Speaking Notes for
Transportation Safety Board of Canada to The Canadian Institute of Marine Engineers
and the Society of Naval Architects
and Marine Engineers (Vancouver Branches) Vancouver, British Columbia
February 11, 2006
Many thanks for the kind introduction. And many thanks to the local branches of the Canadian Institute of Marine Engineers and the Society of Naval Architects and Marine Engineers for inviting me to speak to you today.
The management of fires at sea, and the stability of fishing vessels are two of our top priorities. TSB reports tell us again and again that these are areas where action is needed, and where substantive improvements can be made.
So today, I want to talk to you about a number of recommendations the Transportation Safety Board of Canada has issued - some very recently. These recommendations arose from our investigations into accidents in:
- the domestic ferry sector - specifically the engine room fire on the Queen of Surrey;
- the international cruise sector - the Statendam switchboard room fire;
- the domestic fishing industry on the West Coast - the capsizing of the Cap Rouge II; and
- on the East Coast - the capsizing of the Ryan's Commander.
I have selected these four occurrences because they show how safety deficiencies specific to one accident can - through the process of investigation - be demonstrated as systemic. And how, subsequently, the TSB seeks to use its influence to effect change - whether the results are amendments to relevant international or domestic regulations, the raising of awareness of a safety deficiency, or helping to create a safety culture within a specific transportation sector.
They also demonstrate how effective change can take place quite quickly when everyone is on the same page, when everyone gets behind a solution. While, in others… well, sometimes it seems more like a long uphill struggle.
I've also selected these specific accidents because they are directly relevant to your field of expertise - marine engineering and naval architecture.
For you, ladies and gentlemen, are what we at the TSB call "agents for change."
Perhaps I should just back up a little. So here's a quick refresher on the Canadian Transportation Accident Investigation and Safety Board - usually known as the TSB.
The Board was established by federal statute in 1990 to conduct independent investigations into selected transportation occurrences, in order
- to make findings as to their causes and contributing factors;
- to identify safety deficiencies as evidenced by these occurrences;
- to make recommendations designed to eliminate or reduce these safety deficiencies; and
- to report publicly on our investigations and findings.
It is not the function of the Board to assign fault or determine civil or criminal liability.
We are an independent body. We report to Parliament (not to a minister). And we are definitely not Transport Canada - although many seem to confuse the two.
We are multi-modal. We investigate accidents in all of the federally regulated transportation sectors - marine, rail, pipeline and air.
The professionalism of our investigative teams is recognized worldwide, as is the quality of our reports - whether we are dealing with an occurrence the magnitude of the Swissair crash off Peggy's Cove, or the foundering of a small fishing vessel in the Strait of Georgia.
It has, however, become apparent that, in order to advance safety and fulfill our mandate, we must convey our findings and recommendations to a broader public, and especially to those parties who are "agents for change."
There isn't much point in burying a valuable recommendation in anybody's "permanently pending" basket. Consequently, we have consciously decided to become more visible and to communicate our concerns and recommendations more effectively.
Our recent investigation into the Queen of Surrey occurrence deals with one of the most dangerous marine situations - a fire at sea.
With shoreside fires in buildings or industrial facilities, usually there is ready access to extensive firefighting and rescue resources. But for a vessel at sea, these resources are limited, easily exhausted and non replenishable.
External support and rescue may be hampered by distance and adverse weather. So it is critical that firefighting equipment function correctly - the first time.
Once started, shipboard fires have the potential to increase exponentially. So crews - supported by vessel systems and equipment - must act quickly to restrict the spread of the fire, containing it within its place of origin, extinguishing it quickly and totally.
The principles sound so straightforward. Detect early. Contain effectively. Extinguish quickly.
Effective containment and quick extinguishment were central to the TSB's report on the Queen of Surrey occurrence in Howe Sound in 2003. We released the report this week.
