TSB Findings Report Queen of the North

[JK]

It has finally been released:

http://www.tsb.gc.ca/en/reports/marine/ ... 6w0052.asp

[The Dieselduck]

The local TV stations are all up at arms, why did "three officers" (sic) (really one 4th officer and one quartermaster) on the bridge not make a course change. We want heads! Give us blood !

I had a chance to read the report almost fully, hard to do with a crying baby, but it was for the most part a typical TSB report, I found. Good reading of the facts as they are known. Perhaps not juicy enough for some but not to my surprise.

We all knew that you had to be very busy with something you should not be doing while on watch, to make that kind of mistake. It happens, most time they don't result in such catastrophic consequences, but as I learn from reading many of these reports, my own experience and my training such as Engine Room Management (similar to Bridge resource management) rarely does one mistake, or one person hold the absolute responsibility.

I believe BC Ferries has allowed a culture of egos to develop rather than a culture based exclusively on procedures born of sound risk assessments. Because of the experience and stature of some, I believe they have been able to tweak company procedures effectively to their advantage.

Ultimately, it feels like a more humane way to work, but really makes the system dependent on the the style and abilities of the watchkeeper. People are different, some are trained differently (if at all), have experience or confident levels enough to handle certain levels of distraction that other might not. Then there are those other distractions not really measurable, that kick in, expectations, home stress, union grievances over promotions, and the likes, all have impacts, and obviously personal drama which take away the concentration needed for the task at hand.

It is not the first time that BC Ferries has been involved in accidents because of lack of attention, most accidents always boils down to a long series of errors in judgment. No matter how many rules, SMS, ISM procedures you put in, or VDR you installed, it won't really make the fleet safer until they tackle a fundamental attitude within the company.

And they better not rely on government to lead them, as the report illustrated, Transport Canada was unable to clamp down its own mind on the watertight doors as well. That subject is a thread of its own, but I don't think it would have made one iota of difference. But the fact there was wishy washiness regarding the enforcement of the rules regarding watertight doors, points to my previous assumptions that people are not taking a stand on regulations. Regulations and protocol should be made for a reason and not reinterpretated by individuals because of their pleasant, or not so, demeanor at the time.

I have never worked for BC Ferries but in my observations I feel that the personal relation between the company and its employee are not very good, a corporate culture that is lacking some teamwork qualities. Why exactly, I am not sure, but everyone needs to realize they are in the same boat and quit fighting every one. There always will be the usual us versus them vis a vis ships and office, but they really need to put their people first, and the crew (union) must support them, for the benefit of all.

Like I said above, I believe dominant personalities have emerged over the years and have shaped the workplace; but now they are starting to retire and the status quo that has develop for at least the last decade if not two, is in transition, not just at BC Ferries, but throughout the industry. The training and confidence of the younger guys to take over was not invested in, due, I believe, by severe lack of vision.

Now you have people working in situation they may not be comfortable in trying to have a relaxing atmosphere even though they need more structure. But they learned from the senior guys rather than formal training protocols and therefor are unable to "error trap" and voila, you have accidents.

I think we will see many more accident in the coming years until the system changes, and it will over time, unfortunately at a very high price for some.

BTW, I am not sure what the mood was at the press conference, but from what I saw, the TSB people seemed defensive and combative. I though in the past they seemed to hold themselves with better composure, anybody know if this is normal for them?

My two cents.

[JK]

Given some of the discussion in our office regarding the report I am sure they were nervous.

[conrod]

Although it is tragic that 2 people were / are missing, the real tragic facts of this case, as far as I am concerned, is that when embarking on a proffesional career, such as an officer at sea, one should assume certain responsibities, and proffesional ethic.............where was it ?

This incident, as highlighted by the TSB, was not the case, with the people on the Bridge. As to whom made the mistake...........well, that dispute will go on for a very long time.

May we all learn a lesson from this.

One could say the same thing for the Exxon Valdez...............or many other situations which we face at sea.........times have changed and the mental attitude of many seafarers has changed also.

Perhaps we should reintroduce some of the older standards..............wear uniforms, employ stewards, re-establish the pride that those before us had in wearing a Merchant Navy Uniform............remember why engineers have purple in their stripes.............perhaps then we might see a more positive improvement in our industry.

[Sébastien]

In reply to Martin with regards to not enforcing regulations, I think that ISPS is a large factor in that attitude. Although the reasoning behind security protocols are very easy to justify, in my experience so far it is almost impossible to apply. For example doors that should be locked for security reasons cannot be locked for safety reasons (if a terrorist cannot go through that door, neither can a fire fighter), the result is that security procedures are 'waived' by shipboard personnel. The problem is that this way of thinking makes it way into other areas of ship business and safety as a whole slowly diminishes. Security is something that cannot be successfully retrofitted into an existing ship, it must be integrated into the design stage; unfortunately this is a process that will take years while new more security effective ships are built. In the mean time, we have to ensure that safety procedures are not disregarded the same way that security procedures are.

