Findings from TSB investigation M22C0231: August 2022 collision with dock of passenger ferry Sam McBride

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the August 2022 striking of berth of passenger ferry Sam McBride in Toronto, Ontario, which resulted in 20 passengers sustaining injuries, several factors led to the accident. The four findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made nine findings as to risk.

Findings as to causes and contributing factors

These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

  1. During busy times, such as the day of the occurrence, crews on City of Toronto ferries expedited crossings to address passenger backlog. Without written procedures that defined a safe speed of approach during docking, decisions around docking speed may have been influenced by operational pressure.
  2. On the occurrence voyage, the Sam McBride approached the dock at five knots, which was two knots faster than its typical approach speed, reducing the time available for the vessel to decelerate.
  3. Only the aft propeller was in use to slow the vessel, and it was not enough to stop the Sam McBride from striking the dock.
  4. The Sam McBride’s momentum when it struck the dock caused multiple passengers to lose their footing and fall, resulting in numerous injuries.

Findings as to risk

These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.

  1. If the crew complement specified on a vessel’s safe manning document is insufficient to respond to an emergency, there is an increased risk to the safety of the vessel’s crew and passengers.
  2. If the conditions of a Marine Technical Review Board decision are not implemented by an operator and if the regulator does not enforce their implementation, vessels will not operate at an equivalent level of safety.
  3. If all passenger vessel crew members are not trained in passenger safety management, there is a risk that they will not be prepared to manage passengers in emergency situations.
  4. If there is no accurate method to count the passengers boarding a vessel, there is a risk that not all passengers will be accounted for in an emergency.
  5. If there is no method to identify passengers that require special care or additional assistance during an emergency and there are no provisions in place to provide this additional assistance, the safety of these passengers may be compromised.
  6. If passenger familiarization methods, such as briefings or signage, do not transmit safety information effectively, the safety of passengers may be put at risk.
  7. If passenger evacuation procedures are not validated through a realistic exercise with a representative number of participants, a vessel’s crew will be insufficiently prepared for an emergency and passengers will be at an elevated risk of injury or death.
  8. If a crew does not ensure that the number of lifejackets of the correct sizes is sufficient for the number of children and infants boarding the vessel, there is a risk that children and infants will not have lifejackets in an emergency.
  9. If Transport Canada uses only its Ship Safety Bulletin system to communicate vessel safety information to passengers, there is a risk that they will be unaware of information that may be vital to their safety in an emergency.

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the August 2022 striking of berth of passenger ferry Sam McBride in Toronto, Ontario, which resulted in 20 passengers sustaining injuries, several factors led to the accident. The four findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made nine findings as to risk.

Findings as to causes and contributing factors

These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

  1. During busy times, such as the day of the occurrence, crews on City of Toronto ferries expedited crossings to address passenger backlog. Without written procedures that defined a safe speed of approach during docking, decisions around docking speed may have been influenced by operational pressure.
  2. On the occurrence voyage, the Sam McBride approached the dock at five knots, which was two knots faster than its typical approach speed, reducing the time available for the vessel to decelerate.
  3. Only the aft propeller was in use to slow the vessel, and it was not enough to stop the Sam McBride from striking the dock.
  4. The Sam McBride’s momentum when it struck the dock caused multiple passengers to lose their footing and fall, resulting in numerous injuries.

Findings as to risk

These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.

  1. If the crew complement specified on a vessel’s safe manning document is insufficient to respond to an emergency, there is an increased risk to the safety of the vessel’s crew and passengers.
  2. If the conditions of a Marine Technical Review Board decision are not implemented by an operator and if the regulator does not enforce their implementation, vessels will not operate at an equivalent level of safety.
  3. If all passenger vessel crew members are not trained in passenger safety management, there is a risk that they will not be prepared to manage passengers in emergency situations.
  4. If there is no accurate method to count the passengers boarding a vessel, there is a risk that not all passengers will be accounted for in an emergency.
  5. If there is no method to identify passengers that require special care or additional assistance during an emergency and there are no provisions in place to provide this additional assistance, the safety of these passengers may be compromised.
  6. If passenger familiarization methods, such as briefings or signage, do not transmit safety information effectively, the safety of passengers may be put at risk.
  7. If passenger evacuation procedures are not validated through a realistic exercise with a representative number of participants, a vessel’s crew will be insufficiently prepared for an emergency and passengers will be at an elevated risk of injury or death.
  8. If a crew does not ensure that the number of lifejackets of the correct sizes is sufficient for the number of children and infants boarding the vessel, there is a risk that children and infants will not have lifejackets in an emergency.
  9. If Transport Canada uses only its Ship Safety Bulletin system to communicate vessel safety information to passengers, there is a risk that they will be unaware of information that may be vital to their safety in an emergency.