Toronto ferry had no written procedures for safe docking speed, other ‘safety deficiencies’: TSB report

August 19, 2024 Canuck

The Transportation Safety Board of Canada says it found a number of safety deficiencies in its investigation into a Toronto ferry crash that injured 12 people two years ago.

The Sam McBride ferry collided with the dock as the vessel approached the Jack Layton ferry terminal on Aug. 20, 2022, leaving 12 people injured.

The investigation released Monday found that the city of Toronto did not have written procedures to define a safe approach speed during docking.

“Instead, decisions around docking speed were left to the discretion of the vessel master, who may have been influenced by operational pressures, such as passenger backlogs or running behind schedule,” Investigator-in-Charge Étienne Séguin-Bertrand told reporters at a news conference.

Video analysis of several trips made during the day found that at the time of the crash, the ferry was approaching the dock faster than it had during several previous trips that day.

While the ferry has two propellers, just one was turning at the time of the crash.

“The footage also showed that only the back end propeller was turning as it was approaching. Given the vessel speed and distance from the dock, the reverse thrust provided by the one propeller was not enough to stop the ferry,” Séguin-Bertrand said.

Officials said Monday that while just one propeller was turning, they were not able to conclude that there had been mechanical failure.

Séguin-Bertrand said that the investigation also uncovered several “safety deficiencies” related to passenger safety management and emergency preparedness.

For example the vessel had just six crew members on board, fewer than the 13 recommended by Transport Canada for the Sam McBride back in 2009.

There were approximately 910 passengers on-board when the crash occurred.

“The investigation determined that if there had been a fire on board or a need to evacuate the vessel, there would not be enough crew members to effectively respond. Crew members would have to be in two places at once,” Séguin-Bertrand said.

In such a circumstance, three crew members would be assigned to deal with the emergency, leaving just two crew members to manage over 900 passengers and oversea their possible evacuation.

While vessels are required to have a “safe manning” document issued by Transport Canada, which sets the minimum number of qualified crew members needed to ensure safety, the organization allowed the Sam McBride to operate with just six crew members following a request from the city.

It did so “without verifying that any mitigation procedures were in place to offset a smaller crew in the event of an emergency,” Séguin-Bertrand said.

It wasn’t clear why the request was granted.

He said the crew also lacked the proper training to deal with a possible emergency.

“Emergencies usually develop rapidly, and passengers who are unlikely to be familiar with the vessel and its equipment rely on the fast and coordinated actions of the crew to keep them safe,” Séguin-Bertrand said. “This is why ferry vessel crew members need to have the knowledge and skills related to crowd management and human behavior in emergencies, none of the crew members of the Sam McBride had received such training, and nor were they required to.”

He said that while a 2017 TSB report flagged a safety concern around crew training for all vessels carrying more than 12 passengers in sheltered waters such as rivers, harbors and small lakes, Transport Canada has yet to implement any requirements for passenger management training.

The TSB is making a number of key recommendations based on its investigation, including implementing written docking procedures.

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