Marine Investigation Report M02c0030 Sinking and Loss
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MARINE INVESTIGATION REPORT M02C0030 SINKING AND LOSS OF LIFE AMPHIBIOUS PASSENGER VEHICLE LADY DUCK OTTAWA RIVER NEAR THE HULL MARINA GATINEAU, QUEBEC 23 JUNE 2002 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Marine Investigation Report Sinking and Loss of Life Amphibious Passenger Vehicle Lady Duck Ottawa River Near the Hull Marina Gatineau, Quebec 23 June 2002 Report Number M02C0030 Synopsis At about 1610 on 23 June 2002, the amphibious vehicle Lady Duck took on water while on the Ottawa River during a combined land and water-borne sightseeing tour of the National Capital Region. The vehicle sank rapidly by the bow in eight metres of water when near the Hull Marina. Of the 12 people on board, 6 passengers, the driver, and the tour guide escaped from the vehicle and were recovered by private craft on the scene at the time of the sinking. Four passengers, trapped within the sinking vehicle, drowned. There was no environmental damage. Ce rapport est également disponible en français. ©Minister of Public Works and Government Services 2004 Cat. No. TU4-14/2004E ISBN 0-662-36854-1 TABLE OF CONTENTS 1.0 Factual Information ...................................... 1 1.1 Particulars of the Vehicle ............................................. 1 1.1.1 Description of the Vehicle ............................................ 1 1.2 History of the Voyage ................................................ 4 1.2.1 On-land Operation of Vehicle ......................................... 4 1.2.2 First Amphibious Tour of the Day ...................................... 4 1.2.3 Second Amphibious Tour of the Day ................................... 5 1.3 Injuries to Persons ................................................... 8 1.4 Search and Rescue Response .......................................... 8 1.5 Vehicle Recovery .................................................... 9 1.5.1 Recovery Operations ................................................. 9 1.5.2 Vehicle Condition on Recovery ........................................ 9 1.5.3 Vehicle Examination after Recovery .................................... 9 1.6 Passenger Seating ................................................... 11 1.7 Bilge Pumping Arrangements ........................................ 12 1.7.1 Bilge Pumps Installation ............................................. 12 1.7.2 Bilge Pump Condition ............................................... 15 1.7.3 Bilge Pumping Requirements ........................................ 17 1.8 Vehicle Operational Trials ........................................... 17 1.8.1 Trials Preparation and Sequence ...................................... 17 1.8.2 Hull Integrity, Trim and Freeboard Tests ............................... 18 1.8.3 Speed, Bow Wave and Forward Freeboard Trials ........................ 19 1.8.4 Bilge Piping Syphonic Action Trials ................................... 22 1.8.5 Ramp Launching Trial .............................................. 22 1.8.6 Floodwater and Trim at Various Forward Freeboards .................... 23 1.9 Sinking Sequence ................................................... 24 1.9.1 Vehicle Route and Location of Sinking ................................ 24 1.9.2 Downflooding and Sinking Sequence ................................. 26 1.10 Ministry of Transportation of Ontario Vehicle Inspection ................. 28 1.11 Vehicle Inspection and Certification (Marine) ........................... 29 1.11.1 Small Passenger Vessel Inspection Requirements ........................ 29 1.11.2 Lady Duck Inspection Following Previous Occurrence .................... 31 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 1.11.3 Small Commercial Vessel Registration/Licensing ........................ 32 1.12 Personnel Qualifications and Certification ............................. 33 1.12.1 Driver Training ..................................................... 33 1.12.2 Tour Guide Qualifications and Training ............................... 34 1.12.3 Mechanic Qualifications and Training ................................. 36 1.13 Company’s Standard Operating Procedures ............................ 36 1.14 Weather Conditions ................................................. 36 1.15 Vehicle Maintenance Records ........................................ 37 1.16 Communications ................................................... 37 1.17 Passenger Safety .................................................... 38 1.17.1 Passenger Safety Briefing ............................................ 38 1.17.2 Evacuation Sequence ................................................ 38 1.17.3 Use and Availability of Life-saving Equipment .......................... 