TSB launches national investigation after report on P.E.I. ferry fire reveals safety gaps
Watchdog finds confusion over safety roles in MV Holiday Island fire
The Transportation Safety Board of Canada has released its final report into the July 2022 fire aboard the MV Holiday Island ferry off Prince Edward Island's coast, saying it will launch a national safety issue investigation on vessel fires and emergency response practices to lessen the impact of future incidents.
That investigation "opens the door to a national conversation on vessel fire safety to ensure that every person who steps aboard any vessel in Canada can do so with confidence that systems are in place to protect them," the board's chair, Yoan Marier, was quoted as saying in a news release.
The TSB's findings on the Holiday Island fire were presented during a news conference in Charlottetown, P.E.I., on Wednesday.
Among other things, the watchdog agency raised concerns about role confusion between Transport Canada and Northumberland Ferries Limited, the vessel's operator, when the fire broke out as the Holiday Island was approaching the dock in Wood Islands, on P.E.I.'s southeastern coast.
The report found that although Northumberland Ferries was responsible for operating the vessel, Transport Canada retained accountability, with the federal transport minister acting as the vessel's "authorized representative" — the person legally responsible for the ship's safety.
The report found that staff at both organizations were unclear about what the role of authorized representative entailed and who was ultimately responsible for key safety and oversight duties.
"The lack of clarity extended to critical areas such as operations, emergency repairs and oversight. Communications between the operator and Transport Canada were informal, and oversight of vessel maintenance and operations was limited," Marier said.
'There is still more to do'
Mark Wilson, president and CEO of Northumberland Ferries, said in a statement that the company welcomes the TSB's findings.
He said NFL has already taken 16 corrective actions to improve its performance in advance of the report's release.
"These actions included enhancing our emergency training, revising and updating procedures, and strengthening operational protocols," Wilson was quoted as saying in the statement.
"We recognize that there is still more to do and we will work with Transport Canada to ensure that the report's findings are implemented in a timely and effective fashion."
What happened aboard the Holiday Island?
The fire broke out in the ferry's engine room at around 11 a.m. AT on July 22, 2022, about an hour into the ferry's crossing from Caribou, N.S., to Wood Islands.
More than 200 people were evacuated from the vessel. No injuries were reported.
The 50-year-old ferry had been scheduled for replacement in 2027, but had to be scrapped early due to the extensive damage it suffered in the fire.
Étienne Séguin-Bertrand, the senior investigator and safety analyst with the TSB, said the age of the vessel was not a contributing factor in the blaze.
He said the fire began after a non-standard repair to the ferry's fuel injection system failed, causing fuel to spray onto hot engine parts and ignite.
The issue started with a small leak in the fuel rail of the main engine's injection system. The crew initially patched it with gasket material and consulted the manufacturer's representative while waiting for replacement parts, Séguin-Bertrand said.
"The repairs kept failing, so they kept applying further temporary repairs," he said.
"What is especially concerning in this case is that there was no reviewed risk assessment performed by the operator of the ferry to take into account the additional risks that were posed by the presence of those temporary repairs on board."
Long-standing issue
Marier noted this is not the first time the TSB has flagged concerns related to the authorized representative role.
"If authorized representatives do not have a clear understanding of the scope of their responsibilities with respect to safety, vessels may operate without the minimum defences provided by meeting the regulatory requirements, and critical safety obligations can be inadequately addressed or worse, overlooked," he said.
The Holiday Island fire was one of nearly 400 fires on commercial vessels reported to the TSB over the past decade. Since its inception 35 years ago, the board has issued nine safety concerns and 10 recommendations related to fire safety.
As a result of this latest investigation, the board has issued a formal recommendation calling on Transport Canada to provide detailed guidance for authorized representatives.
"This guidance should support authorized representatives in understanding and complying with applicable regulations, thereby reducing the risks of vessels and crews operating without the minimum safety defenses afforded by regulatory compliance," Marier said.
Do not mistake luck for emergency preparedness.— Yoan Marier, Transportation Safety Board of Canada
The investigation also found that the Holiday Island engine room's CO2 fire suppression unit was not initially activated due to unclear instructions.
Although the crew believed the system had engaged, the supression unit had not actually discharged. The delay allowed the fire to intensify.
"Additionally, the engine room had not fully been sealed. As a result, when the CO2 was finally released, it likely dispersed and allowed oxygen to continue entering the space. This reduced the suppression system's effectiveness, and the fire continued to burn." Séguin-Bertrand said.
Thanks to the efforts of the crew and first responders, the fire was contained to the ferry's engine room and did not spread further.
Marier noted the emergency response was ultimately successful, but said that was largely due to luck.
"The fire broke out when the vessel was near the terminal. It was daylight, the weather was manageable. The seas were calm. A modern evacuation system had been installed earlier that year, and help was nearby," he said.
"We've said it before, and we're saying it again: Do not mistake luck for emergency preparedness."
With files from Wayne Thibodeau