VANCOUVER -- The Transportation Safety Board of Canada has released a final report on its investigation into an incident that sent two BC Ferries crew members overboard in August 2018.

The crew members fell during a training exercise on the Spirit of Vancouver Island while it was Swartz Bay Ferry Terminal. One of them sustained minor injuries, while the other was unharmed, according to the TSB report.

The incident caused significant delays on the Tsawwassen - Swartz Bay route during the busy Labour Day long weekend, prompting an apology from BC Ferries at the time.

The TSB report issued Friday goes into greater detail about what actually happened to the crew members, why it happened and what the ferry service has done to prevent it from happening again.

What actually happened

According to the TSB report, the crew members fell shortly after 6:15 a.m. on Aug. 31, 2018. They had been conducting a rescue boat drill, one of four drills occurring aboard the vessel simultaneously before its first voyage of the day.

The two crew members donned the required protective clothing and boarded rescue boat No. 1, while a third crew member began operating the davit - a tool that swings lifeboats away from the hull of the main vessel and lowers them into the water.

As the davit arm was swinging rescue boat No. 1 away from the Spirit of Vancouver Island, a brake release line snagged on a section of the rescue boat's cradle, causing tension.

This tension mounted as the davit arm swung further out from the ferry, causing the rescue boat to drop suddenly and collide with the larger vessel's deck. This caused the rescue boat to tip suddenly toward the water, causing the two crew members to fall out.

The one who sustained minor injuries fell approximately 14 metres into the water, while the other one managed to grab the rescue boat's "painter line," roughly four metres above the water's surface. This crew member eventually fell roughly two metres as the rescue boat came down with them.

The ship's master quickly broadcast a person overboard call, and other crew members - who had just launched rescue boat No. 4 simultaneously as part of another drill - rescued the two who had fallen.

They were given first aid on board the Spirit of Vancouver Island and then transported to hospital, where both were released later in the day.

Why it happened

The TSB names a number of factors that contributed to the incident. The board's report starts by noting that new rescue boats installed on "Spirit class" BC Ferries vessels have a "greater height" than the original rescue boats, but the configuration of brake release lines was not changed when the new boats were installed.

This change meant the brake lines sagged under each davit arm, and caused an earlier incident in which a brake line got caught on a rescue boat's stern light.

After this incident, the Spirit of Vancouver Island's master issued a directive that brake lines should be stored in containers aboard the rescue boats, rather than under the davit arms.

That, too, proved problematic, as another incident occurred involving a brake line becoming tangled with rescue boat No. 1's propeller during a drill.

Crew members addressed this issue by developing an "informal practice" of removing the brake release line and bag from rescue boat No. 1 and giving it to a supervisor to hold, or leaving it on deck if a supervisor was not around.

"This practice was contrary to the directive issued by the senior master," the TSB report notes, adding that this is what happened during the August incident.

"When the crew removed the brake release line bag from the rescue boat, no deck officer was present to take the bag from the crew; it was therefore left unattended on the deck," the report says.

The report cites emergency drill planning as a factor that contributed to the incident. Because the crew was conducting four drills simultaneously instead of sequentially, there were fewer people available to supervise each activity, and those who did were less familiar with the drills than they could have been.

"By launching three rescue boats at once while conducting a fire drill, the second and third officers were not available to assist the chief officer with his duties in supervising all rescue boat stations," the report says. "The emergency drill plan also did not take into account individual crew member qualifications for certain tasks … Because resources were not sufficiently allocated for this drill, the work plan and task allocation compromised the drill’s effectiveness and the crew’s ability to fully perform their duties in case of emergency."

The report also notes external pressures that led to the decision to run four drills at once, citing a requirement that each rescue boat be put in the water at least once every month.

"Launching the three rescue boats at once allowed crew to meet the schedule requirement while saving time and resources," the report says. "The decision was also influenced by the fact that the drill was conducted before the vessel’s first voyage of the day, which created a time urgency among crew to resume normal vessel operations."

What BC Ferries has done

The TSB report lists eight steps BC Ferries has taken since the incident in order to improve safety, though it doesn't go into much detail about any of them.

According to the TSB, BC Ferries has:

  • Created and resourced a new Asset Management Services Office.
  • Updated all vessel-specific manual procedures, checklists, and quick reference guides related to rescue boat operations.
  • Completed its rescue boat policy with Fleet Operations Manual policy updates.
  • Checked crew proficiency.
  • Updated its risk management policy to include the requirement of a task analysis or risk assessment for introductions or modifications of safety-critical assets.
  • Created a Nautical Equipment Management Office to assist in the management and quality assurance of safety-critical assets by reviewing policy, procedures, and equipment as part of an ongoing Asset Management Improvement Strategy.
  • Added more focus on equipment readiness during audits.
  • Developed a controlled fall system for rescue boat crew.