Thursday, March 13, 2008

Queen of the North. TSB report.

The Transportation Safety Board report on the sinking of BC Ferries Queen of the North (QOTN) was an understandable let-down but from the point of view of industry insiders, about what could be expected.

There were no earth-shattering revelations and some of what is contained in the report is essentially the same as the BC Ferry Services divisional report. Some of the information in the report is being misread by news outlets, an understandable outcome since the information is technical in nature and unique to shipping and the maritime transportation industry.

Of note is that the composition of the bridge watch (personnel) as required by BC Ferries actually exceeded that of the Canada Shipping Act at the time. Notwithstanding, the actual watch on the bridge of QOTN did not meet the minimum standard laid out in the Canada Shipping Act for two reasons:

1. The 4th Officer was not qualified on the Electronic Chart Display Information System (ECDIS), a training endorsement required if the system is fitted, which it was Electronic Chart System (ECS) which would have required familiarity in accordance with company requirements and general practice requiring the officer of the watch to be familiar with all bridge electronic equipment;
2. The quartermaster was an ordinary seaman who possessed no certificate beyond that of Marine Emergency Duties. The CSA requires that the additional person on the bridge watch have a qualification of either Efficient Deckhand, Able Seaman or Bridge Watchman.

BC Ferries had issued two fleetwide instructions, well prior to the QOTN sinking, that ships entering areas of reduced visibility required a third qualified person on the bridge; exceeding the CSA requirements. QOTN was in a rain squall at night.

The TSB makes something of a point about the fact that QOTN's electronic chart system was loaded with a raster chart as opposed to a vector chart. Simply explained, raster charts are not as accurate detailed as vector charts. The raster version is rather like a photograph of a paper chart. A vector chart is developed from detailed information and provides a much more accurate detailed picture. I'm sure the TSB had some reason for including it, but given the QOTN's distance off her intended safe track and the late awareness of proximity to Gil Island, I am at a loss to understand how a vector chart would have made a difference. Since the bridge watch apparently did not have cross-track or navigation danger alarms engaged and thought the alteration to port after passing Sainty Point had already been made, the chart detail doesn't possess much weight. Not only that, but the recovered ECDIS ECS playback provides an accurate picture of the QOTN connecting with Gil Rock and then veering off to port before coming to a stop.

News reports are suggesting that the TSB report is recommending a third officer is required on the bridge. That is not accurate. TSB is recommending that a third certificated person be on the bridge during reduced visibility. That would be a rating qualified to assist the officer of the watch but in no way responsible for the decisions regarding safe navigation.

Apparently, the Automated Radar Plotting Aid (ARPA) was not set up for the 27 minute transit across Wright Sound. It would be a normal practice to establish safety margins on the ARPA parallel to the intended track (parallel index lines) and then monitor them relative to known landmarks. Even in the spacious waters of Wright Sound a ship can drift and be set by wind and tide and since the ship would have been approaching another narrow pass at MacKay Reach, minor course adjustments carried out early in the transit are much preferred over larger ones later on.

There was a comment in the TSB report that suggested the 4th Officer was not familiar with advancements in radar technology. I'm not sure what that means. Given his certification he would have possessed an ARPA qualification.

The missed course alteration is mind-numbing. There is a fairly standard practice after altering course, particularly in large ships - make sure you're where you want to be. (Measure twice; cut once). Ships don't maneuver like cars. After putting helm on to make a turn the ship actually continues for some distance on its old course then, once it has reached its new heading it takes some time to settle onto the new track (advance and transfer). The effect of wind and tide will influence the turning radius. On a good day a ship making an alteration will need to make course adjustments after a turn in order to regain track. QOTN was in a rain squall.

Whether the 2nd Officer had made the alteration or not, the next several minutes should have been fully occupied determining the actual position of the ship by both visual and radar fixes.

The lack of a Voyage Data Recorder has been interpreted by many news outlets to mean a "voice recorder". A VDR is actually all the data associated with the ship's progress including date and time; position; speed; heading; depth of water; radar picture; alarms; rudder order and response; hull openings; watertight and fire doors; wind; hull stress; radio communications and bridge voice recording. The type of VDR required by BC Ferries, if they were making international voyages, (and they're not) would be a simplified-VDR. It contains less data, but would have been useful all the same.

However, a VDR would not have prevented the event. Once a VDR has floated to the surface it's too late. It might have resolved some outstanding questions in the investigation but it would not have prevented the sinking.

News reports have tended to spread blame equally across the entire bridge staff, including the quartermaster. That's a problem for me. The rating on the bridge is not responsible for safe navigation with regard to positioning the ship. Such persons have a vital role in handling the ship as directed by the officer of the watch and in providing another set of eyes. In short, the quartermaster executes the orders of the officer of the watch: nothing more; nothing less.

Whether the quartermaster in this instance was doing her job properly, (uncertified though she was), has really not been resolved. But her level of responsibility for the safe navigation of the ship was considerably less than some news reports have suggested.

There are still some unanswered questions. Critical ones. For answers we will probably have to wait until they are asked and answered in a more formal venue.

Note: A commenter has pointed out that QOTN was NOT fitted with ECDIS but ECS, a less functional electronic chart system. In that regard QOTN was still required to navigate using paper hydrographic charts. What that adds to the situation on the bridge was the condition requiring the OOW to actually locate the ship by visual and electronic fixing and then physically plot that position on a paper chart. Why that did not happen remains unexplained although the distraction discussed in the post above seems to bear most of the weight.

Apologies for the confusion.

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