The trouble began with the failure of an improperly oriented fuel pipe, resulting in a spray of diesel onto the engine exhaust manifold. The fire started within minutes. Detection was immediate.
The transmission of heat from the engine room to the lower car deck was rapid and threatened to set fire to the parked vehicles. The prompt operation of the sprinkler system, however, effectively mitigated this risk until the fire was extinguished.
When the fixed CO2 fire-smothering system was activated, several components of the distribution piping system failed so that the full charge could not be released into the machinery space. But sufficient CO2 was available to extinguish the fire.
The TSB investigation found that the following four factors were causal:
- a fuel oil pressure gauge pipe ruptured, spraying oil onto the hot exhaust manifold;
- the failed pipe was copper, not the prescribed steel;
- the shields on the exhaust system, which should have protected the manifold, had been removed some six years previously; and
- there were improper pipe connections in the CO2 system that failed from vibration-induced fatigue.
In addition, we identified seven findings as to risk. And two of these led directly to our recommendations, namely:
- current regulations do not address the means of ensuring the continued integrity of the CO2 extinguishing system; and
- the lack of fire-retardant insulation on the underside of the engine room deckhead increased the risk of fire propagation from the engine room to the car deck.
At this juncture, I should note that BC Ferries has already completed a variety of corrective actions across its fleet. And, where structural fire protection needs upgrading, this is being done during mid-life refit.
In our report on the Queen of Surrey, we noted that there are no requirements for ensuring the continuing structural integrity of CO2 systems, and that pressure testing is not required.
Consequently, the Board recommended that:
- Transport Canada, in conjunction with other stakeholders, review Canadian and international regulations respecting fixed fire-extinguishing systems to ensure that their design, maintenance, inspection and testing regimes effectively demonstrate continued structural and functional integrity.
You will note that we are asking Transport Canada to approach this on both the national and international levels. We believe that effective action can remove the risks associated with this safety deficiency.
Before going into the second recommendation arising from the Queen of Surrey investigation, I want to make a brief detour into a previous occurrence in Pacific Canada - the fire on the Statendam in 2002.
Shortly after the vessel's departure from Vancouver on an Alaska cruise, the main circuit breaker for one of the diesel generators suffered a catastrophic failure. Fires started in the main switchboard room and the adjacent engine control room. The crew successfully extinguished both fires using portable CO2 extinguishers. The vessel returned to Vancouver under tow and there were no injuries.
In our report, we established that the lack of fire-retardant insulation between the main switchboard room and the engine control room allowed cables in the engine control room to ignite and spread the fire.
In addition, the fixed fire-smothering system for the main switchboard room was not independent. Since activation of the fixed system would have flooded the engine room with CO2, stopping the main power plant, it was decided to fight the fire in the switchboard room with portable extinguishers. This was successful. But it was undoubtedly high risk, since the room was filled with smoke and contained "live" high-voltage electrical equipment.
In our report on the Statendam, the TSB recommended that
- Transport Canada submit a paper to the International Maritime Organization (IMO) requesting a review of requirements for structural fire protection and fire extinguishing systems to ensure that the fire risks associated with compartments containing high levels of electrical energy are adequately addressed (in SOLAS).
Last October, Canada submitted a paper - based on the Statendam investigation - to the IMO subcommittee on fire protection, where it is currently under consideration. We are pleased with the progress to date, and we expect that relevant provisions will be included in the next set of revisions to the International Convention for the Safety of Life at Sea (SOLAS) Chapter II-2.
I have included this Statendam detour to show how adoption of TSB recommendations can lead to international measures to address identified safety deficiencies.
Unlike the Statendam, our second recommendation arising from the Queen of Surrey investigation deals with structural fire protection under existing Canadian regulations. Namely that:
- Transport Canada require Canadian passenger vessels over 500 GRT to meet a standard of structural fire protection that ensures a level of safety equivalent to SOLAS-compliant vessels.
