Associated links (M21P0030)
Speaking Notes - M21P0030 (Ingenika)
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Introduction - Kathy Fox
Good morning everyone and thank you for joining us.
Today we are here to outline our investigation findings following the 2021 sinking of the tug Ingenika while towing a barge from Kitimat to Kemano Bay, British Columbia –fatally injuring two crew members. Our thoughts and condolences are with those who lost their loved ones and were impacted by this tragic accident, including elders and members of the Skidegate First Nation and other First Nations in and around this territory.
In addition to explaining what happened and why, the Board is issuing four recommendations to mitigate future towing accidents from occurring; specifically, with regards to Transport Canada’s regulatory surveillance and operator risk assessments for tugs of 15 gross tonnage or less, and the oversight of pilotage waivers issued by the Pacific Pilotage Authority.
I would like to remind Canadians that, in accordance with our enabling legislation, the sole purpose of the TSB is to advance transportation safety—by conducting independent investigations, determining causes and contributing factors, identifying safety deficiencies, and making recommendations to reduce them. We do not assign fault or determine civil or criminal liability.
To begin, I will turn things over to Clifford Harvey.
Accident summary – Clifford Harvey
Thank you, Kathy.
On February 10th, 2021, at around 4:00 pm local time, the tug Ingenika with a master and two deckhands onboard, departed Kitimat for its voyage to Kemano Bay, British Columbia. It was towing a barge, the Miller 204, which was carrying an estimated 1100 L of diesel fuel, 6.5 tons of sulphuric acid in bulk, and other cargo.
The forecast was for gale force winds and freezing spray along the voyage route.
The initial part of the voyage was uneventful. However, just before 10 pm, as the vessel made its way around Europa Point, its course changed relative to the wind and current. The change in conditions impacted the tug’s ability to tow the barge, and the tug’s speed began to fluctuate and decrease significantly.
At some point, the tug heeled over to starboard. The master made a Mayday call, and then ordered the crew to abandon ship. The tug began rapidly sinking.
Deckhand 1 was below deck in his bunk when the tug heeled over. By the time he made it up to the wheelhouse, he did not have time to don an immersion suit. He stepped into the cold water and swam away from the vessel. The master and deckhand 2 followed behind him partially wearing their immersion suits.
The Ingenika was fitted with a self-inflating life raft that released soon after the tug sank. Deckhand 1 was able to swim and climb aboard the life raft, however the master and deckhand 2 were unable to reach it.
The Ingenika was also fitted with an emergency position-indicating radio beacon that activated when it sank and automatically sent the tug’s coordinates to search and rescue. This helped search and rescue to home in on the area of the occurrence and concentrate their efforts there.
Deckhand 1 had drifted to shore in the life raft and was eventually located by search and rescue approximately 10 hours later and was transported to hospital. He suffered hypothermia and frostbite. The bodies of the master and deckhand 2 were also recovered.
The barge was located aground downriver of Europa Point and was later towed to Prince Rupert. The Ingenika sank in deep water with approximately 3500 L of diesel fuel onboard. Despite efforts by multiple federal agencies, the vessel was not located.
Investigation findings – Clifford Harvey
Our investigation found that numerous factors contributed to this accident:
The tug and barge departed in adverse weather conditions without a comprehensive assessment of the Ingenika’s suitability for the towing operation being undertaken.
As the Ingenika and barge made their way around Europa Point in opposing wind and current, the heavily loaded barge may have continued on its trajectory instead of following behind the tug. The drag force of the barge may have led the tug to heel over and the deck edge to submerge, resulting in down flooding through deck openings and the vessel sinking.
The master and deckhand 2 were only partially wearing their immersion suits, which allowed cold water to enter and contributed to hypothermia and subsequent drowning.
The surviving crew member, unencumbered by restrictions from a partially donned immersion suit, was able to remove himself from the water and get into the life raft.
The investigation found that:
- If towing companies do not prioritize risk management and provide guidance to help masters assess the suitability of tugs for the towing operations – operational limits can be exceeded, placing the crew, the tug, the tow, and the environment at risk.
- Since tugs of 15 gross tonnage or less are not subject to adequate regulatory surveillance, there is a risk that hazardous conditions and practices will not be addressed, leading to accidents.
- If crew members do not have an opportunity to regularly practise responding to emergencies through drills, there is a risk that they will not respond effectively in an emergency, decreasing their chances of survival.
