Marine Investigation Report M04L0105
The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Striking of Wharf
High-Speed Passenger Catamaran
Famille Dufour II
Public Wharf, île aux Coudres, Quebec
24 August 2004
At approximately 0930 on 24 August 2004, in clear and calm conditions, the high-speed passenger catamaran Famille Dufour II, with 159 passengers on board, struck the southwest side of the public wharf at île aux Coudres at a speed of 8.7 knots. The force of the striking caused injuries to nine passengers and one crew member, and the vessel sustained hull damage on the port side forward.
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Other Factual Information
Particulars of the Vessel
|"FAMILLE DUFOUR II"|
|Port of Registry||Québec, Quebec|
|Type||High-speed passenger catamaran|
|Draught||Forward: 2.5 m||Aft: 2.5 m|
|Built||1994, île aux Coudres, Quebec|
|Propulsion||2 Hamilton Waterjets, 4176 kW, 30 knots|
|Crew||On board: 15
|Passengers||On board: 159
|Owner||La Goélette Marie-Clarisse Inc.|
Description of the Vessel
The vessel is a carvel-flush built, aluminum-hulled high-speed passenger catamaran, propelled by two water jets (see Photo 1). It is highly manoeuvrable and has a service speed of 30 knots.
The main and upper decks are fitted with forward- and aft-facing seats and tables for the use of the passengers. An open-air observation deck is located above the upper deck just aft of the navigating bridge, and similar open deck areas for passengers are provided at the bow and stern.
The bridge layout is typical of a high-speed vessel and includes two seats; the vessel master normally occupies the starboard seat, the first officer, the port-side seat. Manoeuvring and navigation-related instrumentation is arrayed below window level across the fore part of the bridge. Dual-control levers for the propulsion system are in a centre console between the two seats. Helm commands are provided by a joystick located on the starboard arm rest of the master's seat. Navigation instrumentation consists of radar, gyro compass, global positioning system, depth finder, and two electronic chart systems.
The vessel operates primarily between Québec, île aux Coudres, and Tadoussac, Quebec, providing day and evening cruises and whale-watching excursions during the summer navigation season. The vessel also provides transportation for guests staying at the operator-owned hotels at île aux Coudres and Tadoussac.
History of the Voyage
At approximately 0730 eastern daylight time3 on 24 August 2004, the Famille Dufour II departed Québec bound for île aux Coudres and Tadoussac. On board were 159 passengers and 15 crew members, including a naturalist to act as a guide for the passengers during the voyage. The bridge team consisted of the master, an observing master, and the first officer.
At the start of the voyage, the naturalist, as part of his duties, briefed the passengers over the public address system on the vessel's life-saving equipment. The vessel proceeded at a cruising speed of 25 to 30 knots along its intended route toward île aux Coudres. The master had the con of the vessel and the voyage went without incident.
At about 0915, the vessel approached the public wharf on the north side of île aux Coudres, and the first officer left the bridge to prepare for berthing operations. The master was in control of the vessel, and the observing master occupied the port-side seat, a position from which most controls are easily accessible. Approximately 5 to 10 minutes before arrival, the naturalist announced over the public address system that passengers departing the vessel at île aux Coudres would be doing so shortly.
Weather conditions were good with clear visibility, light winds, and calm seas. The tide was flooding, and high tide was predicted to occur at approximately 1224.
Although the vessel's speed was reduced as it neared the wharf, the first officer observed that the speed was faster than normal for berthing operations. He then alerted the bridge by hand held radio that the speed of approach was too fast. As the vessel continued toward the wharf without any further reduction in speed, the first officer made two more radio calls to the bridge. The observing master heard one of the radio calls and made a remark to the master about the excessive speed of approach. None of the calls were acknowledged by the master.
At approximately 0930, the vessel struck the southwest face of the public wharf at a speed of 8.7 knots and at an approach angle of about 37 degrees. The port corner of the bow and the port hull at the waterline sustained damage (see Photo 2).
When the vessel struck the wharf, passengers were either in their seats or moving around the main and upper decks. Some passengers were using the stairway. The nine passengers and one crew member who sustained injuries were not seated at the time. Their injuries were due to either falling on deck or against an object. One of the injured passengers fell in the stairway.
After the vessel was brought alongside, the first officer noticed that the stern was pulling away from the wharf and he went up to the bridge to investigate the cause. On his way, he had a crew member make an announcement over the public address system requesting assistance from passengers with medical experience. One of the passengers, an orderly, came to the aid of the injured passengers.
