TORONTO - An investigation into a Toronto ferry crash that injured multiple people two years ago found several safety deficiencies, the Transportation Safety Board of Canada said Monday, noting the vessel's speed and a lack of training on emergency passenger management.
The Sam McBride ferry struck the dock while berthing at Toronto’s Jack Layton Ferry Terminal with six crew and approximately 910 passengers on board just after 5 p.m. on Aug. 20, 2022, resulting in approximately 20 passengers standing on or above the stairs being injured from losing their footing and falling.
The investigation made public Monday found that the ferry had completed eight crossings earlier that day, six of which were at full capacity and it was behind schedule, which is not unusual on a busy summer day.
Senior Investigator Étienne Séguin-Bertrand said the ferry was approaching the dock at a speed faster than on previous trips that day, and only one of the vessel’s two propellers was turning as it approached the dock, which was not enough to stop the ferry given the speed and distance from the dock.
He said the City of Toronto did not have written procedures to define a safe approach speed during docking.
"Decisions around docking speed were left to the discretion of the vessel master who may have been influenced by operational pressures such as passengers backlogs or running behind schedule," he said.
"Following this occurrence, the City of Toronto put in place documented procedures for berthing."
Investigators also said the ferry crew were not trained in emergency passenger management because it was not mandatory.
Séguin-Bertrand said the Sam McBride ferry was operating with only six crew members on board and the investigation determined there would not be enough crew members to respond if there had been a fire on board or a need to evacuate the vessel.
"Crew members would have to be in two places at once," he said. "Three crew members would be assigned to respond to the emergency leaving only three crew members to oversee the management of more than 900 passengers and possible evacuation of all people on board."
The board recommended that Transport Canada implement a requirement for crew members of all passenger vehicles to complete training in passenger safety management.
It also recommended Transport Canada implement a process to validate passenger vessel evacuation procedures.
In Canada, all passenger vessels are required to have emergency procedures that dictate how all passengers and crew will evacuate from a vessel within 30 minutes of an abandon ship signal, the board said.
"The investigation found that the ferry’s evacuation procedures were unrealistic, leaving only six crew members to manage over 900 passengers, while potentially completing multiple competing tasks at once throughout the vessel."
The Transportation Safety Board of Canada also called on Transport Canada make sure passenger vessels are keeping an accurate count of all passengers, including a separate count of children and infants.
"On the Sam McBride, counts were estimated and tracked using a hand-held tally counter; children, infants, and those who may require extra assistance were not counted separately," the board said.
"In the event of an emergency, it would be impossible to account for all passengers on board or ensure that there are an adequate number of appropriately sized life jackets available."
Investigators said the City of Toronto has increased the size of the Sam McBride’s crew to 13 since the 2022 crash and the city has also addressed some passenger safety issues, including updating pre-recorded safety briefings, adding additional signage, and warning passengers to not stand on the stairs while the vessel is moving.
This report by ºÚÁϳԹÏÍø was first published Aug. 19, 2024.
