The Transportation Safety Board (TSB) says an inadequate risk assessment and supervision along with informal practices contributed to two BC Ferries crew members falling overboard during a safety drill in 2018.
It happened on Aug. 31, while the crew of the Spirit of Vancouver were conducting a rescue boat drill at Swartz Bay, ahead of an early-morning sailing.
The incident caused multiple sailing cancellations on one of BC Ferries’ busiest travel days of the year.
READ MORE: BC Ferries workers fall into water during rescue drill, leads to cancellations on major route
According to a TSB report released Friday, the vessel’s rescue boats had been replaced with new variants that were taller than the originals — but the vessel still had older davits (small cranes) sized to the original model.
“The changes to the system resulted in the brake release line being out of adjustment, and following a previous incident, some of the crew responsible for the launching and retrieval of the boats had developed an informal practice to compensate,” the report states.
The crew’s chief officer also had multiple simultaneous tasks to attend to, meaning that he was unable to supervise the drill, states the report. The coxswain who had taken over the officer in charge’s duties was engaged in his own duties and had a limited ability to supervise, it found.
“Without the chief officer or another deck officer present to supervise, the informal practice of compensating for the maladjusted brake release line allowed the line to snag while the rescue boat slewed out from the davits,” found the report.
“The snag created tension on the brake line, to the point that the davit arm brake released.”
The rescue boat then dropped suddenly, striking the edge of the ferry’s deck and tipping outward, knocking the crew members overboard.
One crew member was treated for minor injuries in the incident, while the rescue boat sustained minor damage.
The report concluded that BC Ferries had previously adopted a safety management system that complied with international standards, but that it had not identified safety hazards associated with changing the type of rescue boat in use.
The TSB said BC Ferries has since made changes to policies and procedures related to its rescue boats.
Global News has requested comment from BC Ferries.