The occurrence
On August 20, 2022, the Sam McBride departed Centre Island toward Toronto’s Jack Layton Ferry Terminal with six crew 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 5:00 PM local time, the ferry struck the dock while berthing, resulting in approximately 20 passengers standing on or above the stairs being injured, mainly from losing their footing and falling.
Safety communications
In the case of an emergency on board a passenger vessel, it is essential that crew members have training in passenger management and effective procedures to guide their overall response. Emergency situations usually develop rapidly, and passengers, who are likely to be unfamiliar with the vessel and its equipment, are relying on the fast and coordinated actions of crew to keep them safe. The TSB investigation into this occurrence identified safety deficiencies related to passenger safety management that led the Board to issue three recommendations.
Crew training
The need for crew members to respond quickly and effectively to an emergency on a passenger vessel is the same for all vessels and voyages. When faced with an emergency, crew members need to have knowledge and skills related to crowd management and human behaviour in emergencies.
While the Marine Personnel Regulations require that crew members of passenger vessels greater than 500 gross tonnage (GT) on unlimited, near coastal Class 1, or near coastal Class 2 voyages have a Specialized Passenger Safety Management certificate or endorsement, there is no such requirement for crew members of vessels on sheltered waters voyages or those on vessels of 500 GT or less. The Specialized Passenger Safety Management certificate provides training on crowd management, crisis management and human behaviour in emergencies, passenger safety, and safety for personnel providing direct services to passengers. It also provides familiarization training.
While passenger vessels that are on sheltered waters voyages are closer to shore and shore-based emergency responders than vessels on other types of voyages, there are a number of types of emergencies that need an immediate response that cannot await the arrival of shore-based responders.
Currently in Canada, there are only 46 passenger vessels greater than 500 GT, while there are 5025 passenger vessels of 500 GT or less.The numbers for passenger vessels were obtained from a query of the Transport Canada Vessel Registry on 17 May 2024 using the vessel type “Passengers.” Vessels may have safe manning documents to operate on different classes of voyage, so it is difficult to assign an accurate number of vessels to each class of voyage. The maximum complement of a passenger vessel depends on more factors than just its gross tonnage, which means that passenger vessels of 500 GT or less may be carrying more passengers than those greater than 500 GT. Requiring training for only vessels greater than 500 GT leaves out the majority of passenger vessels.
The Sam McBride is less than 500 GT and was on a sheltered waters voyage. None of the crew members had received such training, nor were they required to. Following an occurrence on board the passenger vessel Island Queen III 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 on sheltered water voyages. However, TC has yet to implement passenger management training requirements to fully address this concern. 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.
For this reason, the Board recommends that
the Department of Transport implement a requirement for crew members of all passenger vessels, including those on sheltered waters voyages, to complete appropriate training in passenger safety management.
TSB Recommendation M24-01
Passenger vessel evacuation procedures
The Life Saving Equipment Regulations require all passenger vessels to have an evacuation procedure that dictates 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, TC has no formal procedure to assess if this requirement is being met. Operators who develop evacuation procedures have no approval process to confirm their procedure meets the requirement or to obtain approval from the regulator. Presently, each TC inspector or recognized organization surveyor is left to individually determine how this requirement is assessed; the requirement is most frequently assessed by the inspector or surveyor witnessing a drill on board the vessel.
For vessels, emergency drills are an opportunity to validate the evacuation procedures; the Fire and Boat Drills Regulations require that the master of a vessel ensure that drills are carried out as if they were a real emergency, as far as is feasible. For a passenger vessel, realistic drills require a large number of people acting as passengers, as indicated in TC’s Ship Safety Bulletin 04/2022. However, due to the logistical challenges of finding and managing a large number of volunteers, “as far as is feasible” often means that drills are conducted without passenger involvement, which means the drill cannot evaluate the crew’s ability to evacuate passengers from the vessel.
As is the case for many other vessels, drills on the Sam McBride were typically carried out without passengers on board, which meant that they did not provide an opportunity to realistically validate the feasibility of the vessel’s evacuation procedure. The investigation determined that the evacuation procedures for Sam McBride were not sufficient to support the evacuation of a large number of passengers, as they required crew members to be in multiple places simultaneously, assist an unreasonably large number of passengers, potentially complete multiple tasks at once, and move quickly within the vessel even if it was crowded. 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.