When the first officer arrived on the bridge, no one was there, and he proceeded to check the position of the port and starboard single-lever controls. The port control was in the idle reverse position and the starboard control, in the idle forward position, which caused the vessel to turn. Consequently, he set both controls to the zero speed position. The engine speeds and the position of the split-duct reverse deflectors are both controlled by the single-lever controls. When they are in the zero speed position, the engine speed demand is at a fixed minimum (about eight per cent of maximum speed) and the reverse deflectors are positioned to generate zero forward thrust; however, steering is still available. In the idle forward and idle reverse positions, the deflectors are positioned so as to cause the generated thrusts to move the vessel forward or in reverse, respectively.
The observing master had left the master alone on the bridge earlier to view the damage to the vessel. The master then left the bridge to go ashore and view the damage from the wharf.
The incident was reported by the first officer to the Canadian Coast Guard's Marine Communications and Traffic Services at 0950.
The first officer and crew members dealt with the needs of the passengers and their disembarkation. A bus waiting for passengers planning to stay at a hotel on the island was used to transport some of the injured to the local medical clinic for treatment. One of the injured passengers and the injured crew member were taken by ambulance to a hospital off the island. The remaining passengers returned to Québec by bus.
The vessel underwent an inspection by Transport Canada (TC) and was permitted to depart for repairs.
At 2243, the vessel was under the command of another master when it departed the public wharf for the company shipyard, also located on île aux Coudres.
A sketch of the occurrence area is shown in Appendix A.
On 11 May 2004, a new life-saving equipment plan had been received by TC for approval. The plan had not been approved at the time of the last inspection. Upon completion of this inspection, the vessel was issued an Inspection Certificate for a Passenger Vessel to which the Safety Convention does not Apply (Form SIC 16) on 14 May 2004; changes to the life-saving equipment were not commented upon. The certificate permitted the vessel to operate within the limits of minor waters voyages, Class I. It also allowed the carriage of 340 passengers (including not more than 50 children) and 10 crew, for a maximum of 350 persons. Two certificated officers were required to be on the bridge while the vessel was under way.
As a vessel navigating waters solely west of a line drawn from Pointe-au-Père to Pointe Orient along the St. Lawrence River, it is not subject to the International Maritime Organization (IMO) International Code of Safety for High-Speed Craft, 1994 (1994 HSC Code) or the International Code of Safety for High-Speed Craft, 2000 (2000 HSC Code).4 Because it was a passenger vessel of over 5 in gross tonnage and certified to carry more than 12 passengers, TC determined that the vessel had to be equipped in accordance with the requirements for a Class IV vessel as specified in the Life Saving Equipment Regulations.
Personnel Qualifications, Training, and Experience
The master was issued a master mariner certificate in 1991. He had served as master on several vessels with a variety of companies. This was his third voyage as master of the Famille Dufour II without the presence of another master with experience on the vessel. It was his first voyage since returning from an extended absence from work due to recurring back pain. Other than his work on the Famille Dufour II, the master had no experience in operating a vessel capable of travelling at high speed or with water jet propulsion.
As this was the master's first season with the company, he worked initially as first officer aboard the Famille Dufour II for three voyages before taking the vessel out as master. During these voyages, he had some opportunity to dock the vessel under the supervision of another master. He had been master during an incident early in the season, when the vessel had struck the dock at Tadoussac, after which he was given some additional training with an experienced master and served as first officer for three of four additional voyages before taking medical leave.
During these four voyages he again had some opportunity to manoeuvre the vessel under the supervision of a master with more experience on the vessel. Other than the normal vessel logs, no records of this training were kept by the company and no test of competency was carried out. The duration and nature of the training was left to the discretion of the experienced master providing the training, with little or no guidance provided by the company.
As this was the master's first trip after medical leave, the company had placed an observing master on board. The observing master was issued a master, minor waters certificate in 1997. He had been serving as master of the seasonally operated Aquaria II, a company catamaran that carries up to 244 passengers and has a service speed of 18 knots. The observing master had no experience operating the Famille Dufour II.
The first officer was issued a master, limited certificate in 2001. He had been serving as a first officer for three seasons, two of which were on board this vessel.
This was the second summer in which the naturalist had worked on board the Famille Dufour II. He had no marine emergency duties (MED) training, but had attended a one-day company briefing on the location and use of safety equipment on board the vessel at the beginning of the 2003 summer season and another at the beginning of the 2004 summer season. He had participated in some emergency drills on board the vessel during his first summer season but none during his second season.