So in this instance we are not dealing with changes to SOLAS, but rather regulations under the Canada Shipping Act, regulations that are based on SOLAS 1948, that effectively grandfather Canadian vessels, thereby allowing an identified safety deficiency to continue... a safety deficiency that exposes the travelling public in Canada to a lower level of safety than that provided elsewhere on ships that are compliant with existing IMO provisions. And it is worth noting that, since 1990, 18 engine room fires have been reported in Canada on board passenger vessels and ferries over 500 GRT.
Change is therefore necessary to ensure that the underlying principle of structural fire protection regulations under SOLAS is applicable to all Canadian passenger vessels - namely that a fire is detected, contained and extinguished in the space of its origin.
These two reports merit your attention because there is work to do, both at home and abroad. We have the opportunity not just to establish better domestic rules, but to establish better worldwide standards.
In 2002, a new set of IMO requirements for fire protection, fire detection and fire extinguishment on board ships came into force as part of a new, revised chapter of SOLAS. This chapter incorporated technological advances in fire detection and extinguishment as well as lessons learned from fire incidents over the years.
Our recent investigations and findings are now part of an international dialogue that may well result in further improvements. We hope that the result will be an even stronger push for better design and better safety management.
Here at home, I urge you to incorporate improvements into design and practice, improvements that can enhance the capacity of Canadian vessels and their crews to deal with onboard fires.
I also wanted to use this opportunity to talk about another safety priority at the TSB, and that's small fishing vessel stability. I am especially concerned because we know what the problems are. We know what some of the solutions could be. We just don't seem to be able to get there!
Just a few years ago, the capsizing of the small fishing vessel Cap Rouge II captured headlines and saddened hearts. In August 2002, the Cap Rouge II overturned near the entrance to the main arm of the Fraser River in British Columbia. Two persons abandoned ship successfully. Five others, including two children, remained within the overturned hull and drowned.
The Cap Rouge II had a reputation as a wet boat. Lightly loaded at the time, and in moderate seas, water was being shipped and retained on deck. Deteriorated seals on the weather deck manhole covers allowed water below. The fuel tanks, water tanks and fish holds were all partially full. The resulting free surface effect overcame her residual righting ability, and over she went.
Since being built in 1974, the vessel had been modified extensively; this included the addition of a stern ramp, net-handling gear, cargo equipment and other items. For this voyage, a heavy West Coast seine net was also added. These modifications progressively reduced her transverse stability, leading directly to this tragic accident.
None of these modifications had been monitored or assessed by a suitably qualified person. Nor were they brought to the attention of Transport Canada inspectors between or during routine quadrennial inspections.
Our investigation report into the Cap Rouge II contained three recommendations relating to small fishing vessels. Firstly, stability data approval for all new and updated vessels; secondly, basic stability testing for all existing inspected vessels; and thirdly, measures to address unsafe working practices.
Transport Canada's response deferred any action to the existing regulatory reform process.
Then, last year, the Ryan's Commander was lost off the coast of Newfoundland. The investigation is still underway, but we issued an interim safety recommendation last November. This was done ahead of the full report because we believed there is a recurring safety deficiency that warrants urgent remedial action.
Why? Because we had raised the same stability issue before in our Cap Rouge II investigation report, but that didn't avert the Ryan's Commander's> similar fate.<
Almost brand-new, the Ryan's Commander foundered in the fall of 2004. The 1.7 million dollar fishing vessel encountered fairly rough seas and appears to have fallen prey to a serious stability problem. She capsized, taking two lives and putting other crew members through a harrowing rescue.
The sad truth is that since the Cap Rouge II occurrence, the TSB has initiated investigations into at least five capsizing incidents: the Hope Bay, Prospect Point, Melina and Keith II, the Ocean Tor and Ryan's Commander. These accidents have resulted in considerable loss of property and, much more important, eleven lives.
