Presentation to the Canadian Ferry Operators Association

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Slide 1: Title Page

Thank you for the opportunity to speak today. My name is Ken Potter and I am the Manager of Investigation Operations at the TSB’s head office in Gatineau, Quebec. Dr. Jon Stuart could not be with us today because he is working with the team investigating the tragic crash of the First Air flight in Resolute Bay last month.

Slide 2: TSB Mandate

Slide 3: Marine Occurrences

Slide 4: Integrated Safety Investigation Methodology (ISIM)

Slide 5: ISIM Process

Slide 6: Sequence of Events

Slide 7: Sample Events Diagram

Slide 8: Basic Assumptions of Accident Causes

While the 80 per cent figure is often cited in human factors circles, I don’t agree with it. I believe that, because people design, build, operate and maintain ships, the true figure is closer to 100 per cent.

Slide 9: Human Factors

Human factors is not a new concept. Back in the 1800s, Joseph Conrad recognized that ships were rarely the problem.

Slide 10: Human Factors (Not “Human Error”)

Slide 11: Diagram

This complex relationship is shown in the diagram here. You will note that, with the exception of the environment, which people have yet to control, the other three elements in the model are all influenced by human factors.

Slide 12: Human Factors

Slide 13: Unsafe Condition

Many people mistakenly believe occurrences to be the result of “human error.” Pilots, for example, are blamed for causing planes to crash, much like officers of the watch are blamed for missing turns. Modern investigators, including those at the TSB, understand that underlying every unsafe act is an unsafe condition that permitted or supported the act. For example, failing to accurately account for all passengers during an emergency is an unsafe act. However, if no procedure was in place or if the crew had not been adequately trained or drilled, then it is an unsafe condition that resulted in the crew not accounting for all passengers. By asking why this happened, we identify an unsafe condition.

Slide 14: Diagram

Slide 15: Human Factors Elements in Marine Investigations

Slide 16: Photos of Various Ferries

With regard to organizational factors,  the TSB has investigated several occurrences involving large and small ferries. I have selected one occurrence from each coast to briefly review.

Slide 17: Joseph and Clara Smallwood (2003)

On 12 May 2003, a fire broke out on the vehicle deck of the roll-on/roll-off passenger ferry Joseph and Clara Smallwood (TSB Investigation report M03N0050). The vessel was 8 nautical miles south of Port aux Basques, Newfoundland and Labrador.

Slide 18: Joseph and Clara Smallwood (2003)

The fire originated in a drop trailer on No. 1 vehicle deck. The cause of the fire could not be determined.

Slide 19: Fire Damage

The fire was so intense that it melted plastic components on vehicles on the deck above.

Slide 20: Human Factors Aspects of the Investigation

The cause of the fire was of interest to the TSB, but our investigation led to a dead end, and we could not conclusively determine the source.

Extensive interviews with officers, crew and passengers were carried out and a written passenger survey was conducted. Two different perspectives helped provide us with a good understanding of the events. When applying our ISIM process, we began to see issues with the crew’s response to the emergency.

Slide 21: A Selection of Findings

Here is a selection of findings related to the human factors aspects of the investigation.
Remember, this was 2003. We have come a long way since then, as passenger management training is now mandatory.

However, accounting for passengers still remained an issue after this occurrence.

Slide 22: Queen of the North (2006)

We now switch our attention to Canada’s West Coast, to what is one of the most challenging and complicated investigations ever undertaken by the TSB. On the night of March 22, 2006, the Queen of the North struck Gil Island and sank in Wright Sound, British Columbia (TSB Investigation Report M06W0052).

The investigation was challenging from a human factors perspective, as we tried to determine what had happened with the witnesses statements sometimes conflicting. Attempting to maintain non-adversarial relationships with the vessel’s operators during a time when the media was touting questionable circumstances as the cause of the accident proved particularly challenging. In fact, at one point, the TSB brought in a specialist in witness statement analysis.

Slide 23: Human Factors Aspects of the Investigation

Slide 24: A Selection of Findings

Slide 25: ECOLOS

Since that time, the Board continues to note occurrences with emergency preparedness and passenger headcount issues. These issues are not limited to large operators. The cable ferry ECOLOS experienced a propulsion system and double cable failure on a cold winter night in December 2010 near Ottawa. The investigation is ongoing.

Slide 26: TSB Watchlist

Slide 27: TSB Watchlist

When faced with an emergency, those who have received training and practice respond more instinctively and thoroughly. This amounts to precious time saved—time that is even more vital when lives are at stake. It is therefore critical that crew members have access to detailed and accurate passenger lists, and that crews practice mustering and crowd-control.

As indicated at the beginning of the presentation, there is a direct relationship between incidents and accidents. Incidents indicate that there are problems within the system and foreshadow accidents to come.

So when the TSB places an issue on its Watchlist, it does not do so lightly. The TSB acknowledges that progress has been made within the ferry industry, but based on the number of incidents that continue to occur, a problem still exists.

Slide 28: Summary

Slide 29: End

That concludes our presentation.