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Exposed: Ferry Maintenance Mess-up Hurt Passengers

Queen of Nanaimo crash stemmed from faulty fix say released records, contradicting official explanation.

By Andrew MacLeod 10 Dec 2010 | TheTyee.ca

Andrew MacLeod is The Tyee's Legislative Bureau Chief in Victoria. You can reach him here.

In the days after the Queen of Nanaimo ferry slammed into the berth on Mayne Island, toppling motorcycles, injuring several people and sending one passenger to hospital with a head injury, a company spokesperson blamed the accident on line from crab traps getting tangled in the vessel's propeller.

Now, four months after the Aug. 3, 2010 accident, records released through the freedom of information process tell a different, more troubling story that raises questions about vessel maintenance and safety practices at British Columbia Ferry Services Inc. The Vancouver Sun filed the request with the government-owned company, which has only been subject to FOI legislation since Oct. 1, 2010.

On Aug. 5, the Vancouver Sun quoted BC Ferries spokesperson Deborah Marshall saying the crab lines likely caused vibrations making the dowels fall out. She and company CEO and president David Hahn were handling the media strategy, another record said.

But while the 46-year-old vessel had run through some lines, that had nothing to do with what went wrong, the internal report released through FOI said.

"There was almost 300 feet of crab trap rope removed from both propellers after the incident," the Sept. 29, 2010 report into the crash at Village Bay terminal said. "This was not considered to be a factor contributing to the incident."

Dowels installed wrong

The problem was loose dowels in an oil distribution box in the ship's hydraulic system, the report found. Without the dowels, the system lost pressure, making it impossible to switch the propeller from a forward position into reverse and slow the vessel.

Despite dropping an anchor as the vessel approached the berth, it hit at five knots, just over nine kilometres per hour, knocking over six motorcycles and sending passengers and employees reeling.

After the crash, a passenger who had fallen during it and struck her head was taken to a hospital for treatment. Four passengers sought medical treatment for their injuries. Three employees required first aid and three others required medical treatment from a physician, the report said.

Vibration would not normally be enough to remove the dowels, had they been properly installed, the report said. Normally it requires a hammer and a drift, a tool for drilling a hole in metal, to remove the dowels, it said.

"Correctly installed... dowels are difficult to remove," said the report. While the dowels on the starboard side were secured with nuts and locked in place, it said, "the port dowels had no such nuts securing them."

It was unclear how long the problem had existed, but nobody noticed the problem, the report said. "The non standard configuration of the port dowels was not corrected at any stage prior to the incident."

There had been related work done in 2008 and the problem wasn't noted then.

At some undetermined point, one of the dowels fell out, but the vessel still operated as normal. When the second fell out, at 7:17 a.m. on the way to Village Bay on Aug. 3, it made it impossible to reverse the propeller.

The problem could have been noticed by the bridge team or engineering team -- different indicators would have been "at variance" -- but they did not see the inconsistency. They missed it during normal watch, when the control was handed over to the master, and when they first tried to reduce the vessel's speed.

Previous problems

The loose dowels are reminiscent of the findings from the investigation of a 2005 BC Ferries crash. On June 30 that year, the Queen of Oak Bay lost power and slammed into a marina in Horseshoe Bay in North Vancouver. The failure was blamed on a missing cotter pin.

"The investigation concluded that a mechanical failure of an engine speed control device (governor) on one engine led to a loss of power," said a July 7, 2005 BC Ferries press release.

"A control arm connecting the engine speed control device to the engine fuel rack disconnected when a nut came off the attachment bolt," it said. "A cotter pin that is normally in place to prevent the nut from coming off the bolt was missing. The disconnection of the bolt allowed the propulsion system to over speed."

The vessel had recently been through a $35-million refit.

Hahn at the time said, "Every vessel in our fleet has been checked and cleared in response to this incident."

"I've had concerns about maintenance issues with B.C. Ferries," said NDP ferry critic Gary Coons on Friday. "Major concerns here. I've heard there are many flaws in maintenance practices."

The economy of coastal British Columbia depends on having a safe, dependable ferry system, he said, adding that a follow up on former Auditor General George Morfitt's 2007 report on B.C. Ferries safety is badly needed.

Passenger count problem

Another element of the report into the Queen of Nanaimo crash was reminiscent of the 2006 sinking of the Queen of the North.

It noted, "The accurate counting of the passengers on board proved difficult during the incident."

An incident overview from the day of the crash goes into more detail.

"Passenger count discrepancy," it said. "TAS count and physical head count do not match. 199 on physical count and 191 on TAS."

Somehow the ferry had more people aboard after it crashed than had been counted before it left.

"RCMP are going to conduct a body count by having passengers file single file off of vessel, do a vessel sweep and confirm actual count." The company wanted it completed in "some urgency" so the passengers would be ready to get on the Queen of Cumberland to be taken to Swartz Bay on Vancouver Island.

Since 1993, the Transportation Safety Board has recommended, "The Department of Transport ensure that federally inspected passenger ferries maintain an accurate passenger count and that such count is communicated to both the master and a designated person ashore before departure."

When there's a problem at sea, help from shore is crucial, the TSB website says. "To carry out a timely and successful search and rescue operation, it is critical that shore staff and Search and Rescue personnel have accurate information as to the number of lives at risk aboard vessels involved in an occurrence."

One of the TSB recommendations out of the Queen of the North sinking was that ferry operators should keep more detailed passenger manifests.

Recommendations made

The internal report on the Nanaimo's August crash at Mayne Island included 12 recommendations.

"Critical operating control components must be inspected by BCF Marine Engineers during and after assembly at refit or during repairs," it said. "These items should be signed off as inspected as safe to operate to ensure correct assembly and operation."

Nor should anyone working on a BC Ferries vessel use "incorrect" components or ones that don't meet the manufacturer's specificiations. "In the case of this incident, not only did the tapered dowels in the port [oil distribution] box not meet the specification, they did not even look the same as the [starboard oil distribution] box tapered dowels."

It suggested adding an alarm system for when the propeller pitch is not aligned with what the controls on the bridge are showing and requiring ships to slow down sooner when approaching terminals.

"All ships need to confirm the minimum distance to the berth at which they slow down and/or engage astern thrust," it said. "These distances must be adequate to allow for either an aborted landing or to stop the vessel with the remaining propulsion options when a failure of a single propulsion and/or control system occurs."

Ship managers should regularly check to make sure heavy objects are secured, it said, and the company should "develop and implement a system of tracking passengers in an emergency."

As TSB member Jonathan Seymour noted in an October editorial published in the Vancouver Sun, "Regulations aren't much good if they're not put into effect."

Despite the lessons of the Queen of the North, he wrote, when the Queen of Nanaimo crashed, "A series of conflicting passenger counts offered up three different totals, none of which matched the number written in the ferry's log. Clearly there is room to improve."

BC Ferries' FOI response indicated the company anticipates being sued over the Queen of Nanaimo crash.  [Tyee]

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