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Marine transportation safety recommendation M04-03

Reassessment of the responses to
marine transportation safety recommendation M04-03

 M04-03 in PDF [152 KB]

Passenger evacuation


The Lady Duck was an amphibious vehicle based on the conversion of a Ford F-350 truck chassis and arranged to carry up to 12 passengers on combined road and water-borne tours in the National Capital Region and on the Ottawa River. The vehicle was developed and built by the owner and entered commercial service at the start of the tourist season in June 2001.

The Lady Duck started the amphibious tour at about 1500 on 23 July 2002, with the driver, 10 passengers and a tour guide on board. When the vehicle entered the water at the Hull Marina, the main bilge pumps were switched on to clear the hull of any shipped water. Because no water was seen to be discharging from the outlets, the emergency bilge pumps were also switched on. Water was then seen to be discharging intermittently from outlets on both sides of the vehicle. The vehicle was driven to the Ottawa side of the river to various points of interest. The river was calm, with waves caused by wakes from boats and other watercraft in the tour area. On occasion, the vehicle encountered waves that washed over the hood and up to the windshield.

Toward the end of the tour, while returning to the Hull Marina, the driver noticed that the front end of the vehicle was floating lower than normal and that water was being continuously discharged from both sides of the vehicle. The driver then ordered the four foremost passengers and the tour guide to move to the back of the vehicle to try to decrease the forward trim.

The forward trim continued to increase and, realizing that the safety of passengers was at risk, the driver instructed the tour guide to tell passengers to don personal flotation devices. The driver then broadcast a MAYDAY on VHF radio. The situation deteriorated rapidly as more floodwater accumulated in the forward end of the vehicle. The driver then called on the passengers to abandon the sinking vehicle. The driver, tour guide and six passengers managed to get free of the sinking vehicle. The remaining four passengers became trapped under the fabric awning and sank with the vehicle in 8 metres of water.

The Board concluded its investigation and released report M02C0030 on 03 June 2004.

Board Recommendation M04-03 (June 2004)

The passengers and crew of the Lady Duck experienced difficulties in abandonment due to the rapidity of the sinking, the trim of the vehicle as it sank, and the overhead canopy that prevented passengers from floating free from the vehicle. Additionally, other design features, such as the narrow aisle between the seats, the inadequate exit door aft, two windows that were zipped closed, and the lack of exit signage on the side windows, contributed to a bottleneck when passengers attempted to evacuate the vessel. As a result, the Lady Duck sank so rapidly that some of the passengers were unable to egress before the vehicle was underwater, and they drowned.

Small passenger vessels are rarely of standardized design and, consequently, the arrangements for boarding, accommodating, and disembarking passengers vary greatly, particularly in vessels of novel construction such as the Lady Duck. TC has standards for commercial passenger vehicles, such as buses, trains and aircraft, and, to a lesser extent, for small passenger vessels with a gross tonnage greater than 15 or carrying more than 12 passengers. However, there are no statutory requirements for small passenger vessels, such as the Lady Duck, to be ergonomically designed to afford passengers and crew the best possible opportunity to safely evacuate in the event of an emergency. Regulatory amendments are being proposed to incorporate by reference the Construction Standards for Small Vessels (TP 1332). However, review indicates that small commercial vessels in excess of 6 m, such as the Lady Duck, are not required to incorporate sufficient inherent buoyancy to prevent sinking, and there are no provisions for the timely and unimpeded evacuation of passengers in the event of an emergency. The Board, therefore, recommended that:

The Department of Transport ensure that small passenger vessels incorporate sufficient inherent buoyancy and/or other design features to permit safe, timely and unimpeded evacuation of passengers and crew in the event of an emergency.
Transportation Safety Recommendation M04-03

Response to M04-03 (August 2004)

Transport Canada agrees with the intent of this recommendation. The Department has commissioned a study on the design, construction and operation of the four models of amphibious vehicle operating in Canada at this time. This study, scheduled to be completed in September 2004, examines regulatory requirements in Canada, Australia, the United States and the United Kingdom. The study will help to determine which requirements are recommended to address concerns related to intact and damaged stability, swamping and means of escape.

