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.