Background and Safety Action Taken for the Marine Investigation Report No. M02C0030
Sinking and loss of life - amphibious passenger vehicle Lady Duck Ottawa River June 23, 2002
Pre-departure Safety Briefings
In July 2002, the TSB sent Marine Safety Advisory (MSA) 07/02 to Transport Canada (TC) indicating that steps should be taken to ensure that operators of passenger vessels conduct required safety briefings before departure and that the content and delivery of those briefings are in keeping with the intent of the regulation.
In response, TC has indicated that the following action, among others, was taken to date:
- On 11 July 2002, a letter was issued to Ontario operators and one manufacturer of amphibious passenger vehicles, informing them of the regulatory requirement for passenger safety briefings. Similar letters were issued to operators of amphibious passenger vehicles throughout the country. The same information, including reference to passenger safety briefings, was sent out as an advisory note to TC marine inspectors.
- On 27 July 2002, TC issued Ship Safety Bulletin (SSB) 06/2002 to advise operators of the regulatory amendment requiring safety briefings on all passenger vessels, and the importance of these briefings.
- TC has added the above SSB and a discussion of safety briefings as a teaching point in the Small Passenger Vessel Inspection Course for marine inspectors.
TC further advises that efforts are being undertaken to educate the general public to expect and request a safety briefing before departure. These communication efforts include, as of 03 July 2003, three different public service announcements broadcast on Météo Média and the Weather Network and posters in tourist areas.
Bilge Pumping System
In August 2002, the TSB sent MSA 08/02 to TC, indicating shortcomings with the operation of the bilge pumping system.
In response, TC has indicated that the following actions were taken:
- Immediately after the accident, all amphibious passenger vehicles were inspected, including bilge pumping and alarm systems.
- On 11 July 2002, a letter was issued to Ontario operators and one manufacturer of amphibious vehicles, informing them of precautionary measures and best practices concerning bilge pumping systems. The same information was sent as an advisory note to TC marine inspectors.
- On 23 August 2002, TC issued SSB 09/2002, highlighting the importance of bilge pumping and alarm systems on small vessels.
On 23 December 2002, the TSB sent Marine Safety Information Letter (MSI) 12/02 to TC, indicating that the lifebuoy fitted on the vehicle did not meet the size requirement contained in the Small Vessel Regulations (SVR). Furthermore, examination of the lifebuoy revealed that, although it was stamped with TC's approval number TC.143.014.045, it did not meet applicable standards as set out in both TP 7325, Standards for Lifebuoys and Integral Equipment, and section 8, Schedule III of the SVR. The lifebuoy grab lines were of varying lengths (570, 590, 600, and 610 mm), rather than the required length of not less than 610 mm for each line. In addition, the lifebuoy was attached to the top of the after bulkhead of the vehicle by way of a bungy cord, the hooks of which were clasped together behind the lifebuoy and out of sight. Because of the mode of attachment, it was not available for immediate deployment.
In response, TC agreed that the lifebuoy should have been 762 mm in diameter and it appears that the manufacturer did not produce the lifebuoy according to the approved prototype. TC met with the manufacturer and reviewed its quality assurance and inspection procedures. An audit of four lifebuoys revealed that grab lines met the lifebuoy standard.
Small Vessel Regulations
On 10 January 2003, the TSB sent MSI 01/03 to TC, advising that a summary review of the SVR revealed inconsistencies that could be confusing to operators who must abide by the regulations and to inspectors who must enforce them.
TC indicated that, as a result of ongoing initiatives, amendments to the SVR were published in Canada Gazette, Part I, in December 2003, which will, inter alia:
- incorporate TP 1332, Construction Standards for Small Vessels, by reference, establishing minimum mandatory standards. TP 1332 has also been reformatted to make it easier to read;
- establish life-saving equipment carriage requirements for vessels with a gross tonnage of 0 to 15;
- address inconsistencies regarding lifejackets;
- introduce stability requirements for new vessels.
The amendments incorporating TP 1332, expected to come into force in 2004, will require new small vessels to comply with that construction standard. Existing small vessels, including small passenger vessels, will be required to comply with the standard insofar as it is reasonable and practicable to do so.
