Safety management and regulatory surveillance deficiencies identified in March 2019 berthing incident in Matane, Quebec
Québec, Quebec, 6 July 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M19C0054) on a March 2019 berthing incident involving the roll-on/roll-off ferry Apollo in Matane, Quebec.
On 16 March 2019, the Apollo was making a routine crossing from Godbout, Quebec, to Matane, Quebec, with 94 people on board when it struck the 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 struck the dock, sustaining damage as a result, 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 before the STQ put 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.
Safety management and regulatory surveillance are TSB Watchlist 2020 issues. In this occurrence, known hazards associated with the Apollo’s operation went unmitigated in the absence of a risk assessment, which is an integral part of implementing an SMS on board a vessel. As well, in this occurrence, TC had delegated statutory inspections of the Apollo to a recognized organization but retained responsibility for monitoring the regulatory compliance of the vessel and the performance of the recognized organization through compliance inspections. However, TC’s monitoring was insufficient to identify safety issues on the vessel.
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.
See the investigation page for more information.
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.
For more information, contact:
Transportation Safety Board of Canada