In reply to Conrod, I also think the return of the uniform would be a good thing. Not only is your level of responsibility and accountabilty prominently displayed on your shoulders, it is very easy to distinguish who is who in emergency situations. But then again I am strongly biased (ten years Navy, one year Coast Guard).

[conrod]

I am glad to see that I am not the only old fart who has some recall of " better times " on high seas. I must admit, I was not really thinking of the safety aspect, but it is a very valid point, regardless of your start in this career............but when I was a cadet in Ocean (Blue Flue for those older chaps), we wore our uniform most of the time, certainley it was expected between 07:00 and 19:00 during the week. It was also expected that we wore it when travelling home, on public transit.............many didnt, but I did feel a certain pride in doing so.

That at the end of the day, was what it was all about. Pride. Feeling good about being in the Merchant Navy (not like those weekend sailors in the Grey Funnel line). As a result you took pride in your position, and in your job. If that level of comitment had been continued, maybe the casual attitude of many who go to sea, would not exist..........and maybe just a few accidents might not happen.

Ironically in the UK at the moment, soldiers at a base in Cambridgeshire, are being advised to hide their identity...........ie no uniforms in public places, because some ******* idiots in the street, started giving some young squadies a hard time about Afganistan / Iraq. I tell you, I some times wonder if I was born too late !!

[JK]

When Costs are declared to be too high and the shareholder is not getting enough returns, the first two things cut are training and the uniform budget. What a false economy!

[conrod]

And then the safety gear goes............and so on and so forth.

[invictamarine]

None of these issues were unknown by BC Ferries when I was there. I raised the issue of the watertight doors and we had an agreed procedure, i.e. closed at sea except for the safe working of the ship i.e. transiting with stores etc. Not to mention inherent damaged stability deficiencies which made the closing of the w/t doors even more critical.

Complacency is a major part of the problem and I do believe a uniform and professional pride can make a difference if you have had to earn it. With junior officers yo yo-ing up and down to unlicensed positions it is hard to be sure that the professionalism is always there. I spoke with both RCMP and the TSB and was happy to see that the issue of domestic standards was addressed but believe that they missed an opportunity to recommend mandatory ISM for domestic passenger vessels. The voluntary nature of BC Ferries system makes it less effective since the normal sanctions i.e. ship's prevented from sailing due to major non-conformities, is not enforceable. The report was good, TSB met their mandate (although I believe there was a great deal of political pressure to make sure neither Ferries nor the Provincial government were apportioned any blame). What is needed now is a judicial inquiry that will apportion responsibility and ensure that changes are made throughout the domestic passenger ferry industry.

[conrod]

Not being one to shy away from stiring the pot, I think ISM should have been made mandatory for all vessels, regardless of trading area, or service.................OK, well maybe not in its initial format, but certainley something (instructions) that crews had to follow.

It was once said that ISO 9000 1/2 was a prescribed and controlled way of producing a product. Didnt matter if the product was crap, just as long as it was controlled crap.

When I was developing the system for my Company, this kept on cropping up. Howevere we stuck to the concept..........this is what we do, and this is how we do it............

Things do get lost along the way, its only human, but I think Clause 6.2 and 6.3 of the " Code " indicates where the motivation has to come from.

I have travelled 6 times on the new Renaissance, and quite honestly was not that impressed with the attitude of some " officers ". On one crossing all the staircases to deck 7 were roped off. I had an incling as to why, and was not surprised. It was something I picked up on my first crossing, but when I asked someone in a " woolly pully " with stripes, as to why they were closed, and how did I get on to the outside decks............I was told they did not know, and " Go see the Chief Steward ". There were no notices up, offering alternate access, and although the CS did direct me, it was not obvious. There were a lot of people wandering about looking lost that night !! My more basic impression is that allthough the " staff " all wear uniform, its more about " how many things can I get on my tool belt, look like an RCMP officer, and still look cool ".

OK granted the Bridge / ER guys probably have a different attitude, but there did not appear to be any " pride " in those I saw. Its just a job. Same crap, different place. Every position on a vessel at sea demands a skill level, which should be enforced by the Company. With this goes pride, and perhaps a little more respect............which makes us all a little bit safer.

I hope that a judicial enquiry points the finger, and firmly. Its time our ferry system had a wake up call.

[ArkSeaJumper]

I worked for a company a little while back that had a dress code for dinner, no white shirt and eppy’s no dinner.
The ship was a shit heap.
The curtains in my forward facing cabin where tattered ribbons, and every night I was asked to turn my cabin lights off, because it was interfering with navigation.

I order to get new curtains, or as it turned out a blind, I had to refuse to keep the lights off.
But every night I wore a clean white shirt etc, in order to get fed.

[conrod]

ASJ,

I know what you mean, and I think that situations like yours do in fact create an adverse affect on moral and personel............which I think contribute to an attitude of complacency, and disregard that lead to accidents like the Q of the N.

Just a couple of days ago, off China, an offshore support vesel rolled over and sank, taking 18 sailors. It was T boned by another vessel........I wonder who was on that Bridge...........????