Toronto ferry had no written procedures for safe docking speed, other 'safety deficiencies': TSB report

An investigation into a 2022 Toronto ferry boat crash has uncovered a number of safety deficiencies that could have led to a dire situation in other circumstances.

The Transportation Safety Board of Canada (TSB) says its investigation found a number of issues, particularly around passenger safety and emergency preparedness.

The Sam McBride ferry collided with the dock as the vessel approached the Jack Layton ferry terminal on Aug. 20, 2022, leaving 20 people injured.

The injuries thankfully were not serious, but raised questions around safety on the vessels.

The TSB report released Monday found that the city of Toronto did not have written procedures to define a safe approach speed during docking.

"Instead, decisions around docking speed were left to the discretion of the vessel master, who may have been influenced by operational pressures, such as passenger backlogs or running behind schedule," Investigator-in-Charge Étienne Séguin-Bertrand told reporters at a news conference.

Video analysis of several trips made on Aug. 20 found that at the time of the crash, the ferry was approaching the dock faster than it had during several previous trips that day.

While the ferry has two propellers, just one was turning at the time of the crash.

"The footage also showed that only the back end propeller was turning as it was approaching. Given the vessel speed and distance from the dock, the reverse thrust provided by the one propeller was not enough to stop the ferry," Séguin-Bertrand said.

Officials said Monday that while just one propeller was turning, they were not able to conclude that there had been a mechanical failure.  

 

Multiple 'safety deficiencies'

Séguin-Bertrand said that the investigation also uncovered several "safety deficiencies" related to passenger safety management and emergency preparedness.

For example the vessel had just six crew members on board, fewer than the 13 recommended by Transport Canada for the Sam McBride back in 2009.  

There were approximately 910 passengers on-board when the crash occurred.

"The investigation determined that if there had been a fire on board or a need to evacuate the vessel, there would not be enough crew members to effectively respond. Crew members would have to be in two places at once," Séguin-Bertrand said.

In such a circumstance, three crew members would be assigned to deal with the emergency, leaving just two crew members to manage over 900 passengers and oversee their possible evacuation.

While vessels are required to have a "safe manning" document issued by Transport Canada, which sets the minimum number of qualified crew members needed to ensure safety, the organization allowed the Sam McBride to operate with just six crew members following a request from the city.

It did so "without verifying that any mitigation procedures were in place to offset a smaller crew in the event of an emergency," Séguin-Bertrand said.

It wasn't clear why the request was granted.

 

'Ferry passengers aren't safety experts'

The TSB found that the crew also lacked the proper training to deal with a possible emergency.

"Emergencies usually develop rapidly, and passengers who are unlikely to be familiar with the vessel and its equipment rely on the fast and coordinated actions of the crew to keep them safe," Séguin-Bertrand said. "This is why ferry vessel crew members need to have the knowledge and skills related to crowd management and human behavior in emergencies, none of the crew members of the Sam McBride had received such training, and nor were they required to."

He said that while a 2017 TSB report flagged a safety concern around crew training for all vessels carrying more than 12 passengers in sheltered waters such as rivers, harbours and small lakes, Transport Canada has yet to implement any requirements for passenger management training.  

The report also noted imprecise tracking of passengers on the vessel, with counts estimated and tracked using a hand-held tally counter

"Children, infants, and those who may require extra assistance were not counted separately," the report found. "In the event of an emergency, it would be impossible to account for all passengers on board or ensure that there are an adequate number of appropriately sized life jackets available."

While the youngest ferry in Toronto's aging fleet is 61 years old and all of them have been refurbished to extend their lifespan, the report did not conclusively find any mechanical failures with the Sam McBride.

The TSB is making three key recommendations to Transport Canada based on its investigation. They include implementing a requirement for appropriate training in passenger safety management for all crew members; implementing a formal validation and approval process for passenger vessel evacuation procedures; and implementing a process to ensure that passenger vessels are keeping an accurate count of all passengers, including a separate count of the number of children and infants, on all voyages.

"The Sam McBride occurrence highlighted the vulnerabilities related to passenger management in ferry operations and the importance that must be put on passenger safety," Séguin-Bertrand said. "Ferry passengers aren't safety experts."

Toronto's overworked ferry system has been a point of concern for some time, with long lineups in the summer to board the ageing vessels.

The ferries currently in use by the city are between 61 and 114 years old years old. Toronto City Council has been considering replacement options since 2015.

The city is currently in the process of procuring two large new fully electric ferries to replace the aging fleet, with the first expected to arrive by December 2026. However councillors have expressed concerns about the ballooning costs – currently pegged at $92 million – as well as further delays.

While the ferries are expected to add greater capacity, the TSB said all of it recommendations would still apply to newer vessels.