How is BC Ferries Regulated?
BCCTS takes a look at how BC Ferries’ safety systems are regulated by Transport Canada, the marine safety regulator for all maritime matters in Canada.
To say, ‘We are not to blame” is to say, “We could not have prevented it” which is to say in future situations, “We are helpless…”
International Standards for Maritime Safety
The International Maritime Organization (IMO) is the United Nations agency created in 1948 responsible for drafting instruments for International Shipping Regulations. The purposes of the Organization, Article 1(a) of the Convention, “to provide machinery for cooperation among Governments in the field of governmental regulation and practices relating to technical matters of all kinds affecting shipping engaged in international trade; to encourage and facilitate the general adoption of the highest practicable standards in matters concerning maritime safety, efficiency of navigation and prevention and control of marine pollution from ships”. The regulations are drafted in the format of Conventions to which member nations of the IMO are signatories. This means they become responsible for writing national regulations that reflect the intent and spirit of the various Conventions to which they have agreed.The first of these Conventions, and arguably the most important, was The Safety of Life at Sea Convention (SOLAS) created in the aftermath of the sinking of the RMS Titanic which saw the loss of more than 1500 lives and sinking of the most expensive and modern passenger vessel of its time. The IMO Conventions pertain expressly to vessels trading internationally from port state to port state. What the IMO Conventions do not apply to are domestic national passenger ferry and commercial shipping. Generally, however, in response to significant incidents, member nations, including Canada, have adapted parts of Conventions to apply to the domestic fleet. The IMO, as well as various National Accident Investigation Boards, have recently recognized there is a significant gap between domestic fleet operations and international operations as it pertains to the regulations governing how those vessels are constructed, maintained, manned and operated on a daily basis. As a result of the safety gap, and in an effort to address the alarming number of casualties worldwide in domestic ferry operations, IMO has partnered with a number of governmental and non-governmental organizations to harmonize domestic and international regulations. Their work is ongoing with a number of agencies, including the industry organization Interferry. These two groups are currently working on a domestic ferry regulations project using Bangladesh as a model for future assistance to developing countries. However, the safety project currently underway does not address first world domestic fleets.
So where does BC Ferries fit into all of this and how is it regulated?
It is operated under a voluntary implementation of the International Safety Management System Code (ISM) and is regulated under certain provisions of the Canada Shipping Act. While all shipping in Canada must comply with certain provisions of the Canada Shipping Act, glaring exceptions such as mandatory compliance to ISM persist and BC Ferries’ is essentially self-regulated in that regard. Special domestic regulations have been drafted by Transport Canada expressly for ferry operations including Domestic Ferry Security Regulations. Furthermore, BC Ferries has a history of petitioning Transport Canada for variances to regulations to which it is expected to comply and Transport Canada has issued hundreds of Board Decisions permitting those variances. Some of those variances to regulations can make some sense however they should only be permitted in context and so that the overall integrity of the Safety Management System (SMS) is not compromised. In 1989 the Auditor General of Canada’s report analyzed the Department of Transport – Canadian Coast Guard – Protecting Mariners’ and the Public’s Interests. The Department of Transport/Transport Canada/Coast Guard is the regulator overseeing safety for all marine, air, road and rail operations in the country.
Specifically, the Auditor General’s report expressed these concerns regarding Transport Canada/Coast Guard’s oversight of ferry operations in Canada:
22.29 Safety of passenger ferry operations not emphasized. Canada is a heavy user of ferries. Annually there are in excess of 20 million passengers on Canadian ferries. Ferries operating in Canadian waters vary in size from small cable ferries to large ocean-going ships on both the east and west coasts.
22.30 Although there have been no major ferry accidents in Canada in recent years, there have been serious incidents in other parts of the world. Recent accidents involving ferries, for instance the sinking of the “Herald of Free Enterprise” in Europe, were caused by unsafe operating practices rather than by unsafe ships.
22.31 We looked at the activities of the Branch in inspecting the ferries operated by the British Columbia Ferry Corporation and by Marine Atlantic. British Columbia Ferry Corporation operated 38 ferries in 1987, carrying more than 18 million passengers and 6.5 million vehicles. Marine Atlantic carried almost 2.5 million passengers and more than 800,000 vehicles in 1987.
22.32 We noted that the Coast Guard had not done an overall risk assessment for passenger ferries, such as would identify key risk areas — structure, operating practices and the transportation of dangerous goods, for example. An appropriate assessment would also set out the Coast Guard’s objectives, jurisdiction and safety priorities. We were informed that the Coast Guard was not aware of the extent of provincial activities or private initiatives in this area.
