Notes for Remarks by
Transportation Safety Board of Canadaat the release of a report into the sinking of the
"TRUE NORTH II"
Report No. M00C0033
Port Elgin, Ontario
11 May 2001
I want to thank you all for coming here today to hear what the Transportation Safety Board of Canada learned from its investigation of the sinking of the "TRUE NORTH II", a passenger vessel that sank off Flowerpot Island in Georgian Bay on June 16 last year.
The vessel was carrying a captain and 19 passengers, 13 of whom were children -- Grade 7 pupils on their way home from an overnight camping trip.
The vessel sailed in rough weather, including winds of near-gale force. With the high waves, the vessel took on water and sank quickly, before the captain could issue a Mayday or distress signal.
The seven adults and 11 of the students managed to survive the 10-degree water by holding onto two rigid floats from the vessel; the wind eventually pushed them to shore.
But, tragically, two of the children drowned.
Before we proceed, I would like to acknowledge the support we have had from the families of the victims, and all the other families whose lives were forever affected by this tragic sinking.
Personally, I can tell you that I have been deeply moved by the strength that they, and the community at large, have shown in the months that followed.
But I was also highly troubled. Because, while any accident involving loss of life is terrible, one in which children perish is particularly tragic.
Sometimes, it is said that a person did something incorrectly, or that piece of equipment was broken, or this rule was not followed.
In this case, there was a combination of too many things.
The sinking of the "TRUE NORTH II" was one of those situations where many things were wrong. No one thing alone would have caused the accident, but all of them together created a disaster.
Small factors, which in and of themselves would appear insignificant, combined to produce fatal results.
Much as we might wish it, we can never undo the past. What we can do, however, is to try our best to understand what happened, in the hopes that we may prevent a tragedy like this from happening again.
While the Transportation Safety Board does not assign fault or blame, it tries to find out what happened and why, and make recommendations to advance safety.
It is then up to others - the regulator, the industry, and individual operators of vessels like the "TRUE NORTH II" - to make the changes necessary to protect our children and families.
I would now turn over the microphone to the two investigators involved, Mr. Paul van den Berg and our naval architect Lance Bedlington, to tell you about the findings of the investigation team.
Thank you, Paul and Lance.
Ladies and gentlemen, there are risks in any type of transportation, and travelling aboard a vessel on open water is no exception.
But the job of the owner and the operator of the vessel, and of the regulatory authorities, is to reduce that risk as much as possible.
This is the case for any vessel, whether it is carrying fishing personnel out to sea or cargo through the Great Lakes.
But, it is even more crucial when the vessel is carrying passengers - passengers who board the vessel with the full expectation that they will arrive safely.
And when those passengers are young school children, on an end-of-school-year trip, the need for safety is so obvious that it should be unnecessary to even have to mention it.
Most adolescents are oblivious to danger. They place their reliance on the adults and systems that shape their world. And - the have learned that their safety depends upon this reliance. That is why we are so disturbed, when our children are put at risk because of this trust.
There are many questions we need to ask about the risk to safety last June 16th:
- Did the captain recognize the limitations of his vessel and the risk of operating in poor weather? No, yet his certification was renewed several times.
- Was there a second crew member on the vessel, apart from the captain, as required by regulation? No. The captain was alone.
- Did the liferaft and lifebuoys deploy? No, they sank with the vessel.
- What about the scuppers and freeing ports that were supposed to let the flooded water drain off the deck? The scuppers were ineffective and two of the four freeing ports were welded shut.
- Was the vessel watertight? No, hatch openings in the deck could not be sealed.
- Was there a means to alert others of the distress? No, all the means of communication sank with the vessel.
- Were lifejackets readily available? No. They were wrapped in opaque plastic bags and stowed in a poorly marked location. Passengers were not briefed on the whereabouts of the safety equipment or how to use it.
- Were these problems identified during safety inspections? No, but the vessel had been inspected by Transport Canada Marine Safety every year since it was converted to a passenger vessel in 1972.
I could go on, but you all have the report in front of you. All of you can read for yourselves the list of contributing factors and deficiencies that led to this catastrophe.
The point is; there were many, many problems, some of which were not corrected over the years, even decades.
And all this says just two things to me:
One, the safety of the vessel was not challenged. And two, the status quo should always be challenged in order to safely operate every vessel, especially those carrying passengers.
Therefore, the Transportation Safety Board, having investigated all the circumstances of this tragedy, makes three main recommendations:
First, we call on the regulator, the Department of Transport, to expedite the review of the deficiencies in the inspection and certification process. We are recommending that the regulator publish progress reports to let Canadians know how fast the problems are being corrected.
Second, we urge Transport Canada Marine Safety to develop within its organization an approach to safety that would enable managers and safety inspectors to identify and address all unsafe practices and conditions.
Specifically, inspections should not be limited only to compliance with the rules. We believe there is an intent behind those rules, and that intent is to keep crew members and passengers safe, by recognizing and addressing unsafe practices and conditions not necessarily proscribed by regulations.
And third, we recommend that Transport Canada require small passenger vessel operators to take a number of specific actions to improve safety.
These include briefing travellers before departure about safety equipment and emergency procedures. The vessels should also be equipped with a readily deployable liferaft, easily accessible life-saving equipment and a mechanism to immediately alert others of an emergency situation.
In addition, the Board is concerned that in some cases vessel operators may not be adequately trained and the certification system may not catch these shortcomings.
I should point out that Transport Canada, which regulates marine and other modes of transportation, is working on a number of measures in the wake of this accident.
For instance, Transport Canada has announced that it intends to require small vessels to carry liferafts that float free if the vessel sinks. It is also developing a series of initiatives to improve the hiring, training and monitoring of inspectors. And it has pledged to review the quality of selected inspection reports on passenger vessels.
While I welcome those initiatives, I would also underline that follow-up is crucial.
It is also critical that, whatever changes are made, they are sustained. It makes no sense for the regulator to say, "we are ordering this change or that change" if, in two or three years, things are still the same.
Ladies and gentlemen, the sinking of the "TRUE NORTH II" was a profound tragedy.
We can only express our deepest sympathies to the parents and families of these children, and to all the other families touched by this tragedy.
But it is not enough to simply offer sympathies. As a society, we must commit to change, meaningful change --changes in equipment and manpower and procedures, and, above all, to a safety culture that says, "when passengers are involved, and especially when those passengers are children, we must not be content merely to meet the rules. We must exceed them."
For every passenger vessel that crosses Georgian Bay, for every whale-watching vessel on the west coast and deep-sea fishing charter on the Atlantic coast, we need a safety culture that says: This vessel is safe for passengers and crew.
Why do we need an accident like this, to make us think about safety.
But, the tragedy did happen. And therefore, we must learn from it, in the hope that such a thing will never happen again.
It is what the families would want. It is what all Canadians expect.
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