TSB recommends improved passenger vessel safety measures following investigation into the fatal 2015 Leviathan II capsizing off Vancouver Island, British Columbia

VANCOUVER, June 14, 2017 /CNW/ - Today the Transportation Safety Board of Canada (TSB) is issuing three recommendations to improve passenger vessel safety resulting from its investigation (M15P0347) into the fatal October 2015 capsizing of the passenger vessel Leviathan II in Clayoquot Sound, British Columbia.

"It's time for Transport Canada to work with whale-watching companies and other passenger vessel operators to ensure the experience they offer is not just thrilling, but as safe as it can be," said Kathy Fox, Chair of the TSB. "When people find themselves in cold water, every second counts. Our recommendations today are aimed at putting in place measures to avoid accidents in the first place, and to expedite rescue efforts if an accident occurs."

On 25 October 2015, the Leviathan II was on a whale-watching excursion in the Plover Reefs area near Tofino, British Columbia, with 27 people on board. As the vessel was about to leave the area, a large breaking wave approached and impacted the vessel on the starboard quarter. The vessel broached and rapidly capsized, throwing all 24 passengers and 3 crew into the cold seawater without flotation aids. The subsequent rescue operation recovered 21 survivors. Six passengers died.

The investigation determined that the sea conditions in the area were favourable to the formation of breaking waves. However, none had been seen when the vessel first approached the area to observe sea lions. Moments after the master became aware of the large wave approaching the starboard quarter, he tried to turn the vessel to minimize the impact, but the wave struck the vessel before these actions could be effective. The crew did not have time to transmit a distress call before the capsizing, nor did the vessel have a means to automatically send a distress call. It was only by chance that the crew retrieved and activated a parachute flare, alerting nearby Ahousaht First Nation fishermen who arrived on the scene first, alerted search-and-rescue (SAR) authorities, and began recovering survivors from the water.

The Board's first recommendation is that Transport Canada (TC) require commercial passenger vessel operators on the west coast of Vancouver Island to identify those areas and conditions conducive to the formation of hazardous waves, and adopt practical strategies to reduce the likelihood of an encounter (M17-01). The Board is also recommending that TC require passenger vessel operators across Canada to adopt explicit risk-management processes that identify hazards and then implement proactive strategies to reduce these risks. These risk management processes should also be accompanied by comprehensive guidelines so that vessel operators and TC inspectors can implement and oversee them effectively (M17-02).

The TSB's third recommendation is aimed at reducing response time in the event of an accident. It took 45 minutes after the capsizing before SAR authorities became aware of the capsizing. The TSB wants TC to require all commercial passenger vessels operating beyond sheltered waters to carry emergency position-indicating radio beacons (EPIRBs) or other similar equipment. These are designed to float free in the event of a capsizing or sinking and automatically transmit a continuous distress signal to SAR authorities (M17-03).

See the investigation page, investigation findings backgrounder and recommendations backgrounder for more information.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

The TSB is online at www.tsb.gc.ca. Keep up to date through RSS, Twitter (@TSBCanada), YouTube, Flickr and our blog.

BACKGROUNDER

Investigation findings (M15P0347) in the October 2015 capsizing and sinking of the passenger vessel Leviathan II off Plover Reefs in Clayoquot Sound, British Columbia

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex – an accident is never caused by just one factor. The October 2015 accident off Plover Reefs in Clayoquot Sound, British Columbia, was no exception. There were many factors that caused this accident, the details of which are contained in the seven findings as to causes and contributing factors. Furthermore, there were four findings as to risk as well as two other findings.

