Queen of the North Divisional Report

[Northern Exploration]

Here it is:

www.bcferries.com/about/qnorthdivisionalinquiry.html

[Political Incorrectness]

" The heroic and extraordinary assistance provided by the residents of Hartley Bay, F/V Lone Star, and the CCGS Sir Wilfred Laurier was invaluable" to what? This report clearly states it was human error but there is no accountability in the crews actions. It seems to be a bit covered up of some rumors.

[kylefossett]

ferrymaniac101 said:

" The heroic and extraordinary assistance provided by the residents of Hartley Bay, F/V Lone Star, and the CCGS Sir Wilfred Laurier was invaluable" to what? This report clearly states it was human error but there is no accountability in the crews actions. It seems to be a bit covered up of some rumors.

rumours are exactly that rumours.
so if anybody wants to read the whole thing and then send me the cliffnotes i will cover your passenger fare on your next route one trip. if you are a child fare then i will throw in a chocolate bar from the vending machine.

actually i'll just wait until easter weekend when i see both my union and management contacts and have them sitting together and then i'll bring up this topic

[Northern Exploration]

Well, after a cursory reading the bulk of the crew of the QoftN can be proud of the work they did. The report clearly outlines some concerns however. One brief comment by the Chief Master (will add the page number later- Page 24 of 28) concerning the very relaxed (casual is actually the word he used) atmosphere on the bridge was interesting. Hence the sound of music in the background during radio transmissions. The handover between individuals in the Quartermaster position (actually steering the vessel) went wrong because the upcoming turn wasn't clearly on everyones mind. And the watch of the person in command on the bridge was severely deficient to go so long without noticing the position of the vessel. The Master - while he was sleeping and not on watch, may bear some minor responsibility for the tone on the bridge and not following the new procedures by the Chief Master. The Master whether on the bridge, on duty or not is accountable for how the ship is run.

I was impressed by the appendicies provided. As an asside it gives you some idea of the details tracked and attended to during refits.

There are still some gaps as to really why these things happened but what happened is pretty clear. The rumors will persist probably as to what was going on behind the scenes. Unless they two individuals were very forthcoming with the TSB we may never know. Especially without voice recorders on the bridge. The addition of those will be a huge help in any situations in the future.

It will now be interesting to see how the TSB report jives with what we have already seen. It wouldn't be in BCFC best interests to have left anything off. And since the draft report is being circulated you would think they are somewhat in sync. Well we will have to wait and see. Probably one month for individuals comments on the draft report and then another month of final preparation.

I would think we will begin to hear a bit more now about lawsuits etc. now that the situation is far clearer.

On the radio shows that BCinNJ posted in another thread I was very impressed with the passenger who had said they weren't interested in suing but rather that they were interested in the truth and ensuring it never happened again. However the family who lost their loved ones are in a different situation.

If I could I would be on one of the first trips on the NorAd to help set the whole situation in perspective for me. I have friends in NYC who still have not been anywhere near ground zero. For me however I found it very helpful to me to go right back to the area and even to stay in the hotel I was in the weekend before 9/11 as soon as it reopened a little bit more than a year later. I hope the family of the lost couple gathering together in Hartley Bay and experiencing the wonderful hospitality of the feast that is planned, and visiting the site will help with their healing process.

[Northern Exploration]

Kyle: Define children. How about a White Spot burger instead? hehe.

[kylefossett]

pnwtraveler said:

Kyle: Define children. How about a White Spot burger instead? hehe.

under 11 the cheap kids fare
i am cheap so i figure go with the child labour

[Scott]

Just read the whole thing... very interesting. I wonder if they have this thing available in print? Interesting that the gender of EDN #7 is never mentioned but all the others are.

[BrianWilliams]

The report's attachments ARE very informative. Thanks for the link.

For all readers: www.bcferries.com/files/AboutBCF/QNorth_DI_ATTACHMENTS_-_ALLii.pdf
contains 77 pages of documentation on the ship; Master's notices (esp concerning autopilot/manual changeovers); radar and chart samples of the Sainty Point-Gil Island zone; and a transcript of radio communication on that awful night. See pp 41-46 for the navigation info.

The radio log follows right after, and it's a chilling re-creation of the events after impact.

I have been reluctant to focus on personal blame since the sinking; but I now feel that the bridge watch must completely explain their actions in the vital 14 minutes.

I believe BCF - there was no equipment failure. The weather was normal for coastal BC in March, rough and rainy, but navigational lights in the region were working and visible - as reported by several observers.

There is a long enough reach into Wright Sound after Sainty Point to allow a big vessel to safely pass Gil Island at 20 knots, even if a course correction is delayed a very few minutes by inattention, auto/manual changeover or moments taken to correlate position by radar/GPS with visual ID of markers.

