be underestimated.







FREE-FALLING ELEVATOR

The fishing vessel Mersey Venture was discharging a cargo of shrimp alongside

the wharf in Stormont, Nova Scotia, on 14 August 2000. The forward hatch

is equipped with a freight elevator. The vessel caught and processed its catch of

shrimp, packing the shrimp in boxes in the fish hold. In order to reduce broken

stowage and maximize earning capacity, boxes were shoved in all the hold spaces,

including the elevator platform in the hoistway.



The elevator hoistway was unloaded to the point where the elevator could be used

to prepare pallets of boxes on the platform. After several lifts, the platform was

again raised, with the stevedores also on the platform, for the ride to the factory

deck level. At about 1220 local time, after two of the stevedores had stepped off,

the elevator rope hoist gearbox failed, which caused the drum to freewheel and

the platform to descend in a free-fall. Three of the four stevedores still on the

platform received injuries consistent with elevator accidents, including shattered

heels and broken bones. — Report No. M00M0083



The investigation revealed that:



• Warning signs were ignored, safety devices were intentionally bypassed,

employees were not adequately supervised, and unsafe practices were

routinely accepted in the interests of expediency.









28 REFLEXIONS Issue 22 – July 2005

• The elevator rope guide had been removed, allowing the starboard load

rope to overwrap itself, which caused the port load rope to go slack. This

resulted in an inaccurate measurement of the load on the elevator and

overstressing of the rope hoist.



• Secondary safety systems that were not disconnected were inoperative.



• There was no formal preventative maintenance program for the elevator

in effect at the time of the occurrence.



• Routine repairs and modifications to the elevator

were carried out by unqualified individuals.

Periodic comprehensive

• Repeated overstressing of the rope hoist resulted in

inspection of the elevator

failure of the gear cover, which caused the gears to

de-mesh, the rope drum to freewheel and the elevator would have revealed its

to fall.

poor condition.

• Periodic comprehensive inspection of the elevator

would have revealed its poor condition.



• Confusion surrounding the ownership of jurisdiction over the elevator,

i.e. Transport Canada Marine Safety or the Nova Scotia Department

of Labour Occupational Safety

and Health, contributed to

deficiencies in the frequency

and comprehensiveness of its

professional inspection.



The elevator was repaired and

tested and the owners issued

safe working procedures for

the equipment.



Many of these units are installed in

jurisdictions outside the province.

The Province of Nova Scotia has

revised its Elevators and Lifts Act to

include a design and installation

standard for these types of lifts and

a process for licensing these devices.

The province also took enforcement Fishing vessel

action based on the Occupational Health and Safety Act and its associated Mersey Venture

regulations. Transport Canada is amending applicable regulations as part

of its ongoing regulatory reform process.



REFLEXION

This was a freight elevator that should not have been used by personnel.

The easy way up is not always the safest.









REFLEXIONS Issue 22 – July 2005 29

Investigations

The following is preliminary information on all occurrences under investigation by the TSB that were reported between

01 January 2004 and 31 December 2004. Final determination of events is subject to the TSB’s full investigation of these

occurrences.







DATE LOCATION VESSEL (S) TYPE GRT EVENT OCCURRENCE NO.





JANUARY

11 Horseshoe Bay, B.C. Queen of Ferry 6969 Striking M04W0006

Surrey

Charles H. Tug 69

Cates V



23 Between Lo-Da-Kash Fishing 13 Missing M04M0002

Campobello Island

and Mace’s Bay, N.B.



FEBRUARY

26 Queen Charlotte Hope Bay Fishing — Capsizing M04W0034

Sound, B.C.



MARCH

04 14 miles NNE of Caribou Ferry 27 213 Fire in boiler M04M0013

North Sydney, N.S.



APRIL

27 Port of Sorel, Que. Catherine- Ferry 1348 Grounding M04L0050

Legardeur



JUNE

17 10 M off Persistence I Fishing 47 Taking on water M04L0065

Natashquan, Que.



