Thursday, February 19, 2015

MAINTENANCE DEFICIENCIES AND INADEQUATE EMERGENCY PROCEDURES LED TO NOVEMBER 2013 GROUNDING OF PRINCESS OF ACADIA IN DIGBY, NOVA SCOTIA










29 JANUARY 2015 

DARTMOUTH, NOVA SCOTIA

In its report (M13M0287) released today, the Transportation Safety Board of Canada (TSB) found that maintenance deficiencies and lack of adequate emergency procedures led to the 7 November 2013 loss of electrical power and grounding of the passenger ferry Princess of Acadia in Digby, Nova Scotia. There were no injuries or pollution reported.

The Princess of Acadia was approaching the ferry terminal at Digby, Nova Scotia, with 87 passengers and crew aboard. In preparation for docking, as the bow thruster was started, the main generator blacked out causing a loss of electrical power and disabling the main propeller pitch control pumps. Once the pitch control pumps stopped, the propeller thrust defaulted toward full astern while the engines were still running, causing the vessel to slow down, stop and travel backwards towards the nearby shoreline until running aground.

The investigation found that a deteriorated generator component caused the failure of two main generators and the blackout of the main electrical switchboards, among other system failures. The investigation also identified that neither the bridge nor the engine room had effective procedures in place to respond to the blackout of the main switchboard. Because of this, the master was not informed that engine room personnel were having difficulty restoring power, and the engine room was not aware of the urgency of the situation. 

This impeded an effective response to the emergency. The vessel had voluntarily implemented a safety management system (SMS), but it did not provide the master with guidance to proactively identify risks or investigate hazardous occurrences.

There were also deficiencies with passenger-related duties in written evacuation procedures and with Transport Canada’s oversight to ensure compliance with regulations regarding passenger safety emergency procedures. As such, there is a risk that these procedures will not achieve their intended purpose. Previous marine investigations (M12C0058 and M13L0067) have found deficiencies in the oversight of passenger safety regulations. 

Following the occurrence, Bay Ferries Ltd., the vessel operator, instituted improved operating procedures for when the vessel prepares to arrive at Digby. They have also installed a simplified voyage data recorder, which records bridge audio and information navigation equipment and other available sensors. Llloyd’s Register, the vessel classification society, has increased the frequency for generator breaker testing.

Safety management and oversight is a TSB Watchlist issue. The TSB is calling on Transport Canada to implement regulations requiring all operators in the air and marine industries to have formal safety management processes and for effective oversight of these processes. When companies are unable to effectively manage safety, the regulator must not only intervene, but do so in a manner that succeeds in changing unsafe operating practices.