News conference for the release of Marine Investigation Report M15P0347 Leviathan II: Opening remarks

Kathy Fox
Chair, Transportation Safety Board of Canada
and
Clinton Rebeiro
Investigator-in-Charge, Transportation Safety Board of Canada
Vancouver, British Columbia, 14 June 2017

Check against delivery.

Kathy Fox

Good morning,

On the afternoon of October 25, 2015, a large breaking wave struck the passenger vessel Leviathan II, causing it to broachand rapidly capsize—throwing 27 passengers and crew into the cold waters off the West Coast of Vancouver Island. Six passengers died.

As a result of our investigation, the Transportation Safety Board of Canada is issuing 3 recommendations today aimed at reducing the risks to passenger vessels on the West Coast and across the country:

First, tour vessel operators on the west coast of Vancouver Island must take steps to identify when and where hazardous waves form, and how to avoid them.

Second, all commercial passenger vessel operators—nationwide—should adopt explicit risk-management processes, and Transport Canada needs to develop guidelines to better implement and oversee those processes.

Finally, we recommend the mandatory carriage of emergency beacons, so authorities are automatically alerted when a vessel is in distress.

I'll talk more about each of those recommendations in a few minutes, but for now I'll hand things over to the investigator in charge, Clinton Rebeiro. He'll walk you through the events of that afternoon, explaining what we learned about how and why the vessel capsized, what happened to the passengers, and the challenges they faced trying to survive.

Clinton?

Clinton Rebeiro

Thank you, Kathy.

Prior to departing Tofino harbour, the master checked the weather forecast, and determined that conditions were acceptable: winds of 10-20 knots were predicted, along with wave heights of between 2 and 4m.

Passengers were also given a safety briefing, and one of the deckhands demonstrated how to don a lifejacket. The vessel then headed to nearby Ahous Bay to watch a pod of grey whales, and then to an area known as Plover Reefs, so passengers could observe sea lions.

Scanning the area for hazardous conditions such as breaking waves, the master saw none, and so the vessel passed twice along the southern shore of the reefs, turning 180 degrees to give passengers on both sides of the vessel an equal view. Later, the vessel stopped on the southeast side of the reef for additional viewing, while maintaining a northerly heading. This, however, left the vessel exposed to what are known as "quartering seas"—waves that were coming in at an angle off the stern.

At approximately 3pm, just as the vessel was departing the area, the master and a deckhand heard a noise. Behind and to starboard, or the right, they saw a large breaking wave. The master reached for the throttles to turn the vessel and minimize the impact, but the wave struck the Leviathan II's starboard quarter before his actions could be effective.

The vessel broached. That is, it rose up and pivoted uncontrollably on the wave, leaving it beam-on, or sideways, to the face of the wave … and thus vulnerable to capsizing. You can see this illustrated on screen.

The nature of the sea and the processes that combine to form breaking waves in shallow areas are complex. There are known contributing factors: Offshore waves travelling over a rising ocean floor and meeting opposing tides or currents can cause waves to become higher and steeper, increasing the likelihood that they will break. But exactly when is almost impossible to predict. Quartering seas, as in this case, are particularly hazardous, and the wave in this instance was large—its height reportedly above the Leviathan II's flying bridge.

After impact and broaching, capsizing took only an instant. One of the deckhands and most of the passengers were thrown into the water, many of them sliding down the floor of the deck and striking objects along the way. Others were trapped underneath—or even inside the vessel—before eventually escaping.

None of the passengers were wearing lifejackets and, as they struggled to keep their head and mouth above water in the heavy swells, some passengers ingested sea water and spilled oil and fuel. Others clung to objects that had floated to the surface, including seat cushions, paddles, a life ring, and a lifejacket.