Boat and Fire Drills
The Boat and Fire Drill Regulations require that drills be regularly practised at intervals of not more than two weeks on passenger vessels like the Famille Dufour II. There were no indications that any boat and fire drills had been conducted on the vessel during the 2004 season before this occurrence.
Medical Condition of the Master
The master completed his most recent marine medical examination in November 2003, and in April 2004 underwent surgery to correct a back problem. In June and July of 2004 he worked aboard the vessel, but suffered a recurrence of back pain and was prescribed anti-inflammatory medication. Later, he was ordered off work and prescribed pain medication. A test at the beginning of August showed a strong probability of a recurrence of his back problem. In mid-August 2004, a note from a third doctor indicated that the master was fit for work. This assessment was based on the master's description of his physical state; a physical examination, including a range-of-motion test; and the reasonably sedentary nature of his stated duties aboard ship. The results of the test, conducted at the beginning of the month, were not yet on the hospital file. The accident occurred on 24 August 2004. The master was hospitalized for non-surgical treatment of his back problem on 02 September 2004.
Medical Examination of Seafarers
Requirements for the medical examination of seafarers are set out under the Canada Shipping Act, 2001 in Part I, Division 8 of the Crewing Regulations. Only a designated physician may issue a medical certificate (that is, conduct an initial or periodic examination) for seafarers who require a certificate to conduct their duties. Any physician may conduct an initial or periodic assessment for seafarers who do not require a certificate to perform their duties. In addition, any physician may conduct a medical assessment to allow a seafarer who requires a certificate to return to duties after a medical leave of more than 14 days or, for a seafarer who does not require a certificate, after a leave of unlimited duration. The regulations, however, permit any physician or registered nurse to perform an examination if there is no designated physician within a radius of 200 km of the area of operation of a ship that is operating in waters under Canadian jurisdiction.
Medical examinations must be conducted in accordance with section 63.1 of the Crewing Regulations, which sets out the general standards of physical and mental fitness required, and in keeping with the guidelines provided in the Medical Examination of Seafarers Physician's Guide (TP 11343).
Completed marine medical examination report forms are reviewed by the TC Marine Medical Branch in Ottawa, Ontario. Initially, this review is conducted by clerks within the branch who forward the report to one of two staff physicians for further review when certain criteria have been met (that is, specific conditions or findings reported). Should it be deemed necessary, the reviewing physician can require the re-examination of the seafarer and additional information in the form of specific tests.
Unless re-examination is required sooner under section 71 of the Crewing Regulations, a medical certificate remains in force for two years for seafarers over 40 years of age who hold a certificate (or for seafarers over 60 years of age who do not hold a certificate), and for three years in all other cases.
Currently, there is no requirement for seafarers or physicians to report to the Minister any conditions that may be identified outside of periodic marine medical examinations that could affect safety. In contrast, section 6.5 of the Aeronautics Act requires any holders of Canadian aviation documents that impose standards of medical or optometric fitness (for example, a pilot or air traffic controller licence) to identify themselves as the holders of such documents before the commencement of any examination by a physician or an optometrist. The same section requires that the physician or optometrist report to the Minister any finding that could present a risk to aviation safety. The Canada Shipping Act, 2001, which received Royal Assent in November 2001 and is expected to come into force in 2006, contains a provision (section 90) similar to section 6.5 of the Aeronautics Act.
In addition, TC is presently reviewing the entire medical examination process as part of its regulatory reform. This review is expected to be completed by August 2006. As part of this ongoing work to modernize regulations to support the new Canada Shipping Act, 2001, TC has proposed amendments to the Crewing Regulations and the Marine Certification Regulations to combine them into one new regulatory resource, the Marine Personnel Regulations.
Use of Medication
TC has issued guidance on the use of medication by seafarers,5 which states that "problems can arise when medication started during [an] illness is continued or new drugs are used to suppress or control resulting problems such as long-term pain." This document lists "pain killers that contain codeine, narcotics or muscle relaxants" among classes of drugs that "have the potential to affect a seafarer's ability to perform safety sensitive or critical tasks." It also states that each case must be considered on its own merits and provides a set of factors to be considered in the decision as to whether or not a particular medication is appropriate for use during service at sea.
Training and Proposed Canadian High-Speed Vessel Type-Rating Certificate
As a result of its investigation into the 1992 collision between the high-speed passenger catamaran ferry Royal Vancouver and the roll-on, roll-off vehicle/passenger ferry Queen of Saanich, where all of the injuries occurred on the high-speed catamaran, the Transportation Safety Board of Canada (TSB) issued six recommendations.6 Two of them (M94-27 and M94-28), which took into account the fact that the operation of high-speed vessels is different from and usually more demanding than that of conventional vessels, addressed crew training and operation.
