Marine Transportation Safety Advisory Letter 02/22

November 1, 2022

City Manager
Toronto ON M5H 2N2

On 20 August 2022 around 1700, the passenger ferry Sam McBride, with approximately 910 passengers and 6 crew on board, struck the dock while berthing at the Jack Layton Ferry Terminal in Toronto, Ontario. One passenger sustained serious injuries and 19 other passengers sustained minor injuries. No major pollution or damage to the vessel was reported. The Transportation Safety Board of Canada investigation into this occurrence (M22C0231) is ongoing.

During the course of an investigation, the TSB may communicate safety issues before an investigation is complete. This communication is undertaken to ensure that those best able to take remedial action and effect change are made aware of the identified safety issues in a timely manner. As the TSB is not a regulator, the identified issues are related to safety and not necessarily to regulatory compliance.

Investigation M22C0231 has identified some safety issues relating to emergency preparedness, passenger safety management, and lifesaving equipment on one or more vessels operated by the City of Toronto. These issues are as follows:

Emergency preparedness and passenger safety management

• Pre-departure safety briefings are not being consistently provided to passengers. When briefings are provided, they are transmitted through a pre‑recorded message that is not always audible. The briefings do not include instructions for passengers about how to properly don lifejackets.
• There is no signage, monitoring, or enforcement of the maximum number of passengers permitted on the promenade deck. 
• There is 1 sign posted per deck with information about how to don 1 type of lifejacket. The vessel carries 4 different types of lifejackets.  
• Passengers are permitted to stand on or at the top of the stairs when the vessel is underway and when docking.
• The vessel has a crew complement of 6 when carrying up to 915 passengers. In a situation where the crew are required to respond to an emergency and evacuate passengers, this complement does not allow for tasks set out on the evacuation plan and muster list to be completed simultaneously.
• There is no exact passenger count taken during boarding. As passengers board the vessel, a crew member uses a hand-held tally counter to estimate how many passengers have boarded. Children, infants, and those who may require extra assistance are not counted separately.
• The vessel has large and heavy sliding doors that are kept open while the vessel is operating. There are no means to secure these doors in place.

Lifesaving equipment

• The number of children boarding the vessel is not verified against the number of children’s lifejackets available on board.
• There are no infant lifejackets^{Footnote 1} on board, and although Transport Canada Ship Safety Bulletin 14/2020 advises parents that they should bring their own infant lifejackets, passengers are not advised of this before boarding.
• The lifejackets, which are stowed on the deckheads above the passenger decks, have labels identifying them as being for adults or children. Some of the lifejackets are stowed with their labels facing the deckhead, meaning these labels cannot be read from below.
• The lighting on the bridge deck does not illuminate each life raft launching station.

The above information is provided to help you take action as deemed appropriate. The TSB would appreciate being advised of any action that is taken in this regard. An investigator may follow up with you at a later date. Upon completion of investigation M22C0231, the Board will release its report into the occurrence.

Regards,

Original signed by

Clifford Harvey

Director, Investigations - Marine

CC.

• Director General, Marine Safety and Security, Transport Canada