The Transportation Safety Board (TSB) released its investigation report last week on the 2003 Queen of Surrey fire, citing concerns over regulatory inspections and ferry safety. The report notes B.C. Ferries took fleet-wide action after the fire to fix engine and fire suppression safety issues.
"The Board recommends that Transport Canada, in conjunction with other stakeholders, develop a more effective design, maintenance, inspection and testing regime for fire-suppression systems," states a TSB release. "The Board also recommends that Transport Canada require large Canadian passenger vessels to meet a standard of structural fire protection that ensures a better level of safety. In addition, the Board expresses two safety concerns, one about the adequacy of regulatory inspections and the other about the adequacy of the B.C. Ferry Services Safety Management System."
The report found the causes and contributing factors to the May 12, 2003 fire in the engine room were ship vibrations fracturing a fuel oil pressure gauge pipe, the steel pipe being replaced with a copper pipe, the pressure gauge connection pointing upwards allowing leaks to hit a heat source and a missing heat shield which could have blocked the leak from hitting a heat source.
"The improper orientation of the pressure gauge connection take-off point directed pressurized diesel oil from the fractured pressure gauge pipe to spray onto the hot engine exhaust manifold," states the Feb. 9 report.
Regulatory inspections prior to the fire did not pick up on the deficiencies in the engine room.
"While conditions may change between annual inspections, the shields on the exhaust system had been missing for six years, during which time the vessel had undergone at least five annual inspections by Class and TC," the report states. "A year after the occurrence, TSB investigators visited the vessel and noted that it had been put back into service after the fire with the shields still not in place."
The report concluded, "There is concern that the quality of some inspections conducted by TC may not be attaining the prime objective of the inspection, that is, to ensure that the system being inspected is in a safe operational condition at the time of the inspection."
The report also said, "Canadian and international regulations do not address requirements for ensuring the continuing structural integrity of the CO2 system, nor do Canadian regulations require safeguards to prevent inadvertent leakage or discharge the Board is concerned that, without adequate design requirements to prevent accidental leakage and discharge, and without test procedures to demonstrate continued structural and functional integrity, subsequent failures of fixed fire-extinguishing systems during emergencies may place vessels, crew, passengers and the environment at undue risk."
The TSB recommended that "the Department of Transport, in conjunction with other stakeholders, review Canadian and international marine regulations respecting fixed fire-extinguishing systems to ensure that their design, maintenance, inspection and testing regimes effectively demonstrate continued structural and functional integrity."Transport Canada will be "carefully reviewing the recommendations and will respond within 90 days," spokesperson Rod Nelson said in an interview.
Nelson said Transport Canada has to respond to TSB recommendations and if it doesn't agree with the recommendations it needs to explain why it doesn't agree. Also, TSB will be tracking on its website what Transport Canada does about the recommendations.
The TSB investigation also found deficiencies in B.C. Ferries' Queen of Surrey safety management system, including internal communications, maintenance and repair, shipboard inspection practices, emergency preparedness, analysis of accidents, tracking and closing of recommendations and audit programs.
The report lists the safety actions B.C. Ferries took with its fuel and carbon dioxide systems both fleetwide and on the Queen of Surrey after the fire.
"The public has to recognize that we didn't wait two and half years for the report," B.C. Ferries president and CEO David Hahn said in an interview. "We tackled it straight on."
Regulatory changes won't happen overnight as a result of the TSB recommendations, Hahn explained, because the federal government's new shipping act has been under review since 2001. He suggested Transport Canada may fold the TSB recommendations into the new shipping act. Hahn noted TSB is "a group that investigates and recommends but does not regulate."
In a press released Hahn added, "while B.C. Ferries complies with all current regulations regarding fire protection systems, he welcomes these industry wide recommendations and the company will work with all parties to support this action."
B.C. Ferries will be reviewing the TSB report with Transport Canada.
"Our company philosophy is that safety is priority number one," Hahn said.
The Queen of Surrey is currently undergoing a mid-life refit.
The TSB release states, "The Board is confident that lessons learned from this investigation will make marine passenger transportation safer for Canadians across the country."
A spokesperson for the B.C. Ferry and Marine Workers Union is concerned that TSB does not have the authority to make regulatory changes happen. The recommendations are non-binding and it is up to Transport Canada and other regulatory bodies to make changes, said Mike Davis, the union's acting second vice-president. Davis is a deckhand on the Horseshoe Bay-Langdale route and helped fight the fire onboard the ship in 2003. He witnessed the "thick black plume" of smoke coming out of the engine room, smelt the burning rubber of tires and saw the puddles of boiling water on the main car deck. The deck had 137 vehicles on it that day - about half its capacity - including logging and diesel fuel trucks. The crew managed to prevent the fire from spreading to the vehicles. There were no fatalities.
"I'm really proud of what everyone did on the crew," he said.
He and most of his fellow crew members were never interviewed by B.C. Ferries, Transport Canada or the TSB after the fire, he said. He voluntarily submitted a report to B.C. Ferries and the union detailing the day's events to try to help shed light on what changes were needed.
"I felt I should impart my experience and knowledge to learn from this," Davis said.