Findings as to causes and contributing factors

  1. While the Leviathan II was at Plover Reefs, the conditions were favourable for the formation of breaking waves.
  2. The vessel maintained position on the weather side of the reef, exposed to the incoming swell, to allow passengers to view wildlife. As the vessel was leaving the area, a large wave approached the vessel from the starboard quarter.
  3. Moments before the wave struck, the master became aware of it and attempted to realign the vessel to minimize its impact, but there was not enough time for his actions to be effective.
  4. The forces exerted on the vessel by this large breaking wave caused it to broach and rapidly capsize.
  5. The rapid capsizing resulted in the passengers and crew falling into the cold sea water without flotation aids or thermal protection, exposing them to the effects of cold water immersion.
  6. Approximately 45 minutes elapsed before search-and-rescue (SAR) resources became aware of the capsizing, as the crew did not have time to transmit a distress call before the capsizing, nor did the vessel have a means to automatically send a distress call.
  7. The crew members were able to discharge a parachute rocket, which alerted a nearby Ahousaht First Nation fishing vessel that was instrumental in saving the lives of a number of survivors.

Findings as to risk

  1. If companies that operate passenger vessels do not implement risk management processes to identify and address environmental hazards in their area of operation, such as the potential formation of breaking waves, then there is a risk of a similar capsizing and loss of life.
  2. If there is no requirement for companies to assess their operations to determine under which conditions flotation aids should be worn, there remains a risk that passengers on this class of vessel will be deprived of the benefits of a flotation aid in the event of sudden and unexpected immersion in cold water.
  3. If vessels do not have effective means to promptly notify SAR authorities of an emergency, especially in capsizing situations, there is a risk of a delay in SAR response that will hinder the survival chances of passengers and crew.
  4. If seafarers do not fully disclose medical information, and marine medical examiners do not request supporting data, medical files may be incomplete, increasing the risk that seafarers will carry out their duties when not medically fit.

Other findings

  1. The life raft deployed in the occurrence was fitted with a Class B (Canadian) emergency pack, which did not contain devices effective for initially signalling distress, such as a parachute rocket or buoyant smoke float.
  2. Although the master's eyesight was not causal in the occurrence, there was a discrepancy between test results for unaided vision obtained privately and those obtained during TC medical examinations.

BACKGROUNDER

Safety communications for TSB investigation (M15P0347) into the October 2015 capsizing and sinking of the passenger vessel Leviathan II off Plover Reefs in Clayoquot Sound, British Columbia

Occurrence

On 25 October 2015, at approximately 1500 Pacific Daylight Time, the passenger vessel Leviathan II was on a whale-watching excursion with 27 people on board when it capsized off Plover Reefs in Clayoquot Sound, British Columbia. The subsequent rescue operation recovered 21 survivors, which included 18 passengers and 3 crew members. There were 6 fatalities. As a result of the capsizing, approximately 2000 litres of fuel leaked into the water.

TSB recommendations

The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry. Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.

RECOMMENDATIONS MADE ON 14 JUNE 2017

Risk management of passenger vessel operations on the west coast of Vancouver Island

Voyage planning is one such mitigation process; it consists of taking into account elements such as weather, tides, and navigation dangers, and making a contingency plan and sail plan before setting off on a voyage. The degree of voyage planning necessary for small vessels depends on the size of the vessel, its crew, and the length of the voyage.

In this occurrence, the company had not established guidelines to address the potential formation of breaking waves. Instead, it relied on individual masters' experience and judgment to mitigate this inherent risk. If companies that operate passenger vessels off the west coast of Vancouver Island do not implement risk management processes to identify and address environmental hazards in their area of operation, such as the potential formation of breaking waves, then there is a risk of a similar capsizing and loss of life.

Therefore, the Board recommends that:

The Department of Transport ensure that commercial passenger vessel operators on the west coast of Vancouver Island identify areas and conditions conducive to the formation of hazardous waves and adopt practical risk mitigation strategies to reduce the likelihood that a passenger vessel will encounter such conditions.

TSB Recommendation M17-01

Explicit requirements and guidance for implementation of risk management processes

In Canada, although Transport Canada (TC) provides guidance for SMS, the need for a comprehensive risk assessment process is not clearly stated, and guidance to the industry on how to implement such a process in their operations is minimal.

Risk management processes are considered a critical means of managing safety on board passenger vessels. As well, clear requirements and guidelines are needed to assist vessel operators and TC inspectors in the implementation and oversight of such processes.