22.33 For the two ferry operations examined, the Branch had concentrated its activities on the development of extensive regulations and on pre-arranged annual inspections of structural safety, equipment, lifeboats, etc. The Branch had also attended an annual fire drill on every ferry to ensure that the operators were familiar with necessary procedures. However, the Branch had no formal program of inspecting operating practices. For example, there were almost no random checks of loading and off-loading practices, few checks to ensure that the ferries were under the control of qualified people and few checks to ensure that safety equipment was functional at all times.
22.34 An example of a potentially hazardous situation is the illegal transportation of dangerous goods on passenger ferries. Ferry operators rely on declarations by transporters that dangerous goods are not among those being shipped on passenger ferries. The Ship Safety Branch does not have a program to monitor or inspect such shipments.
22.35 For the most part the Coast Guard relies on others to ensure that safe operating practices are followed. We noted that it had done only limited verification to find out whether this reliance was justified.
22.36 The Coast Guard does not have national or regional risk management plans. Such plans would identify the skills, materials, and other resources required to meet its priorities and would include a multi-year schedule showing time frames and areas covered. It would also highlight any risks not provided for in the action plan. The plan would indicate areas where the Coast Guard relied on others to ensure, for example, the safety of passenger ferries in Canada. The Coast Guard would then be in a position to determine the impact of its activities on such areas as ferry passenger safety, and to identify gaps in its coverage.
22.37 Overall, we concluded that the Coast Guard had not developed analytical procedures for assessing risks related to the safety of ships and had not prepared risk management plans. It allocates its resources based on historical patterns for mandatory inspections rather than on an analysis of current needs.
Since the Auditor General’s report there have been a number of major incidents on BC Ferries and at Marine Atlantic, fires, groundings, collisions, allisions, a sinking and loss of passengers’ lives. Clearly not enough is being done by Transport Canada to address the concerns of the 1989 audit. The Transportation Safety Board has echoed those concerns in many of their BC Ferry Accident Investigation Reports throughout the years. Save Our Ferries believes, as does the TSB that the nature of the oversight, the ferries being Non-Convention is at the root of many of the incidents:
Collision Between – Queen of Alberni and The Shinwa Maru
4.1.1 Emergency Planning
Following this occurrence, the TSB forwarded a Marine Safety Advisory to the Canadian Coast Guard (CCG) regarding the need for a coordinated “emergency response plan” to interact with external emergency teams in organizing and evacuating injured passengers on passenger ferries.
In April 1992, the British Columbia Ferry Corporation (BCFC) carried out a review of its operational procedures with a view to improving passenger and crew safety. In conjunction with the CCG, the BCFC reviewed the capability of its crews to deal with emergency situations. Existing training programs were also reviewed and new ones developed to prepare all employees to cope with emergency situations.
In addition, in its report on a separate occurrence between the ferry “WOODSIDE I” and the tug “TUSSLE” (TSB Report #M90M4053), the Board noted similar safety deficiencies in emergency procedures and recommended that the Department of Transport require that officers and crew members of all federally inspected ferries and passenger vessels receive formal training on crowd control and relevant emergency procedures (M93-07, issued March 1993). In its response, Transport Canada indicated that certificated ships’ officers and ratings form a core of formally trained personnel which, in conjunction with the master’s responsibility to organize and train the entire crew, should enable abandonment to take place safely. The reply made no mention of formal training on crowd control and relevant emergency procedures being considered for all crew members.
Engine Room Fire – Queen of Surrey
1.7 Regulatory Surveys and Inspections
The Queen of Surrey was required to undergo annual hull and machinery surveys by its classification society, Lloyd’s Register of Shipping (Lloyd’s), as well as statutory annual safety equipment and safety construction surveys by TC. Under the system in use at the time of the accident, TC and Lloyd’s carried out joint annual and continuous surveys, while TC carried out the statutory surveys. Under TC’s and Lloyd’s continuous machinery survey program, the No. 2 main engine was required to be surveyed once every five years.
The Fire Detection and Extinguishing Equipment Regulations, made pursuant to the CSA, and SOLAS’s International Code for Fire Safety Systems specify the requirements for the national and international construction, inspection and testing of a CO2 smothering system and distribution manifold. However, being a non-Convention ship, the Queen of Surrey did not have to comply with the SOLAS requirements. The complete installation is required to undergo an annual inspection, at which time the operating gear, gas distribution system and all audible alarms are to be examined and tested by TC inspectors. However, authorized third-party subcontractors.could also perform this function and carry out the necessary repairs, with their reports being accepted by TC. On the Queen of Surrey, several different subcontractors had been given this responsibility over the years.
