Lessons Yet To Be Learned

“Please be advised vessel hard aground Gunboat Passage off Dingle Island. Some underwater damage, suspect tanks from number three double bottom ruptured. Vessel in no immediate danger. Will require immediate dry-docking. Anticipate no more until 0100 tomorrow. Regret”. —– Master, Queen of Prince Rupert in his message relayed to BC Ferry Corporation General Manager, August 25, 1982.

On August 25,1982 the BC Ferries MV Queen of Prince Rupert departed the ferry dock in Prince Rupert headed southbound for Bear Cove at Port Hardy on Vancouver Island. En route, the vessel pulled into Bella Bella as per it’s normal routine, loading a large number of foot passengers and departing approximately one half hour late and anticipating a CSI (Ships’ Safety) inspection upon arriving at Port Hardy. At some point prior to sailing, the master made a decision to depart from the regular route the ship normally sailed through Lama Pass. He made the decision to take the vessel through an alternate route by way of Gunboat Passage. Most, but not all of the officers on watch that night were aware of the change of route plan however all of the officers were present in the wheelhouse as the master prepared to take the ship through an area requiring “visual as well as electronic aids with which to navigate safely”. The chief officer had commented to the master on the one previous occasion when they had taken this alternate route,“Gunboat Passage is no place for this ship.”

The 1st, 2nd, 3rd and 4th officers were all in the wheelhouse as the ship, under the navigational command of the master, neared Anthony Point. On board and in the wheelhouse were two management representatives of the B C Ferry Corporation. The weather was calm and it was a clear twilight as the ship entered the passage on a falling tide. When the 1st officer entered the bridge he was asked by the master to check one of the radars that the bridge was equipped with, even though he wasn’t actually on duty at the time. The 3rd officer also came into the wheelhouse while off duty in order to take photographs of this unusual change of their route plan. The 2nd and the 4th officers were attending to their normal duties. Both the 1st officer and the 2nd officer provided comments to the master as to the position of the ship relative to the navigational hazards they observed...”You’ll have to take the buoy down our starboard side”……”You’ll have to come to port to clear the buoy”……at which point the master ran to the chart table and uttered, “Oh no….” He then returned to his position in front of the controls and “manipulated both handles and we struck”.

The 1st officer was asked in the ensuing inquiry under the Canada Shipping Act what he did next. “Well, my initial action and instinct was to close the watertight doors…..and to go below to do a tank inspection.”

Evidence given by the 2nd officer indicated that after grounding on Dingle Island “the ship somehow bounced off and ended up in a position south of the spar buoy. After that, there was an attempt to get out of the situation by going astern at which time we struck again and stuck. We didn’t float again until next morning.” The 4th officer described in his evidence that the vessel was stuck on the rocks the first time for about 10 minutes and after much effort manipulating the engines and the manoeuvring the ship, it floated free for approximately five minutes at which point the vessel grounded for a second time and remained so until the flooding tide in the early hours of the next morning.

The first on scene to aid the stranded vessel were fish boats including ‘Pacific Eagle’ and ‘Eileen W.’from the area around Bella Bella. The Coast Guard Cutter ‘The Racer’ steamed to the Queen of Prince Rupert, arriving about four hours after she grounded.

In the ensuing inquiry, the Chief Engineer gave evidence that he examined the vessel and determined “She had been breached and the dry tank in which the fuel tank is situated was breached also. Consequently you got the sea into the dry tank and the fuel polluting the sea in the dry tank also.”

Q. The cracks or holes in the bottom seem to have been fairly small, but quite a number of watertight spaces had been breached.

A. Yes.

Q. How many watertight subdivisions then were open to the sea?

A. The forward dry, that’s one; number 1 double bottom, that’s two; number 2 double bottom, that’s three; number 2A which is a void, that’s four; number 5 double bottom, that’s five. Then when we became afloat at five-thirty, five gear box void showed an increase, that’s the port forward void.

Q. So that’s six?

A. Yes.

Q. Six spaces altogether. What would have been the effect upon the buoyancy of the vessel if all these six spaces had become flooded?

A. Now you are speaking if these six spaces, it’s virtually two-thirds of the length of the vessel, so it’s rather far-fetched, you know, situation really. You would have a really

bad situation. I don’t think it could happen.

Q. It could happen. There were holes in all of these voids. If you hadn’t done anything about it, which of course, is rather ridiculous — I just wanted to know what would be the effect of flooding, the compartments that were breached?