There is a smoking gun, I am sorry to acknowlege. It was held by one or more of the bridge watch, who must reveal exactly what transpired on the bridge between Sainty Point and impact.

If there was difficulty in managing the helm, there was enough time to awake a senior officer for assistance - and to reduce speed while the problem was sorted out.

It is rare that a BC Ferries' worker fails in performance of duty; so rare that that all BCF workers and passengers deserve a clear explanation of this disaster.

PS - You all know that a passion of mine is learning about the MV Estonia sinking of 1994. Estonia's tragedy was a combination of dodgy maintenance, incompetent seamanship, poor crew training and very bad luck. 852 passengers and crew out of 929 aboard died.

BC Ferries will never, ever suffer a tragedy like Estonia. Though we sail large vessels in more difficult conditions, our maintenance, training and tradition of seamanship makes this inconceivable.

BC Ferries' standard will be upheld, but we must know why Queen Of The North was allowed to sail into danger. The bridge watch has the answers.

[Northern Exploration]

I noticed the same thing Brian. The newspaper articles I posted last week did mention one of the bridge staff was female. If true then EDN#7 was probably her. She is the one who has cooperated.

I reread it now a second time and started to look at the appendicies too. Between the descriptions, the transcripts of the radio transmissions after the accident, and the voice of the crewman from the CBC interview posted earlier, I have a real chill again just like waiting to hear more news after the initial reports of the sinking. You folks in the west were still sleeping when we started to hear it on early morning news here and less was known.

I agree with you Brian about the overall situation with BCFC as compared to the Estonia.

One recommendation without clear reasons made me pause. Why change the watch schedule to 4 hours on and 8 off from the 12 on to 12 off? Nothing was mentioned yet about anyone being sleepy or not alert enough to do their duty in the report?

I would imagine that conduct on bridges for the next few years will be much more professional and less casual. I also have never stood watch steering in the middle of the night, staring into relative darkness, when it is much the same every trip.

I can remember asking a friend who does long haul flights on a major airline, "does the thrill of flying wear off?" His answer was quite simple and you knew immediately what it was like. Go into your bathroom, sit on the toilet, dim the lights, stare at the wall for 8 hours and you get the idea. Oversimplified but goes to show one of the downfalls of technology can be boredom.

[Low Light Mike]

I found this part interesting:

The subdivision doors on the main car deck were closed and secured properly. Given the significant damage sustained by the Queen of the North and the rapid progressive flooding along the entire length of the hull and then onto the car deck, the subdivision doors on the main car deck slowed progressive flooding and reduced the free surface effect sufficiently to allow the ship to settle on an even keel, and ultimately permitted the successful evacuation of the mustered passengers and crew

The sliding car-deck dividers evidently worked....as intended after their installation following Herald-of-Free-Enterprise & Estonia disasters.

If not for those sliding-doors, the flooding cardeck could have destabilized and perhaps capsized the ship during evacuation.

[WettCoast]

flugelhorn said:

I found this part interesting:

The subdivision doors on the main car deck were closed and secured properly. Given the significant damage sustained by the Queen of the North and the rapid progressive flooding along the entire length of the hull and then onto the car deck, the subdivision doors on the main car deck slowed progressive flooding and reduced the free surface effect sufficiently to allow the ship to settle on an even keel, and ultimately permitted the successful evacuation of the mustered passengers and crew

The sliding car-deck dividers evidently worked....as intended after their installation following Herald-of-Free-Enterprise & Estonia disasters.

If not for those sliding-doors, the flooding cardeck could have destabilized and perhaps capsized the ship during evacuation.

Yes, Fluge, that is my interpretation. The MacGregor doors as they are sometimes called, I believe, apparently gave the ship a lot of extra time; a worthwhile investment for sure.

The QPR does not have such!

[Fenklebaum]

I find it rather disturbing that the bridge crew were unable to correctly give their position in longtitude and latitude. Granted, they were undoubtedly multitasking under extreme duress, but one would hope that they would be able to relay their position to those whom they were requesting assistance from.

I agree with pnwtraveller's assertion that EDN#7 must be the oft-mentioned female crewmember. It is also interesting to note that her co-operation effectively quashes the rumours that her and another crewman were joining BC Ferries' version of the Mile High Club. There was no mention of such activity in the report.

The TSB report should be an interesting read/contrast to this internal report.

Fenk, 49° 11' N by 123° 10' W

[Low Light Mike]

I wonder if the background-music issue was that big of an issue, or if the report is just "playing it up". I ask this because I have no idea of whether music is a common item for a night-time bridge watch. Is this considered professional or not ?

[Low Light Mike]

....and another thing:

I find it surprising that the 4th Officer radioed Prince-Rupert-Control to say that they had passed Sainty Point Light.