The issues found in the Sam McBride’s evacuation procedure are the latest example pointing to a need for TC to validate passenger vessels’ evacuation procedures. In 2020, following the occurrence on board the passenger vessel Island Queen III, the Board issued a safety concern regarding the risk to passengers if evacuation procedures are not validated. More than four years later, the safety deficiency still exists and the risk to passengers remains high. Therefore, the Board recommends that
the Department of Transport implement a formal validation and approval process for passenger vessel evacuation procedures.
TSB Recommendation M24-02
Passenger counting
In any emergency, it is essential to have an accurate count of passengers. Without an accurate count, a crew and emergency responders will be unable to determine if all passengers have been accounted for. To this end, the Fire and Boat Drills Regulations require that, before a passenger vessel sails, the master be provided with the number of persons on board and with details of persons who have declared a need for special care or assistance during an emergency. On voyages of 12 hours or more, there is also a requirement to keep a separate count of the number of children and infants; however, there is no such requirement for voyages of less than 12 hours.
When passengers were boarding the Sam McBride or other Toronto Island Park ferries, the number of passengers was estimated (counted in groups of 5 to 10) by a member of the crew and tracked using a hand-held tally counter. However, this method did not give the exact number of passengers boarding and meant that, in the event of an emergency, it would not be possible to account for all passengers. As well, the Toronto Island Park ferries did not keep a separate count of children and infants on board, nor were they required to. However, this meant that there was no way to determine whether there was an adequate number of lifejackets available in the appropriate sizes for the passengers on board.
Although TSB Recommendation M08-01 addressing passenger counting procedures on board ferries was closed as Fully Satisfactory in July 2010, four subsequent investigationsTSB marine transportation safety investigations M22A0312, M17C0179, M15A0009, and M13L0067. have shown that the provisions in the Fire and Boat Drills Regulations requiring an accurate count of passengers are not being consistently met. 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. Furthermore, 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.
Therefore, the Board recommends that
The Department of Transport implement a process to validate that passenger vessels are keeping an accurate count of all passengers, including a separate count of the number of children and infants, on all voyages.
TSB Recommendation M24-03
The occurrence
On August 20, 2022, the Sam McBride departed Centre Island toward Toronto’s Jack Layton Ferry Terminal with six crew 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 5:00 PM local time, the ferry struck the dock while berthing, resulting in approximately 20 passengers standing on or above the stairs being injured, mainly from losing their footing and falling.
Safety communications
In the case of an emergency on board a passenger vessel, it is essential that crew members have training in passenger management and effective procedures to guide their overall response. Emergency situations usually develop rapidly, and passengers, who are likely to be unfamiliar with the vessel and its equipment, are relying on the fast and coordinated actions of crew to keep them safe. The TSB investigation into this occurrence identified safety deficiencies related to passenger safety management that led the Board to issue three recommendations.
Crew training
The need for crew members to respond quickly and effectively to an emergency on a passenger vessel is the same for all vessels and voyages. When faced with an emergency, crew members need to have knowledge and skills related to crowd management and human behaviour in emergencies.
While the Marine Personnel Regulations require that crew members of passenger vessels greater than 500 gross tonnage (GT) on unlimited, near coastal Class 1, or near coastal Class 2 voyages have a Specialized Passenger Safety Management certificate or endorsement, there is no such requirement for crew members of vessels on sheltered waters voyages or those on vessels of 500 GT or less. The Specialized Passenger Safety Management certificate provides training on crowd management, crisis management and human behaviour in emergencies, passenger safety, and safety for personnel providing direct services to passengers. It also provides familiarization training.
While passenger vessels that are on sheltered waters voyages are closer to shore and shore-based emergency responders than vessels on other types of voyages, there are a number of types of emergencies that need an immediate response that cannot await the arrival of shore-based responders.
Currently in Canada, there are only 46 passenger vessels greater than 500 GT, while there are 5025 passenger vessels of 500 GT or less.The numbers for passenger vessels were obtained from a query of the Transport Canada Vessel Registry on 17 May 2024 using the vessel type “Passengers.” Vessels may have safe manning documents to operate on different classes of voyage, so it is difficult to assign an accurate number of vessels to each class of voyage. The maximum complement of a passenger vessel depends on more factors than just its gross tonnage, which means that passenger vessels of 500 GT or less may be carrying more passengers than those greater than 500 GT. Requiring training for only vessels greater than 500 GT leaves out the majority of passenger vessels.