Inconsistencies regarding lifebuoys will be addressed in phase II of the Regulatory Reform, scheduled to commence in 2005 or earlier.
TC has advised that regulatory amendments being planned include requirements that all passenger vessels carry enough lifejackets suitable for children and that all lifejackets be stored, readily accessible, in clearly marked locations. The Life Saving Equipment Regulations were subsequently amended on 24 February 2004. However, the Life Saving Equipment Regulations do not apply to vessels with a gross tonnage of 5 or less that are certified to carry not more than 12 passengers. It is anticipated that those vessels will be covered by similar amendments being proposed for the SVR.
Small Commercial Vessel Safety
The Canadian Marine Advisory Council (CMAC) Small Vessel Working Group proposed, inter alia, that TC prepare a comprehensive outline on implementing International Organization for Standardization (ISO) stability and buoyancy assessment on new and existing vessels of between 6 m and 12 m in length and carrying not more than 12 passengers.
A study has been initiated to examine amphibious vehicle safety and the following issues will be addressed: hull integrity, bilge pumps, escapes, seating, intact and damaged stability, operation, and personnel. The study is intended to assist TC in making decisions respecting such vehicles.
The Small Commercial Vessel Safety Guide (TP 14070), which is intended to provide owners and operators with an overview of the safe operating practices, certification, construction, and safety requirements, has just been completed and published.
Furthermore, TC has adopted a policy for assessing stability of existing vessels. Owners may choose to have their vessel assessed to one of three standards developed by the United States, the United Kingdom or the ISO. Additionally, there will be a fourth option for assessing stability, a TC-simplified stability requirement based on ISO. For vessels that do not go beyond 20 nautical miles from shore, owners may select one of the three standards or opt to assess their vessel to a set of simplified requirements.
A notice to advise owners and operators of this policy is being prepared for public information for release by the end of May 2004. Presentations, explaining the policy and the procedure for assessing vessels against the simplified requirements, have been held in all TC regions.
In 2003, TC introduced the Small Vessels' Operator Proficiency Course to address, inter alia, minimum training for operators of small passenger vessels with a gross tonnage of less than 5. The goals of this non-mandatory course include: providing participants with a basic understanding of the hazards associated with their vessel and prevention of shipboard incidents; knowledge to deal with emergencies; and knowledge and skills to safely operate a vessel in sheltered waters. To obtain certification upon the successful completion of the course, participants must have met the qualifying sea service and successfully completed the Small .Vessel Basic Safety Training (Marine Emergency Duties A3) and Marine First Aid, Basic Certificate or equivalent. Consideration of making the proficiency course mandatory will be addressed by TC in a discussion paper under the Marine Personnel Regulations.
Requirements for Radio Communication
Amendments to the Ship Station (Radio) Regulations, 1999, published in the Canada Gazette, Part I, on 12 April 2003, will require vessels of more than 8 m in length, of closed construction, to carry a very high frequency (VHF) digital selective calling radiotelephone on all home trade voyages, except for home trade voyages class IV that are within a Vessel Traffic Services (VTS) coverage area. This does not apply to vessels on inland or minor water voyages.
While these amendments do not apply to vehicles such as the Lady Duck, an additional amendment to the regulations is being prepared that will require all passenger vessels that are not currently required to fit a VHF radio, regardless of area of operation, to have a reliable means of two-way communication. When the amendment comes into force, vessels operating in VHF coverage areas will require a VHF radiotelephone and vessels operating in areas where VHF coverage is not provided will require some other means of communicating with a responsible party ashore. In terms of inspection, the operator or master will be required to demonstrate the operational readiness of the selected means of two-way communication.
Small Vessel Inspection System
A database for recording vessel particulars and details of inspections has been developed by TC. A study recommending a framework for evaluating small vessel risk factors has been completed. The findings of the study will be combined with the data collected by the Small Vessel Inspection System to develop risk indices of vessels to aid in selecting vessels for random and targeted compliance monitoring inspections.
The public report, M02C0030, is also available on this site.
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