TSB Recommendation M93-04 on Passenger Evacuation, and the Seventeen Year Response by Transport Canada
The BCCTS looks at the Transportation Safety Board, its investigation process and recommendations and what can transpire after those recommendations are made. For the purposes of this article we will review a specific area of interest to the traveling public and the government safety agencies: evacuation of passengers in an emergency.
Access the TSB website to learn how the recommendation/response process works in law. While TSB recommendations must be responded to, their recommendations are not enforceable, nor does the regulator, Transport Canada have to respond specifically as the TSB recommends. Sometimes, as in the case we are examining, it can take almost two decades and subsequent similar occurrences before Transport Canada responds in full and satisfactorily. Sometimes, it would appear, as in this case, that it took the sinking of a vessel with loss of life for this particular recommendation to finally be addressed. We would argue that there are still issues of concern associated with the final response, which we will reveal during the course of our examination of the information to date.
Reassessment of the Responses from Transport Canada to Marine Safety Recommendation M93-04
In July 1990, the Halifax to Dartmouth ferry “DARTMOUTH III”, with an estimated 40 to 50 passengers on board, was bound for Dartmouth when, in a period of reduced visibility, the vessel narrowly missed colliding with the outward bound research vessel “ALFRED NEEDLER”.
Two days later, a similar occurrence took place. The Halifax to Woodside ferry “WOODSIDE I”, with some 20 passengers on board, was bound from Halifax to Woodside when it became involved in a near collision with the tug “TUSSLE” in reduced visibility.
From TSB MARINE OCCURRENCE REPORT M90M4025 (quotes in italics, emphasis added)
4.0 SAFETY ACTION
4.2 Action Required
4.2.1 Accurate passenger count on Passenger Ferries
Given that reliance on shore assistance is crucial in the event of a serious occurrence involving a ferry laden with passengers, the efficiency of rescue operations may be hampered if the accurate number of persons aboard is not known. Indeed, lack of an accurate passenger count impeded search and rescue operations in the marine disasters involving the ferry “HERALD OF FREE ENTERPRISE”, in Belgian waters, and the charter vessel “MARCHIONESS”, on the Thames River in the U.K.
On the Halifax/Dartmouth ferries, passenger counts are taken during peak periods to ensure that the number of passengers does not exceed 400. However, the method used to tally the number of passengers boarding ferries at peak periods is inadequate. At each terminal, turnstiles that automatically register a passenger count have been reported as being inaccurate. No reliable method of counting passengers is available at a separate gateway that provides access for wheelchairs, children, cyclists, and senior citizens. Furthermore, there is no procedure to ensure that the master is cognizant of the number of passengers on board during off-peak hours.
The Canadian Coast Guard has issued Ship Safety Bulletin No. 10-92 concerning the “Safety of Passengers and Vehicles Embarking and Disembarking from Ferries” to remind ships’ masters that the total number of persons on board must not exceed the certificated capacity of the vessel. However, there is no direction to ensure the maintenance of an accurate passenger count that would be necessary in the event of an emergency evacuation.
On average, some 1.9 million people travel on ferries in and out of Halifax each year. Overall, an average of some 58 million passengers are transported on Canadian ferries and passenger vessels annually. Thus, there is a significant number of marine travelers who may be exposed to unnecessary risks because of inadequate procedures for passenger counts.
To carry out a timely and successful search and rescue operation, it is critical that shore staff and Search and Rescue personnel have accurate information as to the number of lives at risk aboard vessels involved in an occurrence. Therefore, the Board recommends that:
The Department of Transport ensure that federally inspected passenger ferries maintain an accurate passenger count and that such count is communicated to both the master and a designated person ashore before departure. (This reference to a designated person ashore is not the Designated Person (DP) under the ISM Code. Ironically, a DP ashore was exactly what the Code envisioned when it became mandatory for all signatories in 1998, some eight years following this incident and investigation report.)
Both marine incidents found the lack of verifiable accounting of passengers could hamper search and rescue (SAR) operations. As a result, TSB issued recommendations to Transport Canada requesting they review existing regulations and amend where applicable to ensure adequate passenger manifests that would enhance SAR and contribute to overall passenger vessel safety in Canada.
The following from TSB’s website shows just what it takes to get business done in Ottawa when it comes to domestic passenger vessel safety:
Board Recommendation M93-04 (14 July 1993)
Reliance on shore assistance is crucial in the event of a serious occurrence involving a ferry laden with passengers. To carry out a timely and successful search and rescue operation, it is critical that shore staff and Search and Rescue personnel have accurate information as to the number of lives at risk aboard vessels involved in an occurrence. Therefore, the Board recommended that:
The Department of Transport ensure that federally inspected passenger ferries maintain an accurate passenger count and that such count is communicated to both the master and a designated person ashore before departure. M93-04
Response to M93-04 (22 September 1993)
The Minister of Transport agrees with this recommendation. The Canadian Coast Guard currently has in place a bi-annual special inspection/audit program designed to augment the required annual safety equipment inspection of Canadian passenger ferries. These inspections address passenger safety and the distribution of passenger counts. In addition, in this specific case, it is understood that the owners have implemented a manual passenger count in the passenger holding area.
Board Assessment of the Response to M93-04 (15 December 1993)
The response contends that the Canadian Coast Guard (CCG) currently has in place a bi-annual special inspection/audit program that addresses “passenger safety and the distribution of passenger counts”. In a follow-up telephone query, TC officials have confirmed that the operators of these ferries have since implemented an improved manual passenger count in passenger holding areas.