TC agreed with the recommendations and indicated that implementation of the 1994 HSC Code would address the safety deficiencies identified in the recommendations. In 1995, Board of Steamship Inspection Decision No. 5837 ruled that the 1994 HSC Code may be applied, with Canadian modifications, for the certification and approval of Canadian high-speed vessels as an alternative to appropriate Canadian regulations. (Canadian modifications deal basically with construction requirements). Other than the Famille Dufour II, there are only two other Canadian high-speed catamaran passenger vessels currently operating solely within Canada. Both of them have been issued vessel certificates, and the masters and officers with an operational role on board these vessels are issued type-rating certificates in accordance with the applicable HSC Code.7
It is anticipated the new Marine Personnel Regulations, which will come into force in 2006, will include a new high-speed vessel type-rating certificate. Applicants for the certificate will, among other things, have had to complete type and operational training successfully, as per the applicable HSC Code, as well as pass a practical examination on the vessel. The requirement for the type-rating certificate will be limited to officers of high-speed vessels built to the specifications of the HSC Code. There is no indication, however, that the members of the bridge team of a "non-Code" high-speed vessel would be required to have such a certificate.
Provision of Safety Information
In accordance with the Life Saving Equipment Regulations and the Small Vessel Regulations, pre-departure safety announcements or safety briefings are required on all Canadian passenger vessels. Such announcements or briefings are intended to provide passengers with safety information they will need in the event of an emergency.
In this occurrence, the naturalist made the pre-departure safety announcement over the vessel's public address system as the vessel was under way. Some passengers located on the upper deck reported that it was difficult to hear the safety announcement over the ambient noise.
As per the Life Saving Equipment Regulations requirement, passengers were told where the lifejackets, muster stations, and survival craft were located. Passengers were not told, or shown, how to properly don lifejackets. In TC Board Decision No. 7597, effective 02 May 2002, the Board "ruled that in all cases the safety announcement include . . . directions as to how to don lifejackets." The Board decision further stated that "in all situations, handouts that indicate through pictograms the location of equipment, and how to don lifejackets are acceptable." No handouts on safety information were given to passengers. Approximately 10 signs containing written (French and English) and pictorial instructions for donning lifejackets were posted, for the most part, to the panels of the overhead racks in which the lifejackets were stowed.
In addition, vessels are required to carry, and display prominently, their most recently approved life-saving equipment plan, depicting the location, type, and quantity of safety equipment on board. The new plan had been submitted to TC for approval and had not been displayed on board the vessel.
Potential Sources of Injury and Impediments to Egress and Evacuation
On board the Famille Dufour II there were a number of objects that had the potential to cause injury to passengers and crew in an accident because they were unsecured or inadequately secured. These included large metal garbage cans, electric fans, cash registers, a passenger service cart, several service tables, sound equipment, and various food and cleaning stores. Furnishings and finishings in passenger areas were also observed to be potentially injurious: these included, for example, protruding metal coat hooks (see Photo 3), flat-screen monitors, sharp edges on passenger tables (folded position), and non-tempered glass panels used in the gift-shop display case.
Several potential impediments to egress were also identified. Some of the unsecured items described above were located next to emergency exit doors or passageways leading to emergency exit doors. For example, there were large metal garbage cans beside most of the emergency exit doors and at the entrance to each passageway leading to the aft emergency exit doors on the main deck. Similarly, a table was located adjacent to the same passageway on the starboard side of the vessel.
Other conditions that had the potential to impede evacuation of the vessel in a timely way were also identified, including
- unsecured stores stowed near the starboard engine room emergency escape hatch (see Photo 4);
- trash bins lashed to embarkation gates (see Photo 5); and
- two Jacob's ladders for embarkation into the liferafts located at the forward end of the main deck, which were not rigged for immediate use but were stowed forward of the point of embarkation and secured to a deck pad eye by a shackle (see Photo 6).
Photo 6. Port side Jacob's ladder secured to the main deck (left-hand arrow) and points for attachment when deployed (right-hand arrows)
Training for Passenger and Crowd Management
The muster list, which was posted on the bridge of the Famille Dufour II and for which the master is responsible, indicated that the naturalist's assigned emergency duty was "passenger control"; that is, he would be expected to take action to manage up to 340 passengers during an emergency. In the event of an evacuation or fire, a barkeeper was assigned to help the naturalist direct passengers to their embarkation stations. The naturalist was aware of his responsibilities; however, he had not taken any formal training in crowd control, nor was he required to have such training under the regulations.