If he knew he was passing the light, and if he knew that it was standard-procedure to make a radio transmission to that effect, wouldn't he also have known to make the course-correction at that time?

From earlier speculation from folks such as Glentworth, I just presumed that if the course-correction was missed, they must also have missed seeing the Sainty Point light.

It's like saying "I see the red light", and then not stopping....

But now I'm getting too far into speculation, I realise. Too bad the 4th Officer doesn't hold the "hidden immunity-idol", as then he might have participated in the inquiry. (a pop-culture reference to the TV show "Survivor", for those who are wondering....).

Hopefully the transport-inquiry-report will answer this question of mine...

[Neil]

Despite the thorough nature of the report, with all the charts and other attachments, we're not really a lot more enlightened than we were yesterday with respect to the key question of how the bridge crew could have let the ship be so far off course. I was wrong in thinking that BC Ferries might take some responsibility for inadequate training- they put every ounce of blame on the crew. It looks like we're going to have to wait for the TSB report to get a clearer picture as to the level of culpability of the officers in question.
Now BC Ferries embarks on the discipline part of the inquiry. No matter how one feels about what the officers in question are going through, there's clearly only one thing that BC Ferries can do to demonstrate to the travelling public their determination to hold someone to account for what happened. The refusal of the officers to participate in the divisional inquiry, on BC Ferries' terms, makes it easier politically for the company to act, no matter how justified the officers are in protecting their own legal interests.

[WettCoast]

My notes from skimming through the BCFS's internal report documents...

1 - This report will not silence the rumour mill. Hopefully the TSB report will do so.
2 - I am not clear on whether or not the course change at Sainty Point was to have been done by the auto pilot or manually. If by auto pilot is there not a required verification by the crew?
3 - There is no mention at all (that I noticed anyways) of visual or audible alarms going off to indicate the vessel as being off course, or even that such alarms are even present. If present had they been switched off? The QM on duty reports no indication of being off course until trees on Gil Island were spotted at close range. Radio communications with Prince Rupert traffic immediately after the grounding indicate that the crew were not clear on just where they were.
4 - There is no mention also with regard to on board GPS equipment and the crew's use of such.
5 - The report makes it clear that conditions on the water (visibility, weather and seas) at the time of the grounding were not as bad as had been previously stated in some sources.
6 - I had understood that the missing (drowned) couple had not rented a cabin on board. This report makes it look as if they may have been in one of the two cabins left unsearched. Surely the Purser's Office staff would have remembered whether or not a cabin had been rented to them? Obviously they had not reserved a cabin prior to boarding the ferry.
7 - The report talks about the one remaining northern vessel with 'open' lifeboats (the QPR). The report states that as of April 2007 that vessel will no longer be used for winter service on the North Coast, and that it will be retired in 2009. That clears up one mystery, and brings up another question - is the Nimpkish to be a permanent fixture on the north coast or are they going to provide docking facilities capable of handling the NorAd in Klemtu, Shearwater, etc.?
8 - The report makes it pretty clear that the MacGregor doors on the QotN car deck played a very important role in retarding the sinking, a factor which may have saved numerous lives. The QPR does not have these - why? The NorAd does not either (I'm not sure about this - anyone know?).

Lastly, the detailed plan drawings of each of the QotN's decks are great. It will allow me to do a detailed comparison with the NorAd which is still being promoted as bringing "enhanced service" to the North Coast. Enhanced compared to what?

WCK - JST looking forward to the TSB report...

[WettCoast]

More notes:

1 - Music/stereo on the bridge - some would argue that this may distract the crew and could be a contributing factor to the accident.
2 - Shift rotations - some experts in 'circadian rhythms' maintain that long shifts are an issue leading to fatigue, decreased attention, etc. By recommending an alternate schedule BCFS's may be saying in a round about way that the current scheduling of work (12 hours on, 12 hours off) may have been a contributing factor. In this instance, however, the crew had only been on duty since 8 pm so I don't think fatigue would have been an issue. On the other hand, might something known as 'night nurse syndrome' been a factor?

[BrianWilliams]

A very late note - it is bedtime for landlubbers like me:

Several times in the report and comments here; "music in the background" has been cited as evidence of loose discipline on the bridge.

My only recent experience on the central coast was a ride on Q Chilliwack two years ago. Eight hours out of Bear Cove we turned into King Channel. Our QM and two other deck officers were fully occupied until then, steering the boat, entertaining passengers like me; fielding radio traffic, reporting and receiving position reports -and gossip- with BCF, CGS and commercial boats.

As we turned into King Channel, a new QM came on deck to relieve our helmsman. She had a fat bag of CDs. This woman had earlier showed me thru Q Chilliwack's chart collection, so I asked: "Hey, are these your electronic charts?"