1.8 Previous Similar Occurrences
The Transportation Safety Board of Canada (TSB) has investigated other instances of engine room fires caused as a result of diesel oil spraying onto hot engine exhaust manifolds,8 and TC has issued two Ship Safety Bulletins (SSB 13/1985 and SSB 08/2000) in this regard. These bulletins are distributed to the marine community at large, through a voluntary distribution list, and they serve to alert the end users to issues TC considers significant. The SSBs are also circulated among TC inspectors for their instruction and guidance, and are available on the TC Web site.
Both SSB 13/1985 and SSB 08/2000 strongly recommend that attention be given to the following:
the integrity, vulnerability to damage, and wall thickness of fittings, during inspection of fuel, lubricating and hydraulic oil piping installations;
the possibility of fitting shields at connections, to contain or deflect oil spray in the case of breakage and drainage of any leakage to a drip tray;
the fitting of sheathing around lagging if there is a possibility of it being subjected to oil leaks from any source;
the frequent checking of the condition of lagging, oil pipework and fittings; and
any maintenance or replacement of fuel and lubrication oil pipework or components is to be accomplished with due regard to the potential hazards involved and using replacement parts that comply with the specifications for the systems or the components.
The SSBs are received by either the library or the documentation control department at BCFC’s management headquarters in Victoria. Photocopies of these are sent to the company’s various local management offices, with two copies provided to every vessel in the fleet. One each is sent to the wheelhouse and the engine room, and a signed acknowledgement of receipt form is then sent back to management at headquarters.
BCFC has not developed any formal follow-up procedures in this regard and any action taken (or expected), subsequent to the receipt of the SSB, is left to the discretion of the fleet superintendents or the vessel’s senior staff. Aboard the vessels, the SSBs are received by the senior master and senior chief engineer, who may then choose to disseminate the information contained therein to the other ship staff and also take such appropriate action as may be relevant to their vessel.
2.4 Adequacy of Standards for Construction and Testing of CO2 Systems
(Excerpt – Final Paragraph)
The hazards to personnel and a vessel associated with an unwanted release of CO2 into the engine room have been recognized by the International Maritime Organization in the SOLAS regulations,17 which require that the system be designed to safeguard against it. However, as a non-Convention ship, the Queen of Surrey did not have to comply with the SOLAS.
2.6 Adequacy of Regulatory Surveys and Inspections
The safe operation of a vessel is achieved through the combined participation of the vessel’s crew, owners and managers; port, flag and international regulatory authorities; and classification societies. Inspections are an important element in ensuring the continued functional safety of a vessel, and it is essential that these inspections be of the highest practical standard.
In this instance, the heat shields over the exhaust pipes on the No. 2 main engine had been removed in 1997. Since then, the vessel had undergone at least five annual surveys by Class and TC, and the No. 2 engine had one continuous machinery survey, in March 2003.
After the fire, this engine was completely dismantled and overhauled and its exhaust pipes were re-lagged. However, even a year later, it was observed that the heat shields had not been replaced. The lack of heat shields had played a role in initiating the fire, and this was common knowledge among the company management, vessel crew, TC inspectors and Lloyd’s surveyors. BCFC had requested that the engine manufacturer provide SOLAS-compliant heat shields after the fire, but they were not readily available. Shields were fabricated locally for the Queen of Oak Bay and Queen of Cowichan, but not for theQueen of Surrey. This unsafe condition and deficiency, therefore, remained unaddressed.
There had been over 20 annual inspections of the Queen of Surrey ‘s CO2 storage compartment and distribution manifold under TC’s regulatory regime. Although some of the deficiencies, such as improper clamping and support, misaligned and “chewed” pipes, irregularly bent hoses, etc., were readily observable, these had not been identified.
The quality of inspections conducted by TC and by Class may not be ensuring safe operational conditions.
Vessel Sinking – The Queen of the North
1.14.3 Canadian Standards
The standards on subdivision and damage stability for Canadian vessels engaged on domestic voyages are mainly set out in the Hull Construction Regulations, which are based on the 1960 SOLAS Convention.
In 1989, TC began to examine how the new 1990 SOLAS Convention’s international damage stability standards could serve as a basis for TC’s ongoing review of Canadian regulations and standards for passenger vessels.
In April 1990, recognizing that Canadian regulations for passenger vessels operating on international voyages did not incorporate the latest international standards, TC adopted new ones to enhance safety.41 In June 1991, similar standards were adopted, with the same intent, for passenger vessels operating domestically.42 Both standards were based on the 1990 SOLAS Convention, but their residual damage stability requirements were applicable only to new vessels.
