Federal transportation investigators have determined that “inadequate risk assessment, informal practices, and insufficient supervision” were what caused two BC Ferries crew members to fall overboard during an emergency drill last summer.
The Transportation Safety Board of Canada released its investigative findings into the August 2018 incident on Friday morning.
On Aug. 31, 2018, two crew members on the Spirit of Vancouver Island fell from the vessel’s No. 1 rescue boat into the water below while it was being slewed out during emergency drills at Swartz Bay Ferry Terminal in North Saanich. Both employees were saved from the water and taken to hospital. One of the members were uninjured while the other was treated for minor injuries.
Meanwhile, the rescue boat sustained minor damage to its bottom hull.
According to investigators, BC Ferries failed to adjust the brake release lines when new, different rescue boats were installed on the vessel. Instead, “some of the crew responsible for the launching and retrieval of the boats had developed an informal practice to compensate.”
But it was this compensation that caused the line to snag while the rescue boat slewed out from the davits, the report reads. The snag created tension on the brake line, to the point that the davit arm brake released, causing the two crew members to go overboard.
Investigators found that BC Ferries’ safety management system failed to identify hazards related to changing the rescue boat type.
The on-board chief supervisor inadequately supervised the drill, investigators said, because of his high workload which involved simultaneous tasks at various locations aboard the vessel.
The report says that BC Ferries made a number of changes to its policies and procedures following the incident.