Safety management systems should be mandatory for all tug and barge operators: Transportation Safety Board of Canada

The federal transport department does not have an adequate inspection program for tug barge operations even though such operations can be riskier than conventional cargo-carrying vessels, the Transportation Safety Board of Canada suggested in a recent report.

“Tug and barge operations are currently not required to operate under [safety management systems] despite the fact that the combined size and tonnage of the vessels may be similar to that of a conventional cargo-carrying vessel,” TSB said in an investigation report released May 10. “The risks associated with such an operation can be greater given the complexities of connecting and operating the tug-barge combinations.”

TSB, a separate organization from Transport Canada, made that comment in a report on an incident March 2, 2016 off the coast of British Columbia. At 5:30 p.m. that day, the H.M. Scout – a 12-metre-long tug boat – left Victoria, en route to Bamberton, B.C. The Scout was towing two barges.

The Barge Blue Horizon near Clover Point British Columbia. Photo courtesy of the Transportation Safety Board of Canada

“During the passage, the tug encountered severe weather,” TSB said in its report. “The tow line between the barges parted.”

There were no injuries.

The 53-metre long barge HM Blue Horizon, which was carrying scrap construction materials and piles from a dock, grounded near Clover Point. The HM Tacoma, a 46-metre-long barge carrying lifting equipment and construction equipment, grounded near Finlayson Point.

The investigation “determined that inadequate towing equipment was used, which allowed the first barge to break free from the tow,” TSB said in its press release May 10.

TSB recommended in 2004 that Transport Canada “take steps to ensure that small passenger vessel enterprises have a safety management system.” At the time, TSB released its investigation report into the sinking in 2002 of the Lady Duck an amphibious passenger in the Ottawa River near the Hull, Quebec marina. Four passengers on the Lady Duck drowned.

In its report on the March, 2016 incident involving the Blue Horizon and Tacoma barges, TBS stated that neither WorkSafeBC nor Transport Canada “has an inspection program in place to routinely check that owners and operators of tugs less than 15 (gross tons) are complying with safety-critical regulations.”

TSB, a separate organization from Transport Canada. TSB investigates incidents involving aviation, railways, marine and pipelines. TSB reports directly to Parliament through the Leader of the Government in the House of Commons.

In the incident involving the Scout, Tacoma and Blue Horizon, TSB made seven findings as to causes and to contributing factors. Among them was that the “tug and tow encountered the forecasted gale-force winds and rough sea conditions, and the combined forces of these movements caused the ropes between the barges to part; the HM Blue Horizon drifted free and went aground.”

TSB also made six findings as to risk.

“If tugs with a gross tonnage of less than 15 are not subject to adequate regulatory oversight to ensure compliance with regulations, there is a risk that shortcomings in operations will go unresolved,” TSB said. It added that if Transport Canada “does not provide easily understandable standards and guidance to assist towing vessel owners and operators to ensure the adequacy of their towing arrangement and the condition of their towing equipment, including the selection of tow ropes, there is an increased risk of the towing equipment failing, resulting in the loss of tow.”

Safety management and oversight is one issue on TSB’s latest watch list, announced Oct. 31, 2016.

“Safety management systems have not yet been mandated in all sectors of the transportation industry,” stated Kathy Fox, chair of the TSB, in a press release in October, 2016.

In August of that year, TSB said it has “been calling” on Transport Canada “to implement regulations requiring all operators in the aviation industry to have formal safety management processes, and for TC to oversee these companies’ safety management processes.”

At the time, TSB released an investigation report into an incident in 2013 when a King Air ran out of fuel and conducted an emergency landing near St-Mathieu-de-Beloeil, Quebec airport. Four people had minor injuries.

“The aircraft was extensively damaged, and the four occupants sustained minor injuries,” TSB said at the time.

In its investigation into that incident, TSB found that the weight-and-balance form for the King Air “showed that there were 580 pounds of fuel at the time of departure” when in fact there was really about 220 pounds of fuel.

In November, 2015, TSB released a report into a fire in 2014 on the La Relève II sightseeing vessel. That fire sent two passengers to the hospital. La Relève II did not have an SMS nor was it required to have one, TSB said at the time.

In its 2004 report on the drowning of four passengers on the Lady Duck, TSB reported that “the picture that emerged was one of an organization pursuing minimal compliance with regulations rather than one seeking to minimize risk through all available means.”

Lady Duck was an amphibious passenger vehicle operated by Amphibious Lady Dive Inc. It sank June 23, 2002 in the Ottawa River near the Hull, Quebec marina. The Lady Duck was built with a converted Ford F-350 truck chassis and was used to take passengers on tours of the Ottawa area on land and water.

“Characteristics of the vehicle indicated a lack of awareness of marine standards of construction and maintenance, in that the vehicle was constructed with low freeboard, without watertight fittings at through-hull penetrations and with incorrectly installed bilge pumping arrangements,” TSB said in its report released in 2004.

The 2002 tragedy occurred about a year after the Lady Duck capsized and sank during a sightseeing tour. On June 30, 2001, all eight passengers and the tour guide were rescued after the Lady Duck Sank.

Safety management systems were also an issue with the July, 2013 railway accident that killed 47 in Lac-Mégantic, Quebec. In its investigation report into that derailment, released in August, 2014, TSB made 18 findings as to causes and contributing factors.

One finding was that Montreal Maine and Atlantic Railway’s “safety management system was missing key processes, and others were not being effectively used.” As a result, TSB stated MMA “did not have a fully functioning safety management system to effectively manage risk.”

MMA “had what one might call a less than ideal safety culture,” Don Mustard, senior investigator for rail and pipelines at TSB, said at an industry event in 2015.

“They weren’t exactly leaders in that area,” Mustard said of MMA in September, 2015 during the 42nd Annual Engineering Insurance Conference, which is part of the Canadian Boiler & Machinery Underwriters Association (CB&MUA).

“The company never assessed the risks of leaving a train carrying crude oil unattended, on a downhill grade, with no other precautions taken to prevent the train from running uncontrolled, other than the assumed correct application of the handbrakes,” Mustard said at the time.

“The TSB has repeatedly emphasized the advantages of safety management systems (SMS), an internationally recognized framework to allow companies to effectively manage risk and make operations safer,” TSB said May 10, 2017 in its release on the March accident involving the Blue Horizon and Tacoma barges. “Numerous recent investigations have found that companies have not managed their safety risks effectively. The solution will require all operators in the marine industry to have formal safety management processes, with effective oversight by TC.”