Owing to resistance from the industry, TC, in consultation with the Canadian Ferry Operators Association (CFOA), decided not to apply the damage stability provisions of the document Ship Safety Passenger Ship Operations and Damaged Stability Standards (Non-Convention Ships) (TP 10943) to existing Canadian vessels (that is, those built before 1991).43
Full compliance with TP 10943, however, is mandatory for those existing vessels entering into Canadian operation since 1991, although there are phase-in dates for compliance similar to the SOLAS Convention.44
TC has amended TP 10943 based on risk assessment and on risk factors such as area of operation, number of people on board, age of the vessel.45 These amendments came into force on 01 October 2007 and apply damage stability requirements based on the SOLAS Convention to all domestic vessels (new or existing) of more than 15 gross tons or those carrying more than 12 passengers.46 There is a compliance schedule for existing vessels. The compliance schedule of TP 10943 differs from that in the SOLAS Convention, in that the former allows a longer phase-in time for existing vessels. Where an existing vessel is not compliant with these standards, a risk-based methodology might also be used to demonstrate an equivalent level of safety on a route-specific basis.
1.24.1 Emergency Preparedness
In order to comply with the ISM Code, BC Ferries established procedures for identifying and responding to emergency situations. The Emergency Management and Response Manual outlined corporate strategy for emergency management, as well as policies for organizing and activating its response. Vessel-specific manuals contained the procedures for on-site responses to vessel emergencies and emergency procedures checklists were developed.58 Furthermore, the BC Ferries Fleet Regulations required that contingency plans be developed for all identified potential emergency situations – including abandoning ship – and that a schedule of drills and exercises be established for each plan.59 At the time of the occurrence, the Queen of the North had abandon-ship procedures in the vessel-specific manual, but these did not address the various situations that may be associated with an evacuation. Such situations include identifying and locating missing passengers, and directing passengers from assembly stations to embarkation stations.
Pursuant to the Canada Shipping Act, Section 111 of the Life Saving Equipment Regulations requires every passenger vessel to have an evacuation plan that provides for the complement to be safely evacuated from the vessel within 30 minutes of the abandon-ship signal. BC Ferries had sought clarification from TC with regard to what was required to satisfy the requirement, but without success. An amendment to Section 111 was published in the Canada Gazette, Part II, Volume 140, No. 22, on 01 November 006, which clarified the requirement to have an evacuation procedure rather than a diagrammatic plan.
In January 2004, a BC Ferries team prepared an internal, draft version of an evacuation analysis for the Queen of the North, taking into consideration calculations to determine if the lifesaving equipment on board could be launched, and the vessel evacuated within 30 minutes – not including the time to muster. The stated purpose of the analysis was to assist the master in formulating the muster list functions and evacuation plan for the vessel. One of the recommendations included in the draft analysis was the development of a comprehensive evacuation plan.
BC Ferries was in the process of developing evacuation plans for its vessels. Although it has been a regulatory requirement since 1996, it was not until TC inspected the Queen of the North in early March 2006 that the requirement to have an evacuation plan/procedure was singled out. An SI 7 notice was issued to that effect on 02 March 2006.
2.12 Quality of Safety Management System Audits and Reviews
An effective SMS enables ship operators to anticipate and address safety shortcomings/deficiencies with the objective of improving on-board safety and reducing risk. SMS audits and management reviews are carried out to verify that a company’s SMS not only meets these objectives, but that it is being effectively implemented. It provides for safe operating practices, and assures that safeguards against all identified risks have been established. Operators must ensure that the quality of audits and management reviews is such that performance measurement is accurate. Accordingly, operators must also have proper procedures and records to show that the auditing and reviews carried out were adequate.
A review of available audit records dating from 1998, in addition to the quarterly management reviews, revealed that several key non-conformities90 relating to the Queen of the North had not been identified by internal or external audits. These included:
deck officers not being provided with appropriate training to operate the electronic navigation equipment;
BC Ferries certification requirements not being complied with (the certification requirements for several deck officer positions under BC Ferries employment policy exceeded those of TC. There were cases where, although an officer met the minimum TC certification requirement, the higher BC Ferries requirement was not being met);
deckhands, who were expected to perform the duties of a quartermaster, not always being qualified in accordance with the BC Ferries Fleet Regulations;
watertight doors being left open in contravention of Canadian regulations and a TC Board of Steamship Inspection decision;
no vessel-specific contingency plan or procedures being in place for responding to the various potential emergency situations associated with an evacuation;
a less than formal working environment on the bridge; and
an inconsistent application of accepted principles of navigation safety.