Kathy Fox will now talk about the Board’s four recommendations.
Recommendations – Kathy Fox
Thank you, Clifford.
As of September 2022, there were 1,343 tugs of 15 gross tonnage or less registered in Canada, approximately 1,035 of which were registered in British Columbia.
Since 2015, the TSB has investigated 6 occurrences involving tugs of this class operating on the west coast of Canada. These investigations have raised issues around the adequacy of regulatory surveillance, a systemic safety issue that has been on the TSB Watchlist since 2010.
Transport Canada does not certify tugs of 15 gross tonnage or less, nor are these vessels required to undergo regular inspections. Although it has set an annual target of inspecting 3% of tugs of 15 gross tonnage or less nationwide, most will go years between inspections or may never be inspected.
The Ingenika was constructed in 1968, and had been in operation for over 50 years before this occurrence, yet there are no records of Transport Canada ever performing any inspections in the tug’s operational life.
As a result, the onus is on the authorized representative, typically the owner of a vessel – in this case, the owner of Wainwright Marine Services, to ensure compliance with the regulations and the safe operation of the vessel.
However, as highlighted in our most recent Watchlist, many authorized representatives have limited awareness of key sections of the Canada Shipping Act, [2001] and of the broader regulatory framework. As the probability of an inspection and enforcement by Transport Canada is low, authorized representatives may not be motivated to ensure compliance.
Therefore, the Board recommends that:
Transport Canada [The Department of Transport] expand its surveillance program to include regular inspections of tugs of 15 gross tonnage or less to verify that these vessels are complying with regulatory requirements.
Additionally, there is no requirement for tug operators to assess any of the risks that might be present in their operations, even something as essential as assessing the suitability of their vessel for a specific towing operation. This leaves these operators without the benefit of an effective system for managing safety.
Without a formal safety management process in place, operators may not be aware of the risks they face, and that’s why safety management has been on the TSB Watchlist since 2010.
Authorized representatives are required to develop and implement safe operating procedures. However, since what constitutes safe operating procedures is open to interpretation, these requirements have not resulted in the effective management of risk on tugs of 15 gross tonnage or less.
As this category of vessel goes largely uninspected, there is the potential that accidents like the one with Ingenika will continue to occur.
Therefore, the Board recommends that:
Transport Canada [The Department of Transport] require authorized representatives of tugs of 15 gross tonnage or less to assess the risks present in their operations, including the suitability of their tugs for the specific towing operations they are undertaking.
The final two recommendations are addressed to the Pacific Pilotage Authority, the PPA.
At the time of the occurrence, the Ingenika was operating in what is called a compulsory pilotage area that falls under the responsibility of the PPA, which administers safe and efficient pilotage services in British Columbia.
The PPA has a pilotage waiver system under which some vessels may obtain waivers that exempt them from the requirement to have a licensed marine pilot on board in designated areas if they meet certain requirements. However, the PPA does not verify that the information submitted meets regulatory requirements. Without proper verification that crew and vessels meet the waiver requirements, non-compliance can go undetected and compromise safety in compulsory pilotage waters.
Although the master of the Ingenika had been issued a pilotage waiver, he did not hold the required certificate of competency, and therefore should not have been issued the waiver. Further, the tug was not fitted with the equipment required for a vessel operating under a waiver.
This investigation is not the first to identify shortcomings around the PPA’s process for issuing waivers and its reliance on companies to ensure ongoing compliance with waiver conditions. The TSB found similar issues in occurrences involving the tug Ocean Monarch in 2017 and the tug Nathan E. Stewart in 2016.
Given the need to ensure that waivered vessels are operating at a level of safety comparable to that afforded by a licensed pilot, the Board recommends that:
the Pacific Pilotage Authority verify that eligibility requirements are met before issuing pilotage waivers to companies operating tugs in compulsory pilotage areas.
and that
the Pacific Pilotage Authority implement a process to verify ongoing compliance with waiver conditions by companies operating tugs in compulsory pilotage areas.
Conclusion – Kathy Fox
Accidents don't just happen. They are the result of many factors. In this occurrence, inadequate risk management and emergency preparedness, the absence of regulatory oversight and verification of pilotage waivers all played a role.
This accident illustrates the tragic outcomes that may result when all involved do not work together to address potential risks.
Safety is a shared responsibility. Regulators, vessel owners, and crew members each have a role to play to reduce risk, avoid accidents and prevent loss of life.
Thank you.