The master and one deckhand, who had escaped the flying bridge, were able to deploy one of the vessel's life rafts that had floated free. They climbed in, then helped eight others, including the second deckhand, climb aboard. Shortly afterward, by chance they spotted a rocket flare floating nearby. They activated it, attracting an Ahousaht First Nation fishing vessel in the vicinity. When the fishermen saw the capsized hull and people in the water, they immediately requested assistance from other vessels and began rescue efforts. The Canadian Coast Guard lifeboat station at Tofino deployed a fast-rescue craft. Other search-and-rescue resources soon followed, including 2 aircraft, RCMP vessels, and several small craft from the area.

A total of 21 people were rescued, some injured, and many if not most suffering from shock, seasickness, or hypothermia. The bodies of five passengers were recovered later that day. The body of a sixth passenger was found several weeks later.

Kathy Fox

Thank you, Clinton.

The first recommendation the TSB is making today deals with what Clinton mentioned earlier—the complex manner in which breaking waves form in this area, as well as the impossibility of making precise forecasts. Given that numerous whale-watching companies operate around Plover Reefs and along the west coast of Vancouver Island—and that they carry tens of thousands of passengers annually—more must be done to make every trip as safe as possible.

To that end, we recommend that Transport Canada require commercial passenger vessel operators in this area to formally identify areas and conditions conducive to the formation of hazardous waves, and then adopt practical strategies to reduce the likelihood of an encounter.

For example, approaching Plover Reefs from the sheltered side could be a first step. Or keeping a dedicated lookout, ensuring the vessel maintains a safe angle of encounter. Or avoiding the area altogether if conditions are not favourable. Instead of formal directives, however, the company relied on the experience and discretion of individual masters as to whether conditions were "safe." That's simply not a good enough system, even when mariners may have decades of experience.

Today's second recommendation is aimed at the roughly 4000 registered passenger vessels across Canada. Depending on the marine environment in which they operate, they face a wide variety of hazards that can lead to emergencies. Fire. Collision. Swamping. Cold-water immersion. Given that passengers on board may have varying ages, abilities and needs, encountering any of these situations could be catastrophic.

The TSB has previously recommended that Transport Canada require small passenger-vessel operators to adopt a formal Safety Management System, or SMS. This is a well-known, internationally recognized framework that helps companies manage safety risks better. TC, however, has said it does not plan to make this a requirement.

Yet one of the core elements of SMS could still be made mandatory: an explicit risk-management process that identifies hazards in advance and then implements proactive strategies to reduce those risks. That's what we are calling for today, along with comprehensive guidelines so that vessel operators and TC inspectors can implement and oversee them.

Our final recommendation deals with improving survivability by alerting authorities as soon as possible after an emergency.

In this occurrence, it was only by chance that the crew retrieved a rocket flare from the debris and were able to alert nearby First Nations fishermen, who were instrumental in saving lives. Still, it took 45 minutes after the capsizing before search and rescue authorities became aware of what was happening.

When people find themselves in cold water, every second counts—even more in a rapid-capsize situation like this one, where passengers were thrown overboard unexpectedly. Disoriented, separated from loved ones, and without any floatation aid, some of them panicked, were struck by objects, or simply couldn't swim.

If a vessel's distress-alerting equipment has to be operated manually … well, that isn't always feasible. One alternative is the carriage of an emergency position-indicating radio beacon, or EPIRB. These are designed to float free when a vessel sinks, automatically transmitting a continuous distress signal.

Transport Canada is currently planning to require more vessels to carry an EPIRB or other similar equipment. That process needs to be expedited, and the carriage requirements expanded even further, to include all commercial passenger vessels operating beyond sheltered waters.

Whale-watching is a popular tourist activity in Canada. Although accidents like this are relatively rare, this occurrence demonstrates that, when real hazards are neither fully recognized nor adequately mitigated, the consequences can be catastrophic. It's time for the regulator to work with whale-watching companies and other passenger vessel operators—on Vancouver Island and across Canada—to make sure the experience they offer is not just thrilling, but as safe as it can be.

Thank you.