TSB report on ferry crash raises alarms

Barb Sweet
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Cites crew fatigue, electrical problems among reasons Beaumont Hamel ran aground

The Transportation Safety Board (TSB) found recurring electrical problems caused the Beaumont Hamel ferry to strike a dock last year, but its report also contained scathing concerns about provincial ferry operations, from the under-reporting of incidents to crew fatigue and the lack of internal safety investigations.

The Bell Island ferry M/V Beaumont Hamel is docked at the ferry wharf in Portugal Cove after it was taken out of service as the result problems with its electrical system in July 2012.
 — File photo by Joe Gibbons/The Telegram

NDP transportation critic George Murphy contends the report shows the Department of Transportation and Works, which oversees the provincial ferry system, is not trying to fix glaring problems and the operation has gone into “deep crisis.” He said he fears a tragedy will happen.

“It’s being managed in panic scenario — reactionary rather than proactive,” said Murphy, who added the province’s ferry replacement strategy is stalled.

“It’s very damaging for the department.”

The TSB investigation cited the following risks in the routine operations of the department and the Beaumont Hamel: recurring blackouts; management of public pressure; fatigue; a lack of hazardous-occurrence reporting; a lack of safety‑focused investigations; limited maintenance tracking and limited management of maintenance for the aging fleet.

The Beaumont Hamel was built in 1985 and is near the end of its optimal service life, the TSB noted in investigating the May 30, 2012, incident.

The TSB found that there was no internal safety or technical investigation into the incident. Human resources did investigate, but that was focused on determining any possible culpability.

Murphy said the department has shifted from a culture of providing and maintaining a service to a culture of blame.

“To be pointing fingers at people leaves me speechless,” he said.

The TSB report also questioned whether public pressure is being managed properly so it doesn’t compromise safety.

When the Beaumont Hamel struck the wharf that day, there was an electrical contractor on board to deal with a generator problem, as the decision was made to keep to the schedule.

“As with all vessels providing essential passenger service, there is a public expectation that service will be provided on all scheduled runs,” the report reads.

“As such, the vessel is subject to public pressure as part of normal operations. This pressure is to be expected; it must be anticipated and strategies must be in place, so that pressure to maintain service may be balanced appropriately against safety considerations.”

When the TSB delved into the Beaumont Hamel’s troubles, it also raised alarms about crew fatigue on the demanding run.

“A review of the schedules for crew members on the Beaumont Hamel revealed that there were frequent departures from the minimum required six hours of sleep-time, as well as frequent examples of workdays extending to the point when the minimum hours of rest fell below 16 hours in a 48-hour period,” the report says, noting the Beaumont Hamel was not originally designed to have the crew sleep on board.

“Poor sleeping environments that do not provide adequate space, nor appropriate control of heating, cooling, and noise, contribute to reduced sleep quality.”

The TSB also discovered there were no written records of hazardous occurrences or near misses  in the ferry service’s eastern region, and specifically, there were no reports from the Beaumont Hamel.

“The department did not have documentation available to demonstrate that consistent hazardous-occurrence reporting was taking place, nor were there established procedures within the (department) to allow for safety‑focused investigations of hazardous occurrences,” the report said.

Furthermore, the voyage data recorder — a black-box-type device —  failed to store data on the docking accident.

The TSB investigation determined the Beaumont Hamel had a history of electrical failures, and on the day of the accident, the blackout caused the vessel to lose propulsion and steering while docking.

The TSB said there had been previous repairs to address the mechanical cause of the blackout, but risks identified after each occurrence were not dealt with effectively.

Further, it said the Department of Transportation and Works had a safety management system in place that was not effective at managing the operational risks posed by the recurring blackouts.

“Operating an aging fleet without an adequate risk-mitigation strategy in place puts the vessels, the crew, the passengers, and the environment at risk,” the report said.

The vessel sustained damage to the bow visor and caused minor damage to the wharf. One minor injury was reported.

Since the accident, the TSB said the department has installed a computerized maintenance-management system on the Beaumont Hamel and in the operations office. This system tracks corrective maintenance, sends alerts about planned maintenance and can suggest preventative maintenance. As well, the generator engine fuel pumps were overhauled and calibrated.

The Beaumont Hamel sustained blackouts from Day 1, including during its delivery voyage. There have been eight blackouts reported to the Transportation Safety Board (TSB), three of which have occurred since 2009.

But the TSB also revealed the vessel experienced blackouts that were not recorded or reported.

In some instances, the vessel’s logbooks didn’t have enough information to verify events on board.

“Onshore, there was no systematic approach for tracking maintenance and following up on its effectiveness. In addition, maintenance records and other reports relating to the blackouts on the Beaumont Hamel were not consolidated and were stored in various locations,” the report said.

The Beaumont Hamel resumed operations 51 days after the crash.

Transportation and Works Minister Paul Davis was travelling and unavailable for comment on this story.



Organizations: Transportation Safety Board, Department of Transportation and Works

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Recent comments

  • sc
    September 25, 2013 - 15:24

    Cover-ups, missing documentation and records, unprofessional conduct, incompetence, negligence, and non-existent planning. The Dept of Transportation and Works (which doesn't seem to work very well at all) has obviously decided that it's easier to put people's lives at risk than to ensure that these rust-buckets are safe. I wouldn't expect anything different from this government but it's amazing that residents are willing to put up with this. I'm sure glad that I don't have to rely on this province's ferries and I'm definitely not going to use them.