This recommendation pointed out the need for not only maintaining an accurate passenger count, but also for preparing for search and rescue efforts by communicating this count to an appropriate person ashore. However, TC has not indicated any plan to facilitate effective coordination and communication.
The TSB staff therefore believes that the safety deficiency has not been fully addressed.
The response is considered Satisfactory in Part.
Response to M93-04 (December 1999)
Transport Canada issued Ship Safety Bulletin #16/99, Information on Passengers, on 7 December 1999. The bulletin sets out current recommendations with respect to maintaining passengers counts on passenger ferries.
Board Reassessment to the Response to M93-04 (15 September 2004)
The CSA prohibits masters from carrying passengers in excess of that allowed. Large ferry operators do count and record the number of passengers and provide the count to a person ashore. Not all operators of smaller short-run ferries may be aware of the recommended practice and may not be making counts; however this should be validated.
No substantial change to the last assessment.
Response to M93-04 (07 December 2005)
No substantial change to the reassessment of 15 September 2004.
Board Reassessment to the Response to M93-04 (7 December 2005)
No substantial change to the reassessment.
Next TSB Action (7 December 2005)
The TSB staff will request regional offices to conduct spot checks and, if necessary, consider the need for further safety communication.
Response to M93-04 (November 2006)
TC’s update, dated November 2006, indicated that since the receipt of Marine Safety Advisory Letter 09/06 related to the Queen of the North sinking, TC has requested additional comments from industry and will be consulting on this issue at the National CMAC in November 2006.
Board Reassessment to the Response to M93-04 (November 2006)
As a result of its ongoing investigation into the sinking of the passenger ferry Queen of the North, TSB sent MSA 09/06 to TC concerning the adequacy of current guidelines for creating ferry passenger manifests. TC indicated that this issue is to be raised during Regional CMAC meetings, which are currently taking place at various dates and times across the country. TC has also contacted the Canadian Ferry Operators Association and the Canadian Passenger Vessel Association and provided them with a copy of the advisory to solicit their comments on this issue.
As the result of a few queries by TSB staff, it was determined that while large ferry operators do count and record the number of passengers and provide the count to a person ashore, some smaller operators, who charge by vehicle and not by person, do not make passenger counts.
Therefore, the assessment remains at Satisfactory in Part.
Next TSB Action (November 2006)
The TSB staff will monitor to outcome of TC’s consultations on this matter.
Response to M93-04 (June 2008)
TC’s update, dated June 2008, indicated that Ship Safety Bulletin 06/2007 – Information on Persons on Board, Counting, Recording, and Special Needs, was issued in August 2007 to advise passenger vessel owners and masters of upcoming requirements. The bulletin advises that TC intends to adopt the IMO Regulation 27 of Chapter III of the SOLAS Convention in regard to information on passengers and provides details on how Regulation 27 is to be applied.
TC is currently amending its Boat and Fire Drill and Means of Exit Regulations to include this requirement. (Pre-publication in Part I of the Canada Gazette anticipated in spring/summer 2009.)
Board Reassessment to the Response to M93-04 (September 2008)
The SSB was made in anticipation of TC adopting regulation 27 of Chapter III of the SOLAS Convention in regard to information on passengers. The SSB also indicated TC’s intention to require that the names and gender of all persons on board, distinguishing between adults, children and infants, shall be recorded for search and rescue purposes: on Unlimited Voyages (formerly Foreign Voyages) or Near Coastal Voyages, Class I (formerly Home Trade Voyages, Class I or II); on voyages longer than 12 hours; on overnight voyages or voyages on which there is at least one assigned berth. The proposed action if fully implemented will substantially reduce or eliminate the deficiency.
Therefore, the assessment of the response is considered Satisfactory Intent.
Next TSB Action (September 2008)
The TSB staff will monitor to the proposed action.
Response to M93-04 (March 2010)
TC’s update, dated March 2010, indicated that Ship Safety Bulletin 06/07, issued in August 2007, advised that TC intends to adopt the IMO Regulation 27 of Chapter III of the International Convention for the Safety of Life at Sea (SOLAS) Convention in regards to information on passengers.
The proposed Fire and Boat Drills Regulations will include the requirement stated in the recommendation. The regulations were pre-published in Part I of the Canada Gazette on October 10, 2009, with a 30-day comment period and are anticipated to receive final approval and be published in the Canada Gazette, Part II in the second quarter of 2010.
Board Reassessment to the Response to M93-04 (28 July 2010)
The new Fire and Boat Drills Regulations, which apply to passenger vessels of more than 15 gross tonnage that carry more than 12 passengers, were published in the Canada Gazette, Part II, on May 12, 2010, and are now in effect. The regulations require the master of a vessel that carries passengers to ensure that the number of persons onboard and the details of persons who have declared a need for assistance in an emergency are recorded. On certain voyages, and on voyages where there is at least one assigned berth, the master must also ensure that the names and gender of the persons on board are recorded in a way that distinguishes between adults, children and infants, and that this information is kept on shore and readily available to search and rescue services.
The action taken will substantially reduce the risks associated with inadequate passenger accounting. Therefore, the assessment of the response is considered Fully Satisfactory.
From the initial TSB recommendation to the Transport Canada response being considered Fully Satisfactory, 17 years passed, and with one particular ferry operator alone there were at least two instances where evacuation of passengers was either necessary or a distinct possibility (Queen of the North grounding and sinking; Queen of Surrey Engine room fire.)
Next, the BCCTS examines the details of the Transport Canada response and what passengers should be aware of if they are unfortunate enough to have to evacuate from a ship in Canada.