In July 1990, the TSB investigated an occurrence8 involving the near-collision of the ferry Woodside I with the tug Tussle. In view of the large number of passengers carried regularly on ferries and passenger vessels manned by small crews who may have little or no formal training in crowd control, the Board recommended that
The Department of Transport require that officers and crew members of all federally inspected ferries and passenger vessels receive formal training on crowd control and relevant emergency procedures. (M93-07, issued June 1993)
In response, the MED training program was revised. The Officer Certification Course (that is, the MED C course) includes a one-hour session entitled "Crowd Management" to provide junior officers and key personnel with the knowledge and skills to control passengers during an emergency. Crew members are required to have basic safety training (MED A1) and, if they are assigned to a fire team on the muster list, training in survival craft (MED B1) and marine fire-fighting (MED B2). However, these three courses do not address crowd management.
After a fire on the lower vehicle deck of the roll-on, roll-off passenger ferry Joseph and Clara Smallwood on 12 May 2003,9 the TSB sent a Marine Safety Advisory (MSA 01/04) to TC on the adequacy of the crew's training in crowd management and/or crisis management and human behaviour. In response to the MSA, TC indicated that it will adopt regulations V/2 and V/3 of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW Convention), which address training in crowd management, for Canadian non-Convention passenger vessels.
Lifejacket Stowage and Signage
Photo 7. Overhead rack containing adult (left-hand side) and children's (right-hand side) lifejackets
The stowage of life-saving equipment on board the Famille Dufour II had been modified before the start of the 2004 season. One of the changes dealt with the stowage of lifejackets.
Initially, the passenger lifejackets were stowed in lockers, suitably positioned, on deck. After the modifications, they were stowed in overhead racks located above the windows along the port and starboard sides of the main and upper decks. All of the children's lifejackets and the remaining adult lifejackets were stowed in an overhead athwartships rack located above the third row of seats from the forward end of the accommodation space on the main deck (see Photo 7).
Photo 8. View of children's lifejackets (arrow) stowed in an overhead athwartships rack and rows of seats removed from the deck
The lifejackets were tightly stacked within the rack and were difficult to retrieve because of the height of the front panel and the vertical metal strapping used to secure the rack in place. The height from the top of the front panel of the overhead rack to the deck was 2.18 m (86 inches). Although the row of seats under the overhead rack was in place at the time of the occurrence, its removal for seating reconfiguration happens from time to time on this vessel (see Photo 8).
Approximately 10 signs with written (French and English) and pictorial donning instructions for the lifejackets were posted throughout the vessel. For the most part, they were attached to the front panels of the overhead racks in which the lifejackets were stowed. The signs were constructed of paper, laminated in plastic, and appeared to be photocopies. They measured approximately 0.2 m by 0.28 m (8 inches by 11 inches). The colour scheme was pale grey and white with black lettering, and the lifejackets were illustrated in orange. The sign posted in the forward, upper accommodation space (that is, the VIP Salon) was located below a decorative poster. The decorative poster was larger than the sign containing the emergency instructions, and the sign did not contrast with the panelling so as to be readily visible.
Two signs (one written and one pictoral) indicating children's lifejackets were posted side by side on the front panel of the overhead athwartships rack in which they were stowed. The signs could only be seen by a person who was forward of the rack. No other signs indicating the location of children's lifejackets were posted on board the vessel. The children's lifejackets were labelled as such in block letters, but their colour was identical to that of the adult lifejackets.
Securing of Liferafts
The vessel was equipped with ten 25-person and two 50-person RFD Surviva inflatable liferafts secured in their cradles by lashings fitted with senhouse slips (see Photo 9). Such a securing arrangement requires human intervention for the launching.
Passenger vessels 25 m or more in length, carrying more than 12 passengers, and operating in sheltered or protected waters (that is, home trade, Class IV; inland, Class II; and minor waters, Class I and Class II) are not required to have their liferafts arranged for float-free operation.
Industry Standards for High-Speed Vessels in the United States
The unique issues associated with high-speed vessel operations have been recognized by operators in the United States. In 1999, the Passenger Vessel Association, a not-for-profit organization representing nearly 500 vessel-operating and associate members of United States-flag passenger vessels of all types, established the first of two work groups with the United States Coast Guard to develop industry standards for the operation of high-speed vessels to which the 1994 HSC Code does not apply in United States domestic waters. This resulted in the development of guidelines in the areas of crew training, vessel operations, and navigational safety equipment.10 The second work group developed guidelines for manning domestic non-Code high-speed vessels.11
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