Queen of Oak Bay TSB Report

[Kam]

It's out!

Marine Investigation Report
Loss of Propulsion, Subsequent Striking of Berthed
Pleasure Craft and Grounding
Roll-on/Roll-off Ferry Queen of Oak Bay
Horseshoe Bay, British Columbia
30 June 2005

Report Number M05W0111


www.tsb.gc.ca/en/reports/marine/2005/m05w0111/m05w0111.asp

[Retrovision]

In the conclusions section, here are the Findings as to Risk
(www.tsb.gc.ca/en/reports/marine/2005/m05w0111/m05w0111_sec2.asp#3)

3.2 Findings as to Risk

1. British Columbia Ferry Services Inc.'s (BC Ferries) procedures do not provide adequate guidance for the identification and supervision of many safety-critical maintenance tasks.

2. Reliance on verbal communication and lack of detail in the work records may hinder the determination of appropriate corrective action following an occurrence.

3. As no person was designated to stand by during berthing operations, the anchor could not be deployed, depriving the vessel of a potential important tool for use in emergency.

4. In an emergency situation, decisions must be made taking into consideration all available information. Otherwise, subsequent actions intended to resolve the situation may be ineffective, thus placing the vessel at risk.

5. There are fault conditions that may require a main engine on the C Class ferries to be shut down quickly for which automated isolation from the other connected engine has not been incorporated.