Additionally, senior management was advised in an August 2004 quarterly management review that there was an increase in the number of crew members assigned to vessels without being fully trained or cleared as required by the Fleet Regulations. The report indicated that part of that increase may have been attributed to the introduction of a new human resource management system while maintaining the previous system. The Operations Safety Log indicated instances where there was no documentary information of crew members having valid certificates/tests. However, there were no subsequent audit records relating to the Queen of the North identifying that deckhands continued to act as members of the deck watch (bridge team) without appropriate training or certification.
Taken together, this is an indication that the quality of these internal and external SMS audits was less than thorough.
Although internal audit records noted those instances where a non-conformity or an observation91 was raised, there was no recorded information to identify those activities that were audited and found to be in accordance with requirements. Moreover, the audit plans were only retained for four to five months. This lack of audit history precluded internal auditors from effectively planning future audits, based on past results.
Previous TSB investigations have also identified shortcomings with the BC Ferries SMS. In the investigation into the 2002 malfunction of the automatic steering control system on board the ferry Bowen Queen,92 the TSB found that the SMS of BC Ferries vessels did not require repairs to all critical equipment to be documented. In the investigation into the 2003 engine-room fire on board the ferryQueen of Surrey,93 the TSB found that shortcomings in the monitoring, tracking, and correcting of safety deficiencies indicated inadequacies in the performance of the vessel’s SMS.
In 1996, BC Ferries employed four full-time auditors to conduct SMS audits throughout the fleet, as well as in its shore offices and terminals. In the fiscal year ending 31 March 2006, there were only two full-time auditors and, when required, contractors were hired. While additional auditing resources may have been required to verify initial compliance and effectiveness of the SMS, the thoroughness of subsequent audits - so as to ensure continued compliance and effectiveness - is equally important. As per BC Ferries Fleet Regulations, Section 12.1, all 35 vessels94 and the approximately 150 sites were to be internally audited annually. During the 2005-2006 fiscal year, BC Ferries conducted 257 audits, of which 56 were conducted on board vessels, with 694 requests issued for corrective action. During the previous fiscal year, there were 243 audits, of which 92 were conducted on board vessels, with 449 requests issued for corrective action. While recognizing that it is difficult to objectively evaluate the effect of the audit team’s workload upon the thoroughness of their past audits, it nonetheless cannot be ruled out as a contributing factor to the failure of the audits to identify significant non-conformities.
The continuity and thoroughness of safety audits, both internal and external, and thus the effectiveness of the measurement of the safety performance of the organization have been ineffective in identifying safety deficiencies on board BC Ferries vessels. Conditions contributing to this situation include the lack of audit history records and the heavy workload demand upon the audit team.
While there are numerous other incidents that have taken place at BC Ferries and corresponding observations, recommendations and cautions made by the TSB that we could have cited, the following conclusion made by the Transportation Safety Board sums up our concerns regarding the regulatory oversight of BC Ferries succinctly:
From the 2006 Queen of the North TSB Accident Investigation Report
4.2 Action Required
Passenger ferries play a significant role in the Canadian transportation network. In 2006, over 44 million passengers and 16 million vehicles travelled by ship in Canada.100 In all, 113 passenger vessels above 500 gross tons operate in Canada, and some 50 of these vessels carry more than 400 persons.
Most Canadian ferries operate wholly in domestic trade where, taking into account route characteristics and traffic levels, there is an equal (if not greater) risk of damage due to collisions and groundings than there is internationally. Domestic ferries nonetheless operate under a different regulatory regime, which in many instances is less stringent.
International shipping is subject, through flag-state enabling legislation, to international norms negotiated within the International Maritime Organization (IMO) and set out in the relevant conventions, including the SOLAS Convention. Domestic shipping is not subject to these conventions, and the flag state has the option of regulating industry separately or adopting the international conventions to cover domestic shipping - with or without modification to suit perceived local circumstances. Vessels subject to the IMO conventions are frequently referred to as Convention vessels; those that are not are referred to as non-Convention vessels.
Much of the cross-border traffic handled by sea between Canada and the United States is carried by vessels that also trade domestically within their respective countries. Although vessels of one country may traverse the other country’s waters during the course of a domestic voyage, it is accepted practice that such vessels are not required to meet the conventions applicable to ships engaged in international trade; rather, they must meet the requirements of their own flag state.
The TSB is of the opinion that all large passenger vessels should adhere to the same safety standards, regardless of domestic or international operation, and that, in general, the rules set out in the various conventions should apply to all large passenger vessels operating in Canada.
BCCTS is in agreement.