39 1.17.4 Life-saving Equipment Requirements ................................. 39 1.17.4.1 Lifejackets ......................................................... 40 1.17.4.2 Lifebuoy .......................................................... 41 1.17.4.3 Personal Flotation Devices ........................................... 41 1.17.5 Emergency Evacuation .............................................. 42 1.17.5.1 Emergency Exits .................................................... 42 1.17.5.2 Vehicle Cab Doors .................................................. 45 1.18 Safety Organizations Serving Small Passenger Vessels ................... 45 1.18.1 Commission des transports du Québec ................................ 45 1.18.2 Operator Vessel Safety Standards for Whale Watching Vessels ............ 46 1.18.3 Canadian Passenger Vessel Association ................................ 47 2.0 Analysis ............................................... 49 2.1 Vehicle Operation and Characteristics ................................. 49 2.1.1 Vehicle Pumping System ............................................ 49 2.1.2 Passenger Safety Briefings ........................................... 50 2.1.3 Emergency Evacuation Training ...................................... 51 2.1.4 Life-saving Equipment .............................................. 52 2.1.5 Emergency Signage ................................................. 53 2.1.6 Suitability of Rear Exit as a Primary Exit for Egress ...................... 53 iv TRANSPORTATION SAFETY BOARD TABLE OF CONTENTS 2.1.7 Transparent Roll-down Side Screens .................................. 54 2.1.8 Fabric Awning Design ............................................... 54 2.1.9 Vehicle Licensing/Certification ....................................... 54 2.1.10 Vehicle Operational Condition and Characteristics ...................... 55 2.2 Managing Safety ................................................... 56 2.2.1 Cognizance of Risks Presented in the Operation of the Lady Duck ......... 56 2.2.2 Competence to Manage Risks ........................................ 57 2.2.3 Commitment to Safe Operation ....................................... 58 2.3 Regulation of Small Passenger Vessels and Safety ....................... 59 2.3.1 Complexity and Adequacy of Safety Requirements ...................... 59 2.3.2 Promoting Safety versus Ensuring Compliance ......................... 61 2.3.3 Seaworthiness ...................................................... 62 2.4 Emergency Communications ......................................... 63 2.5 Dissemination of Safety Information .................................. 64 3.0 Conclusions ........................................... 65 3.1 Findings as to Causes and Contributing Factors ........................ 65 3.2 Findings as to Risks ................................................. 65 3.3 Other Findings ..................................................... 66 4.0 Safety Action .......................................... 69 4.1 Action Taken ....................................................... 69 4.1.1 Pre-departure Safety Briefings ........................................ 69 4.1.2 Bilge Pumping System .............................................. 69 4.1.3 Lifebuoy Requirements .............................................. 70 4.1.4 Small Vessel Regulations .............................................. 70 4.1.5 Lifejackets ......................................................... 71 4.1.6 Small Commercial Vessel Safety ...................................... 71 4.1.7 Requirements for Radio Communication ............................... 72 4.1.8 Small Vessel Inspection System ....................................... 73 4.2 Action Required .................................................... 73 4.2.1 Management of Safety by Operators of Small Passenger Vessels ........... 73 4.2.2 Adequacy of the Regulatory Framework for Small Passenger Vessels ...... 75 TRANSPORTATION SAFETY BOARD v TABLE OF CONTENTS 4.2.3 Passenger Evacuation ............................................... 77 4.2.4 Distress Communications and Coordination of Search and Rescue ........ 79 4.3 Safety Concern ..................................................... 81 4.3.1 Exchange of Safety-related Information on Amphibious Vehicles .......... 81 5.0 Appendices Appendix A—Bilge Pump Examination and Testing ............................. 83 Appendix B—Statutory and Regulatory Safety Requirements ..................... 85 Appendix C—Previous Sinking on 30 June 2001 ................................. 89 Appendix D—Sinking of the Amphibious Passenger Vehicle Miss Majestic .......... 91 Appendix E—S.I. 7 Related Issues ............................................