Marine transportation safety investigation M19C0054
The TSB has completed this investigation. The report was published on 6 July 2022.
Striking of a mooring dolphin
Roll-on/roll-off ferry Apollo
View final report
On 16 March 2019, the roll-on/roll-off ferry Apollo was making a routine crossing from Godbout, Quebec, to Matane, Quebec, with 94 people on board when it struck a mooring dolphin (a structure that extends the berthing capacity of a dock) during berthing. At the time of the occurrence, there were high winds and it was dark. During the berthing, the master had been attempting to manoeuvre the vessel from the starboard bridge wing console using the engine, rudder, and bow thruster. As the vessel entered the port of Matane, the master had pushed the button on the starboard bridge wing console to transfer control of the bow thruster from the bridge; however, the transfer did not initiate because of a broken electrical wire. This meant that the bow thruster did not respond to any of the master’s inputs made using the bow thruster controls while the vessel was in the port. The vessel sustained damage as a result of the striking and was removed from service. No pollution or injuries were reported.
The Apollo was an aging vessel that the Société des traversiers du Québec (STQ) had recently purchased to provide service on an essential ferry route after the regular vessel on that route was unexpectedly taken out of service. A pre-sale inspection was not conducted, and when the STQ received the vessel from the former owner, the STQ discovered it had a number of unsafe conditions that affected its seaworthiness. The STQ initially postponed the Apollo’s entry into service and began conducting repairs. However, under pressure to restore the ferry service and considering that the Apollo was a temporary vessel for short-term use, the STQ put the vessel into service while repairs were ongoing. A risk assessment was not conducted, which led to the Apollo being in service without adequate identification of hazards and an assessment of the associated risks.
The Apollo was a delegated vessel under the Transport Canada (TC) Delegated Statutory Inspection Program and had been inspected by a recognized organization before and after its purchase by the STQ. TC also inspected the vessel prior to the STQ putting it into service. These inspections did not identify a number of unsafe conditions present on the vessel and resulted in the recognized organization issuing the Apollo the certificates it required for entry into service. The investigation determined that if oversight of delegated vessels by TC and recognized organizations does not lead to the identification and timely resolution of unsafe conditions and regulatory contraventions, there is a risk to the safety of the vessel, its crew, its passengers, and the environment. As well, if TC oversight of recognized organizations carrying out work under the Delegated Statutory Inspection Program is ineffective, there is a risk that unseaworthy vessels will be certified and operated.
The investigation also looked at the vessel’s safety management system, bridge resource management training requirements, the design of the bow thruster’s status indicators on the vessel, and the availability of continuous maintenance records.
Following the occurrence, the TSB boarded the vessel and then notified TC of safety issues identified. TC inspected the vessel on 21 March 2019 and issued a restriction from sailing. The STQ conducted a risk assessment and internal investigation that resulted in several recommendations for safety action that the STQ subsequently implemented.
Safety management and regulatory surveillance deficiencies identified in March 2019 berthing incident in Matane, Quebec
Read the news release
TSB deploys a team following a mooring incident in Matane, Quebec
Québec, Quebec, 17 March 2019 – The Transportation Safety Board of Canada (TSB) is deploying a team of investigators following an incident where the passenger ferry Apollo struck the dock while mooring yesterday in Matane, Quebec. The TSB will gather information and assess the occurrence.
Map showing the location of the occurrence
Line Laroche is the Manager of regional maritime operations with the Central Region. Before joining the TSB, Mrs. Laroche was Manager, Inspection Division at Transport Canada Marine Safety in Quebec. She spent 18 years at Transport Canada, including 11 years as a Maritime Safety Inspector in Montreal.
Mrs. Laroche began her career at the M.I.L. Davie shipyard in Quebec and holds a diploma from the Institut Maritime du Québec in Naval Architecture.
Class of investigation
This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.