"Not if you count Huey Lewis and Johnny Cash as mapmakers."

The last three hours of Q Chilliwack's voyage was livened by recorded music. Though it's just one experience, the bridge personnel were on the job, music and all.

We entered King Channel on a roaring ebb tide. Dumpy QC bit down and beat the current -- until a school of dolphins appeared.

Spin the ship, drift down-current for a while, then hit the power up channel. Whoops, whales.

Stop, spin and drift. Q Chilliwack idled and powered sideways while all the tourists got their humpback photos -- me, too.

There is a point to this. Route 40's crew had three watches. Our happy day trip to Bella Coola was just one of their assignments.

Chilliwack would fuel and leave Bella Coola before dawn for the Bella Bella - Klemtu run; then back to Bear Cove and over again.

The captive crew were cheerful and enthusiastic -and professional.

[D'Elete BC in NJ]

wetcoastkidjst said:

My notes from skimming through the BCFS's internal report documents...

2 - I am not clear on whether or not the course change at Sainty Point was to have been done by the auto pilot or manually. If by auto pilot is there not a required verification by the crew?
3 - There is no mention at all (that I noticed anyways) of visual or audible alarms going off to indicate the vessel as being off course, or even that such alarms are even present. If present had they been switched off? The QM on duty reports no indication of being off course until trees on Gil Island were spotted at close range. Radio communications with Prince Rupert traffic immediately after the grounding indicate that the crew were not clear on just where they were.
4 - There is no mention also with regard to on board GPS equipment and the crew's use of such.

2 - According to the conclusions, whether the course correction was to have been done manually, or automatically, the fourth officer, as the officer on the con, was responsible to confirm the course correction was made.

3 - I would anticipate one of three scenerios...the system had no alarms, the system had alarms and way-points but they were not engaged, or there was a error in the way-point programming and no way-point alarm was programmed...I'm speculating of course.

4 - The GPS system was likely an integral part of the autopilot as it is in the versions used in smaller (read pleasure craft) vessels, so it was in use.

[D'Elete BC in NJ]

I also noticed in the crewing log that the only crew member on the bridge with significant experience on the QotN was the second officer...who was not present at the time the course correction at Sainty Point was to be made. I understand that the fourth officer was experienced, but unfamiliarity with some of the ship's systems could have influenced how decisions were made.

[D'Elete BC in NJ]

wetcoastkidjst said:

More notes:

1 - Music/stereo on the bridge - some would argue that this may distract the crew and could be a contributing factor to the accident.

Going back to your note 3 in the previous post, if there was an audible alarm and the music was loud enough, the alarm may not have been heard.

[Barnacle]

Intriguing... I hadn't thought of that. Personally I don't listen to music on the bridge because it complicates my hearing of radios, conversation with the helms(person), and frankly if it's good rock and roll or jazz I'll be listening to that instead of doing my job.

[D'Elete BC in NJ]

And out on the wire:

www.cbc.ca/canada/british-columbia/story/2007/03/26/bc-ferry.html

[Northern Exploration]

Regarding the missing couple. With all the alarms, banging on neighbouring doors, the lurching of the ferry, the commotion of other passengers evacuating their compartments you would think that no one could sleep through the all the din. Unless:

1. The couple took sleeping pills. No one would recommend doing that on any moving vehicle where you may have to be awake for an emergency such as in an airplane, bus or ship. Perhaps passengers should be cautioned about that. That is the very reason they refuse to board drunk people on airplanes. They would have had to have been in one of the two unsearched rooms.
2. They were on Deck 7 and in an inside stateroom. There are many fewer staterooms on that deck so it is conceivable that they could have been the only one on that side. However how to not hear the alarms and PA? There were speakers in the staterooms. The staterooms weren't sound proof and in the outside cabins you could easily hear someone speaking outside your stateroom window despite the very loud air ventilation in the room. I clearly heard a baby crying one night and the next morning found out it was two staterooms away and on the inside and I was in the corner stateroom outside. They would have had to have been in one of the two unsearched rooms.
3. They went down to their vehicle to get something they thought was valuable and somehow couldn't get back up. A pet perhaps or personal item?
4. They used the elevator and got stuck. Maybe the elevator emergency button was being pushed and couldn't be heard? Maybe the emergency power cut off for the elevator and emergency alarm button.

All conjecture and we may not ever know. However I will keep some of these things in mind next time I travel. Since the NorAd has the swipe cards to enter the staterooms, searching will be much easier. If we ever find out there probably is a series of simple things which combined to put the couple in danger.

[D'Elete BC in NJ]

And another story from the 22nd:

www.cbc.ca/canada/british-columbia/story/2007/03/22/ferry-year.html