TSB reiterates concern on emergency preparedness, regulatory oversight of Canadian passenger vessels

An investigation by the Transportation Safety Board of Canada, into a fire aboard a passenger vessel in the summer of 2014, has found that the vessel lacked written emergency procedures and that it was not required by regulation to have a safety management system.

A recommendation issued by TSB in 2004, that Transport Canada “take steps to ensure that small passenger vessel enterprises” have a safety management system “is still outstanding,” TSB said Tuesday in a press release.

TSB’s mandates include accident investigations involving aviation, railways, marine and pipelines. A separate organization from Transport Canada, TSB reports directly to Parliament through the Leader of the Government in the House of Commons.

TSB reported Tuesday that on Aug. 11, 2014, a fire broke out on La Relève II, which is based in Havre-Saint-Pierre, Quebec. At the time the vessel was on a sightseeing cruise with 33 passengers and two crew members. The vessel, which was built in 1983, is constructed of wood and covered with fibreglass.

During the cruise, the “engine power unexpectedly dropped,” TSB stated in its investigation report, released Nov. 24. “The master pushed the throttle control further forward to resume speed, and the engine power increased. However, shortly afterward, the engine power began to decrease again until the engine stopped.”

TSB noted in the report that passengers “saw smoke coming from around the engine compartment cover and alerted the master.”

At 1:35 p.m., the master broadcast a Mayday call over the radio. The passengers and crew abandoned ship.

“Two passengers were admitted to hospital following the occurrence,” TSB stated. “One was treated for shock and released shortly afterwards, while the other received treatment for a leg injury sustained during the boarding of the port life raft.”

TBS found that the engine “lost coolant when the rubber hose connected to the exhaust manifold outlet burst, most likely due to wear.”

That engine ” was extensively damaged due to overheating caused by the loss of coolant,” TSB added. “The exhaust manifold, the turbocharger, and the cylinder head were rendered unusable.”

TSB found that La Relève II “lacked written emergency procedures, formally assigned emergency duties, and training in these duties.” A safety management system, TSB noted, “helps to ensure that individuals at all levels of an organization have the information needed to make sound decisions in both routine and emergency operations. “

In the case of La Relève II, “the company did not have an SMS, nor was the vessel required to have one by regulation.”

TSB “has called for TC to implement regulations requiring operators to have formal safety management processes,” the board stated Tuesday.

“Previous TSB investigations into occurrences involving passenger vessels in several regions of Canada have identified issues related to emergency preparedness and regulatory oversight,” added in the report.

Other findings, in the investigation into the fire on La Relève II, included one that the insulation in the engine compartment contained polyurethane foam, “which is prohibited for use on passenger vessels.”

TSB also found that two of the three life rafts failed to inflate fully “due to buoyancy tube ruptures at the inflation valves.” Those ruptures “may have been caused by the lifelines becoming entangled with the inflation valve assemblies and creating excessive strain in the tubes.”