Therefore, the Board recommends that:

The Department of Transport require commercial passenger vessel operators to adopt explicit risk management processes, and develop comprehensive guidelines to be used by vessel operators and Transport Canada inspectors to assist them in the implementation and oversight of those processes.

TSB Recommendation M17-02

Automatic distress alerting

In an emergency situation in which a vessel rapidly capsizes or sinks, the survival of passengers and crew often depends on the successful transmission of a distress signal to search-and-rescue (SAR) resources. Although passenger vessels are required to carry distress-alerting equipment such as very high frequency (VHF) radio transceivers, VHF radiotelephones with digital selective calling, and pyrotechnics, this equipment relies on manual activation by a crew member to initiate the distress signal.

At the national Canadian Marine Advisory Council meeting in April 2016, TC updated industry on the proposed Navigation Safety Regulations, which are expected to be completed by 2018. If put into effect, the revised regulations will consolidate the Ship Station (Radio) Regulations 1999, among others, and require that vessels carry EPIRBs when operating outside of sheltered waters if more than 8 m in length; when carrying more than 6 passengers; or if the vessel is a tug/tow boat.

In the meantime, passengers travelling on vessels not equipped with EPIRBs continue to be exposed to additional risk, even when the vessels operate close to the shore, and would benefit from the requirement for vessels to have a distress-alerting capability that does not rely on human intervention to be activated.

Furthermore, in capsizing or sinking situations, passengers forced into the water or onto a survival craft should have the capability to continuously update SAR resources on their position, as the effects of the wind and current may cause them to drift. The proposed amendments by TC fall short of addressing the risk to passenger vessels less than 8 m carrying up to 6 passengers while operating beyond sheltered waters.

Therefore, the Board recommends that:

The Department of Transport expedite the proposed changes to the Navigation Safety Regulations and expand its current emergency position-indicating radio beacon (EPIRB) carriage requirements to require that all commercial passenger vessels operating beyond sheltered waters carry an EPIRB, or other appropriate equipment that floats free, automatically activates, alerts search-and-rescue resources, and provides continuous position updates and homing-in capabilities.

TSB Recommendation M17-03

Previous TSB recommendations

Explicit requirements and guidance for implementation of risk management processes

Following an occurrence in 2002, in which the amphibious passenger vehicle Lady Duck sank in the Ottawa River and 4 passengers drowned, the Board recommended that:

The Department of Transport take steps to ensure that small passenger enterprises have a safety management system.

TSB Recommendation M04-01

Automatic distress alerting

The TSB has issued 2 previous recommendations following occurrences in which vessels carrying passengers were in an emergency situation but were unable to transmit a distress signal.

The first recommendation was issued as a result of an occurrence involving the charter boat 25K6527, which was overturned by a large breaking wave near Barkley Sound, British Columbia, while on a whale-watching trip in April 1992. The occurrence resulted in 2 fatalities. There was no distress call from the vessel, and rescue efforts began only after the vessel was reported as overdue by the company. Following this occurrence, the Board recommended that:

The Department of Transport encourage all charter vessel operators to equip their vessels with life-saving and emergency communication and/or signalling equipment suitable for the type of operation.

TSB Recommendation M94-03

The second recommendation was issued with regard to the passenger vessel True North II, which was swamped by a series of waves while operating in inland waters on 16 June 2000. The vessel took on water, downflooded, and sank in Georgian Bay, Ontario, resulting in 2 fatalities. Although the vessel was equipped with a VHF radiotelephone, the speed with which the vessel sank prevented a distress transmission. The rescue effort began only when SAR authorities were informed of the accident by a passing vessel. Following this occurrence, the Board recommended that:

The Department of Transport require small passenger vessels to provide pre-departure briefings, and to be equipped with a life raft that is readily deployable, lifesaving equipment that is easily accessible, and the means to immediately alert others of an emergency situation.

TSB Recommendation M01-03

 

SOURCE Transportation Safety Board of Canada

For further information: Transportation Safety Board of Canada, Media Relations, 819-994-8053, media@tsb.gc.ca

RELATED LINKS
http://www.bst.gc.ca
https://www.canada.ca

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