TC will also examine the anticipated Coroner's investigation and report on the accident in order to help determine which actions should be taken with respect to amphibious vehicles.

In addition to closely examining design issues associated with amphibious vehicles, Transport Canada will continue to promote and enforce existing requirements that aim to equip passengers and crew to respond quickly and effectively to emergencies. These include, for example, pre-departure safety briefings for passengers and the requirement for operators to complete a course in Marine Emergency Duties.

Board Assessment of the Response to M04-03 (December 2004)

In its reply, TC agrees with the intent of the recommendation. The department is conducting a study on the design, construction and operation of the four models of amphibious vehicles operating in Canada. The study, which is anticipated to be completed by the end of December 2004, is also examining regulatory requirements in Canada, Australia, the United States and the United Kingdom. The study will be used to help determine which requirements are recommended to address concerns related to intact and damaged stability, swamping and means of escape.

Given that TC has initiated an examination of regulatory requirements with a view to addressing concerns respecting means of escape related to amphibious vehicles, the response is considered Satisfactory Intent.

Next TSB action

Any actions taken as a result of the study will be followed up.

Board Reassessment of the Response to M04-03 (December 2005)

The study on the design was completed in February 2005. The study contained 13 recommendations to further enhance the safety of amphibious vehicles and addressed intact and damage stability, swamping and means of escape. TC will review the study and its recommendations, and take into consideration all comments from interested parties, including any recommendations that may come from an anticipated coroner's investigation, prior to implementing any additional safety requirements. TC is currently in the process of approving a simplified intact stability policy for existing small non-pleasure vessels over 6 metres but not more than 12 metres. No change to the last assessment of February 2005. If the study recommendations are followed and fully implemented, the risks associated with small passenger vessel operations will be substantially reduced.

The response is considered Satisfactory Intent.

Next TSB action

TSB staff will monitor the effectiveness of TC’s actions and industry activity with respect to the risks associated with this recommendation.

The deficiency file is assigned an Active status.

Response to M04-03 (November 2006)

TC’s update, dated November 2006, indicated that the Construction Standard for Small Vessels (TP 1332) came into force for new constructions started on or after 01 April 2005, and all vessels up to 6 m in length need to have sufficient buoyancy. Existing vessels of the same size will be applied as reasonable and practicable as possible. Once the proposed new Small Vessel Regulations, 2007 come into force in mid 2007, the compliance notice for small vessels will take place one year later. The compliance notice deals with the liability aspect of the safety of the construction. The regulatory requirements on buoyancy have been established as described above. By introducing the concept of the compliance notice may send a message that there is still some safety requirements on buoyancy to be done, which is not the case. As a result of extensive consultation on the appropriate stability for new and existing non-pleasure craft, a new policy will be communicated to the marine community in the form of a Ship Safety Bulletin by the end of 2006. The Ship Safety Bulletin is self-contained and provides the criteria and procedures on assessing the intact stability in basic terms.

Board Reassessment of the Response to M04-02 (November 2006)

TC’s Ship Safety Bulletin 07/2006, Guidance for Assessing Intact Stability and Buoyancy of Existing Small Non-Pleasure Vessels, was issued on 24 November 2006. The intact stability, buoyancy and watertight integrity requirements for new vessels constructed on or after 01 April 2005 came into effect on 01 February 2005. For existing vessels more than 6 metres long and 15 gross tons or less, which do not need annual inspections, section 391 of the Canada Shipping Act requires that owners and masters of these vessels use all reasonable means to ensure that vessels are seaworthy. Vessels 6 metres or less in length and built on or after 01 April 2005 must remain afloat if swamped. The safety deficiency associated with small passenger vessels that do not incorporate sufficient inherent buoyancy will be substantially reduced.

Therefore the assessment is assigned Fully Satisfactory.

Next TSB action

Because the safety deficiency associated with recommendation M04-03 is considered rectified, no further action is necessary.

The deficiency file is assigned a Closed status.