The Sam McBride is less than 500 GT and was on a sheltered waters voyage. None of the crew members had received such training, nor were they required to. Following an occurrence on board the passenger vessel Island Queen III 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 on sheltered water voyages. However, TC has yet to implement passenger management training requirements to fully address this concern. 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.
For this reason, the Board recommends that
the Department of Transport implement a requirement for crew members of all passenger vessels, including those on sheltered waters voyages, to complete appropriate training in passenger safety management.
TSB Recommendation M24-01
Passenger vessel evacuation procedures
The Life Saving Equipment Regulations require all passenger vessels to have an evacuation procedure that dictates 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, TC has no formal procedure to assess if this requirement is being met. Operators who develop evacuation procedures have no approval process to confirm their procedure meets the requirement or to obtain approval from the regulator. Presently, each TC inspector or recognized organization surveyor is left to individually determine how this requirement is assessed; the requirement is most frequently assessed by the inspector or surveyor witnessing a drill on board the vessel.
For vessels, emergency drills are an opportunity to validate the evacuation procedures; the Fire and Boat Drills Regulations require that the master of a vessel ensure that drills are carried out as if they were a real emergency, as far as is feasible. For a passenger vessel, realistic drills require a large number of people acting as passengers, as indicated in TC’s Ship Safety Bulletin 04/2022. However, due to the logistical challenges of finding and managing a large number of volunteers, “as far as is feasible” often means that drills are conducted without passenger involvement, which means the drill cannot evaluate the crew’s ability to evacuate passengers from the vessel.
As is the case for many other vessels, drills on the Sam McBride were typically carried out without passengers on board, which meant that they did not provide an opportunity to realistically validate the feasibility of the vessel’s evacuation procedure. The investigation determined that the evacuation procedures for Sam McBride were not sufficient to support the evacuation of a large number of passengers, as they required crew members to be in multiple places simultaneously, assist an unreasonably large number of passengers, potentially complete multiple tasks at once, and move quickly within the vessel even if it was crowded. 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.
The issues found in the Sam McBride’s evacuation procedure are the latest example pointing to a need for TC to validate passenger vessels’ evacuation procedures. In 2020, following the occurrence on board the passenger vessel Island Queen III, the Board issued a safety concern regarding the risk to passengers if evacuation procedures are not validated. More than four years later, the safety deficiency still exists and the risk to passengers remains high. Therefore, the Board recommends that
the Department of Transport implement a formal validation and approval process for passenger vessel evacuation procedures.
TSB Recommendation M24-02
Passenger counting
In any emergency, it is essential to have an accurate count of passengers. Without an accurate count, a crew and emergency responders will be unable to determine if all passengers have been accounted for. To this end, the Fire and Boat Drills Regulations require that, before a passenger vessel sails, the master be provided with the number of persons on board and with details of persons who have declared a need for special care or assistance during an emergency. On voyages of 12 hours or more, there is also a requirement to keep a separate count of the number of children and infants; however, there is no such requirement for voyages of less than 12 hours.
When passengers were boarding the Sam McBride or other Toronto Island Park ferries, the number of passengers was estimated (counted in groups of 5 to 10) by a member of the crew and tracked using a hand-held tally counter. However, this method did not give the exact number of passengers boarding and meant that, in the event of an emergency, it would not be possible to account for all passengers. As well, the Toronto Island Park ferries did not keep a separate count of children and infants on board, nor were they required to. However, this meant that there was no way to determine whether there was an adequate number of lifejackets available in the appropriate sizes for the passengers on board.
Although TSB Recommendation M08-01 addressing passenger counting procedures on board ferries was closed as Fully Satisfactory in July 2010, four subsequent investigationsTSB marine transportation safety investigations M22A0312, M17C0179, M15A0009, and M13L0067. have shown that the provisions in the Fire and Boat Drills Regulations requiring an accurate count of passengers are not being consistently met. 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. Furthermore, 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.
Therefore, the Board recommends that
The Department of Transport implement a process to validate that passenger vessels are keeping an accurate count of all passengers, including a separate count of the number of children and infants, on all voyages.
TSB Recommendation M24-03