Since 1990, the TSB has investigated more than 80 accidents involving small fishing vessels that capsized, foundered or sank. The predominant cause was inadequate intact stability or stability-related unsafe working practices. Few of these vessels were required by regulation to meet any stability standard.
Our research shows that 150 small fishing vessels have been built since 2004, but fewer than five percent have submitted stability data to Transport Canada for approval. Regulations, for the most part, do not require it.
Transport Canada is in the process of changing its regulations under the Canada Shipping Act. It will require more stringent stability reporting for vessels under 24 metres in length. But these new fishing vessel safety regulations are not now expected to be in force before 2007.
Consequent to the Cap Rouge II, in 2003 the TSB recommended - in the interim, and prior to new regulation - that Transport Canada ensure that all new, inspected small fishing vessels of closed construction submit stability data for approval. In our interim recommendation flowing from the Ryan's Commander event, we have reiterated our position and urged Transport Canada to take action right now. A response by Transport Canada to this recommendation is due very shortly.
Further, in 2003, the TSB recommended that Transport Canada require that all existing inspected small fishing vessels - currently without any approved stability data - be subjected to a roll period test and a corresponding freeboard verification not later than their next quadrennial inspection. This recommendation was also reiterated.
Still, while waiting for an effective response, we continue to live with a situation in Canada where this valuable data is not often collected and these tests are not applied. Although stability information for a similar vessel had been submitted for approval, no stability data for the Ryan's Commander was submitted, and stability was not fully assessed. Nonetheless, it was granted a steamship inspection certificate by Transport Canada.
There are other anomalies. In British Columbia, for example, the Department of Fisheries and Oceans allows operators to "stack" prawn licences, which means two licences on one vessel. To accommodate the additional traps, vessel modifications are made - without any reference to weight or stability.
Similarly, other rules allow owners to replace a vessel under an existing licence, provided that the new one is of the same or lesser length, or not exceeding certain parameters as to length and capacity. This is often done without any reference to seaworthiness. Bow modifications shorten some vessels. Stern overhangs are added that don't count towards length overall. Almost unbelievable amounts of top hamper are seen (especially in Atlantic Canada).
I think we all understand the motivation to maximize earning capacity at least cost. But does this have to be to the detriment of safety? Is it beyond our collective capacity to have rules that are valid? Rules that are reasonably comprehensive? Rules that provide the basis for a culture of safety that automatically asks "is this safe?"
While we appreciate that Transport Canada and DFO are aware of these issues and endeavour to bring new practices, standards and regulations to bear, my colleagues and I at the TSB continue to press for immediate action.
Section 48 of the existing small fishing vessel inspection regulations allows Transport Canada's inspectors to require any test to satisfy themselves that an inspected vessel is seaworthy for its intended purpose. This, in conjunction with existing stability guidelines, provides an effective opportunity to identify those vessels most at risk and for which stability data should be submitted for approval. However, there is no such provision for uninspected vessels - those under 15 gross tons.
Transport Canada has indicated that it will take action through the new regulations to be implemented in 2007 as part of CSA 2001. But how can that be soon enough, when vessels and their crews continue to be placed at risk?
I have to tell you it is discouraging to me, personally, that these preventable problems continue to plague our fisheries across Canada. At the TSB we will continue to argue for improvement, and we will continue to ask everyone concerned - including naval architects, builders and related professions - to step up to the plate.
Whether you are independent or work for a large marine enterprise, I would like to convince you to re-evaluate and embrace your own role in the business of safety. I'd like to encourage you all to become "agents for change" in your industry. It will serve your professional and business interests, it will contribute to the creation of a robust safety culture in this country and, most important, it will save lives.
Ladies and gentlemen, thank you for your time and attention. I hope that I have been able to explain the value of our investigative process, our findings and recommendations. I hope you may be able to better appreciate what changes need to be made both internationally and domestically in pursuit of enhanced safety in the marine sector. And finally, I hope that I have been able to persuade you that you are all "agents for change."
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