Release of investigation report M22C0231 - Sam McBride

Kathy Fox, TSB Chair
Yoan Marier, Board Member
Étienne Séguin-Bertrand, Senior Investigator/Safety Analyst (Marine)

Toronto, Ontario
19 August 2024

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Kathy Fox - Introduction

Good morning and thank you for joining us.

We are here today to issue three recommendations to Transport Canada, following the 2022 occurrence where the passenger ferry Sam McBride struck the dock at the Jack Layton Ferry Terminal here in Toronto, Ontario, resulting in injuries to approximately 20 passengers, six of whom were taken to hospital.

Our investigation found several safety deficiencies related to passenger safety management and emergency preparedness.

I'll now turn things over to the investigator-in-charge, Étienne, who will explain how the event unfolded and what our investigation found.

Étienne Séguin-Bertrand – Investigation findings

Thank you, Kathy.

On the afternoon of August 20, 2022, the Sam McBride departed Centre Island toward Toronto’s Jack Layton Ferry Terminal with six crew members and approximately 910 passengers on board.

Earlier that day, the ferry had completed eight crossings, six of which were at full capacity. It was behind schedule, which is not unusual on a busy summer day.

Shortly after 5 PM local time, the ferry struck the dock while berthing at the terminal, resulting in approximately twenty passengers being injured, mainly from losing their footing and falling.

The Sam McBride is a double-ended ferry, meaning that it has propellers at both ends of the vessel. Our analysis of security footage from the voyage determined that the vessel was approaching the dock faster than it had on earlier trips that day. The footage also showed that only the back end propeller was turning as it was approaching. Given the vessel’s speed and distance from the dock, the reverse thrust provided by the one propeller was not enough to stop the ferry.

The investigation found that the City of Toronto did not have written procedures that defined a safe approach speed during docking. Instead, decisions around docking speed were left to the discretion of the vessel master, who may have been influenced by operational pressures, such as passenger backlogs, or running behind schedule.

Following this occurrence, the City of Toronto put in place documented procedures for berthing.

When the TSB investigates an occurrence, we look not only at the specific event, but also the circumstances around it. During our investigation, we found several safety deficiencies related to passenger safety management and emergency preparedness.

Under the Marine Personnel Regulations, vessels are required to have a Safe Manning Document issued by Transport Canada, which sets out the minimum number of qualified crew members needed to ensure safety in various scenarios.

In 2009, Transport Canada evaluated that a minimum of 13 crew members were required for the Sam McBride. However following a request by the City of Toronto, Transport Canada allowed the ferry to operate with only six crew members, and without verifying that any mitigation procedures were in place to offset a smaller crew in the event of an emergency. The Safe Manning Document was subsequently renewed every five years, without revisions or modifications.

Our investigation determined that, if there was a fire on board or a need to abandon the vessel, there would not be enough crew members to effectively respond. Crew members would have to be in two places at once. Three crew members would be assigned to respond to the emergency, leaving only three others to oversee the management of over 900 passengers, and the possible evacuation, of all people on board.

While thankfully there were few serious injuries reported and the accident happened close to shore, if an emergency had arisen over the course of the voyage, the crew and those on board would not have been properly prepared.

The safety issues raised today are not new. Many of these issues have also been found in other investigations of Canadian passenger vessels. Following one investigation in particular, the Board raised concerns about the lack of requirements for infant lifejackets, the lack of assessment of passenger evacuation procedures, and the gap in training in passenger safety management.

Kathy will now tell you about the three recommendations the Board is issuing today.

Kathy Fox – Recommendations

Emergencies usually develop rapidly, and passengers, who are unlikely to be familiar with the vessel and its equipment, rely on the fast and coordinated actions of the crew to keep them safe.

This is why ferry vessel crew members need to have the knowledge and skills related to crowd management and human behaviour in emergencies. None of the crew members of the Sam McBride had received such training, because they weren’t required to.

In 2017, the TSB issued a safety concern about the lack of a requirement for training in passenger safety management for crew members on all vessels carrying more than 12 passengers in sheltered waters, such as rivers, harbours, and small lakes. To date, Transport Canada has yet to implement any requirements for passenger management training to address this concern, leaving crews unprepared to manage passengers in emergency situations.

For this reason, the Board recommends that

Our next recommendation relates to passenger vessel evacuation procedures.

We know the importance of conducting realistic emergency drills. Realistic drills require a large number of people acting as passengers AND must include the deployment of lifesaving equipment, to evaluate if the emergency procedures are practical.

The investigation found no evidence that an exercise including a large number of people representing the vessel’s maximum passenger capacity was ever performed. In 2018, the City of Toronto had conducted an emergency drill involving approximately 50 people who acted in the role of passengers; this was the largest number of people that had been involved in an emergency drill.

These drills did not provide an opportunity to confirm if the evacuation procedures would be feasible during a real emergency, when the vessel would be at full capacity.

The Life Saving Equipment Regulations require that all passenger vessels have a procedure that outlines how all passengers and crew members will be evacuated from the vessel within 30 minutes of the abandon ship signal being given. Although this regulatory requirement is in place, Transport Canada has no formal procedure to assess if this requirement is being met.

Therefore, the Board recommends that

This occurrence also highlights the need to have an accurate count of passengers. When people were boarding the Sam McBride or other Toronto Island Park ferries, the total number was only estimated using a hand-held tally counter, and children, infants, and those who may require extra assistance were not counted separately.

Without this information, there is no way to determine whether there is an adequate number of lifejackets available, and in the appropriate sizes, for everyone on board. At the time of the occurrence, the Sam McBride carried 183 child-sized lifejackets. The investigation found that on some voyages, there were many more children on board than the number of child-sized lifejackets.

Estimating is not good enough. If there is no method to accurately count the passengers as they board a vessel, there is a risk that not all passengers will be accounted for in an emergency. Plus, if a crew does not identify those that require special care or assistance during an emergency, their safety may be compromised.

Therefore, the Board recommends that

Kathy Fox – Conclusion

The Sam McBride occurrence highlighted the vulnerabilities related to passenger management in ferry operations, and the importance that must be put on passenger safety. Ferry passengers are not safety experts. They rely on vessel operators to bring them from point A to point B, safely.

However, the responsibility doesn’t just fall to vessel owners or crew members. Safety is a shared responsibility. Passengers need to pay attention to the safety briefings and follow safety instructions from crews.

Furthermore, Transport Canada also needs to ensure that effective regulations are in place and validated, so that if and when disaster strikes, passengers are in safe hands.

Thank you.