21 Magog River, Unknown Small craft — Capsizing M04L0066

Sherbrooke, Que. (unlicensed and

unregistered)



JULY

10 St. Clair River, Evans McKeil Tug 284 Grounding M04F0016

Michigan, U.S.



24 Île de Grâce, Que. Horizon Container 19 872 Grounding M04L0092



27 American Narrows, Salvor Tug 407 Grounding M04F0017

St. Lawrence River, KTC115 Barge 6430

U.S.









30 REFLEXIONS Issue 22 – July 2005

DATE LOCATION VESSEL (S) TYPE GRT EVENT OCCURRENCE NO.





AUGUST

11 Saint-Nicolas, Canada Container 30 567 Collision M04L0099

St. Lawrence River, Senator

Que. Unknown Yacht —



14 Bay of Quinte, Ont. Unknown Service — Collision M04C0043

(runabout)

Elmer H Fishing 3

Unknown Barge —

(barge)



15 Iroquois Lock, Federal Maas Bulk carrier 20 837 Striking M04C0037

St. Lawrence

Seaway, Ont.



24 Île-aux-Coudres, Famille Passenger 465 Striking M04L0105

Que. Dufour II



SEPTEMBER

11 Near Amherstburg, Barge A397 Barge 2928 Striking M04C0044

Ont. Karen Andrie Tug 433



19 Off Cape Ryan’s Fishing 129 Foundering and M04N0086

Bonavista, N.L. Commander grounding



OCTOBER

29 Kyuquot Prospect Point Fishing 70 Capsizing M04W0225

Sound, B.C.



NOVEMBER

06 Georgia Strait, B.C. M.B.D. NO. 32 Barge 409 Sinking M04W0235

Manson Tug 44

McKenzie Barge 505



DECEMBER

10 Georgian Bay, Ont. Unknown Small craft — Capsizing M04C0090

(unlicensed and

unregistered)









REFLEXIONS Issue 22 – July 2005 31

Final Reports

The following investigation reports were released between 01 January 2004 and 31 December 2004.

* See article or summary in this issue.



DATE VESSEL(S) EVENT REPORT NO.



99-09-24 Norwegian Sky Grounding M99L0098

99-11-09 Eternity Grounding and near-collision M99L0126

Canmar Pride

Alcor

00-05-18 Sunny Blossom Grounding M00C0019

00-10-03 Keta V Grounding M00M0106

00-12-18 Miller 201 Striking M00W0303

01-05-14 Canadian Transfer Contact with bottom M01C0019

01-06-15 Rachel M Swamping and capsizing M01C0029

Shannon Dawn

01-08-22 Adanac III Striking M01C0059

PML 2501

Coral Trader

01-09-02 Saute Moutons 14 Persons overboard M01C0063*

01-10-26 Kella-Lee Foundering M01W0253

02-03-17 Katsheshuk Fire and sinking M02N0007*

02-03-19 Lake Carling Hull fracture M02L0021*

02-04-21 Progress Striking M02C0011

02-05-15 Unknown (workboat) Foundering M02C0018

02-05-22 Vaasaborg Grounding M02L0039

02-06-11 Bruce Brown Capsizing M02W0089*

02-06-23 Lady Duck Sinking M02C0030*

02-07-08 Fritzi-Ann Capsizing M02W0102

02-07-16 Kent Crew member lost overboard M02L0061

03-04-15 Emerald Star Grounding M03C0016









32 REFLEXIONS Issue 22 – July 2005

TRANSPORTATION SAFETY









REFLEXIONS

M A R I N E THE CONFIDENTIAL

TRANSPORTATION SAFETY REPORTING PROGRAM

Issue 22 – July 2005



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TSB marine regional offices can be reached during working hours (local time)

at the following phone numbers:





HEAD OFFICE, GREATER TORONTO, Ontario After-hours emergency

Gatineau, Quebec* Phone: (905) 771-7676 reporting: (613) 720-5540

Phone: (819) 994-3741 Fax: (905) 771-7709

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Fax: (902) 426-5143 1 800 387-3557

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Phone: 1 800 426-8563)



GREATER QUÉBEC, Quebec*

Phone: (418) 648-3576

Fax: (418) 648-3656