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When the TSB investigates an occurrence, it not only looks at the event, but also the circumstances around it. By doing so, it found that the crew on the Sam McBride were not trained in emergency passenger management because this training was not required for crew on sheltered waters voyages. However, while passenger vessels that are on sheltered waters voyages are closer to shore and shore-based emergency responders than vessels on other types of voyages, there are a number of types of emergencies that need an immediate response that cannot await the arrival of shore- based responders. For this reason, the Board recommended that Transport Canada implement a requirement for crew members of all passenger vessels, including those on sheltered waters voyages, to complete appropriate training in passenger safety management.
Furthermore, all passenger vessels are required to have emergency procedures that dictate how all passengers and crew will evacuate from a vessel within 30 minutes of an abandon ship signal in Canada. Despite this being a regulatory requirement, Transport Canada has no formal procedure to assess if the requirement is being met. The investigation found that the ferry’s evacuation procedures were unrealistic, leaving its six crew members to manage over 900 passengers while completing multiple competing tasks throughout the vessel. As is the case for many other vessels, emergency drills on the Sam McBride were typically carried out without passengers on board, which meant that they did not provide an opportunity to realistically validate the feasibility of the vessel’s evacuation procedure. However, a vessel’s crew will be insufficiently prepared for an emergency if passenger evacuation procedures are not validated through a realistic exercise with a representative number of participants. With this in mind, the Board recommended that Transport Canada implement a formal validation and approval process for passenger vessel evacuation procedures.
Lastly, on the Sam McBride, passenger counts were estimated and tracked using a hand-held tally counter, and children, infants, and those who may require extra assistance were not counted separately. Currently, there is no explicit requirement to keep a separate count of the children and infants on board on voyages of less than 12 hours. However, Transport Canada regulations specify that a vessel must carry child-sized lifejackets for 10% of the total number of passengers or the total number of children on board. In this occurrence, there was no way to determine whether there was an adequate number of appropriately sized life jackets available on board without a separate count of children. Therefore, the Board recommended that Transport Canada implement a process to validate that passenger vessels are keeping an accurate count of all passengers, including a separate count of the number of children and infants, on all voyages. [M24-03]
Since the occurrence, the City of Toronto has increased the size of the Sam McBride’s crew from six to 13. The City has also addressed passenger safety issues, including updating the pre-recorded safety briefings, adding additional signage, and warning passengers to not stand on the stairs while the vessel is moving.
TSB concerned about Canada’s marine emergency preparedness following investigation into a fire aboard container vessel ZIM Kingston.
The TSB issued two safety concerns following the 2021 loss of containers and fire on board the container vessel ZIM Kingston (M21P0297), off Vancouver Island, British Columbia (BC). The first safety concern relates to the risk of a phenomenon called parametric rolling, which led to the loss of containers, and the second concern addresses gaps in Canada’s preparedness to respond to marine emergencies.
In October 2021, the ZIM Kingston was drifting outside the Juan de Fuca Strait while waiting for an anchorage to become available when it experienced a series of severe side-to-side rolls, resulting in the loss of 109 containers overboard and damage to others. Approximately 36 hours later, while the vessel was anchored off Victoria, BC, a fire broke out in a damaged container that held dangerous goods. The fire then spread to nearby containers and lasted for five days before it was declared extinguished.
During its investigation, the TSB conducted model testing that determined that the ZIM Kingston experienced parametric rolling, a phenomenon that occurs when sea conditions converge with vessel-specific factors in a precise way, resulting in dangerous side-to-side rolling motions.
The investigation found that the risk of parametric rolling could have been identified using guidance material that is generally available to industry. However, this material was not on board the container vessel. The International Maritime Organization is taking steps to update industry guidance, but this will take time. While this work is underway, the Board is concerned that the absence of up-to-date comprehensive industry guidance for the management of parametric rolling may cause company policies, procedures, tools, and training to be inconsistent, ineffective, or absent altogether.
This occurrence also brought to the forefront the challenges that Canada faces when dealing with marine emergencies that go beyond the response capacity of the vessel’s crew. Indeed, unlike the United States, Canada does not require pre-arranged plans for emergency response or marine salvage. In this occurrence, it was fortunate that the vessel’s manager had made pre-arrangements for emergency response, and there simply happened to be two suitably equipped vessels nearby. To address this, Transport Canada has proposed to make regulations to strengthen preparedness requirements for industry, but this will also take time. In the interim, the Board issued a concern that there are gaps in Canada’s preparedness for marine emergencies that exceed the response capacity of a vessel’s crew, posing a risk to vessels, the environment, and the health and safety of the general public.
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THE REPORT | SEP 2025 | ISSUE 113 | 57
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