On March 22, 2006, the BC Ferries’ vessel ‘Queen of the North’ ran aground on Gil Island in Wright Sound. Many of the compartments the chief engineer described did in fact become flooded as the ship was ripped from stem to stern as a result of the forward momentum as the vessel drove up onto the island. She too bounced off, she too was attended to by nearby fishing vessels and a Coast Guard cutter, she too had passengers who remained on board unaccounted for and bridge procedures, training, scheduling, and human error were also eventually determined by the Transportation Safety Board to be at the heart of the disaster. The sad difference in the two outcomes was the loss of two passengers’ lives and of the corporation’s vessel.

So, what lessons could have been learned by both BC Ferries and Transport Canada that just might possibly have spared the ‘Queen of the North’ and her two lost souls?

Wharton School Risk Management Centre is quoted in the first major study by the Nautical Institute on the implementation of the ISM Code, entitled ‘Cracking The Code’:

A near miss is an event that signals a system weakness that, if not remedied, could lead to significant consequences in the future. As such, a near miss is also an opportunity – an opportunity to improve system structure and stability and an opportunity to reduce risk exposure to potential catastrophe.

There were several key pieces of evidence given to the 1983 QPR inquiry that should have set off alarm bells at Transport Canada and with the insurers at Lloyd’s.

BC Ferries vessels exemptions from requirements of SOLAS and the quality of regulations and inspections.

From the transcript:

Q. What were your actions then following the grounding? What did you do?

A. Well, initial action and instinct was to close the watertight doors.

Q. The watertight doors were open?

A. Yes.

Q. Is that normal?

A. During conditions when we had passengers and crew aboard?

Q. Does that conform with Hull Construction Regulations? Do you know what the Hull Construction Regulations require?

‘The Queen of the North’ also regularly sailed with her watertight doors open. Correspondence dating from 1996 between BCFC and Transport Canada contains critical evidence of the ferry operator’s attempts at obtaining variances to regulations in order that they would be permitted to sail their older non-compliant vessels without making major structural alterations or docking the vessels for good. Had the ‘Queen of Prince Rupert’ struck Dingle Island at a greater speed she could well have suffered the same fate as the ‘Queen of the North’. While the ‘Queen of the North’ did sink, she sank slowly enough for the majority of the passengers to make them escape. This was only possible because of the transverse bulkheads BC Ferries installed as a solution for the lack of compliance with more stringent damage stability requirements.

Passenger manifests and searches of compartments in the event of evacuation

Q. But all the passengers had been disembarked at Bella Bella?

A. Except one passenger. During the time in Gunboat Passage there was a passenger asleep on the funnel deck and he appeared at Bella Bella, and I don’t remember him.

Q. So comfortable in the arms of Morpheus he slept right throughout these hours which you have described and turned up at Bella Bella, was that it?

A. That’s the first I became aware of this passenger.

Two passengers also remained onboard the ‘Queen of the North‘ the night she grounded and remained undetected. Should Coast Guard at the time have been more alarmed at the prospect of passengers being unaccounted for in an emergency such as the QPR grounding in 1982?

Bridge Procedures, Bridge Resource Management and Training; Management Directives and Standing Orders

The 1983 Canada Shipping Act Inquiry cited the master of the vessel for not preparing an adequate voyage plan, not adequately assigning necessary duties to his deck officers and not communicating in a timely manner with the required authorities following the incident and stopped short of charging him with negligence for knowingly altering a standard safer course to more risky one that resulted in a serious and costly incident. But throughout the evidence that was given back in 1983 it was clear that BC Ferries was a different sort of operation. While their vessels were Non-Convention vessels which meant they were not required by law to comply with all of the regulations under SOLAS (IMO Convention: Safety Of Life At Sea), enough incidents had happened to that point (Queen of Victoria collision; grounding of the Chinook II) that one would think they should have brought the status of this ferry operator under consideration for full compliance. After several high profile and tragic losses of many lives aboard several vessels internationally, concerns was heightened in Ottawa. In 1998, Transport Canada mandated the following restrictions on one particular BC Ferries’ vessel:

- Reduce the number of passengers to 500 (provides vessel with a 200% lifesaving capacity)

- Two officers on watch at all times

- Daylight only navigation in the Gulf waters

- No passengers below the car deck

- Watertight doors to remain closed while at sea except when opened temporarily for

Operational requirements….In conclusion, the vessel’s current legal requirement is to

Comply with the Hull Construction regulations.

The preceding was contained in a letter written to the senior vice-president of operations for BC Ferries. The vessel was the Queen of the North.