MARINE INVESTIGATION REPORT

M98W0045

SWAMPING WITH LOSS OF LIVES

WHALE-WATCHING PASSENGER BOAT
AOCEAN THUNDER@
OFF TOFINO, BRITISH COLUMBIA
22 MARCH 1998

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

Swamping with Loss of Lives
Whale-Watching Passenger Boat
AOCEAN THUNDER@
off Tofino, British Columbia
22 March 1998
Report Number M98W0045

Synopsis
The vessel, with three passengers and an operator on board, departed Tofino, British Columbia, on a three-hour
trip to watch marine life. All wore Acoverall PFD (personal flotation device) suits@; while the passengers= suits
were properly worn, the operator=s suit was partially zipped. After watching whales, the operator decided to
show the passengers marine life in the vicinity of Plover Reefs. While in that area, the boat was swamped and
broached by a large swell, which threw all the occupants into the turbulent water. The rapidity of the occurrence
precluded transmission of a Mayday message. When the boat did not arrive at its destination, the owner
initiated Search and Rescue action. Two passengers were rescued after about two hours. The operator and one
passenger lost their lives.
The Board determined that the AOCEAN THUNDER@ was swamped and rolled suddenly to a large angle,
throwing all occupants into the cold water. A factor contributing to the occurrence was that the operator did not
fully appreciate the conditions the boat would meet at the time of the accident in the turbulent waters in the
vicinity of reefs. Contributing to the loss of lives were: anxiety associated with sudden immersion in cold water,
the lack of effective communication equipment, and the absence of emergency (medium range) communication
equipment, which resulted in a delay in initiating a Search and Rescue response.

Ce rapport est galement disponible en franais.

TABLE OF CONTENTS

1.0 Factual Information .......................................................................................... 1

1.1

Particulars of the Vessel .............................................................................................................. 1

1.1.1

Description of the Vessel ............................................................................................................ 1

1.1.2

Stability of the Boat .................................................................................................................... 2

1.2

History of the Voyage ................................................................................................................. 2

1.3

Injuries to Persons ....................................................................................................................... 4

1.4

Damage ........................................................................................................................................ 4

1.4.1

Damage to the Boat ..................................................................................................................... 4

1.4.2

Damage to the Environment ....................................................................................................... 5

1.5

Certification ................................................................................................................................. 5

1.5.1

Vessel Certification ..................................................................................................................... 5

1.5.1.1

Transport Canada Regulatory Requirements and New Initiatives ............................................. 5

1.5.1.2

Industry Initiatives....................................................................................................................... 6

1.5.2

Personnel Certification ................................................................................................................ 6

1.6

Personnel History ........................................................................................................................ 7

1.7

Weather and Current Information ............................................................................................... 7

1.7.1

Weather Forecast ......................................................................................................................... 7

1.7.2

Current Information..................................................................................................................... 8

1.7.3

Cold Water Survival .................................................................................................................... 8

1.8

Search and Rescue Issues ............................................................................................................ 9

1.8.1

Sail Plan Monitoring ................................................................................................................... 9

1.8.2

Search and Rescue Operations .................................................................................................... 9

1.9

Life-saving Equipment .............................................................................................................. 10

1.10

Emergency Signalling Equipment............................................................................................. 10

1.11

Safety and Record Keeping....................................................................................................... 12

2.0 Analysis .......................................................................................................... 13

2.1

Impact of Weather in the Vicinity of the Occurrence .............................................................. 13

2.2

Capsizing vs. Swamping ........................................................................................................... 13

2.3

Decision to Operate the Boat .................................................................................................... 13

2.4

Small Boat Operation and Safety .............................................................................................. 13

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2.5

Factors Affecting Survival ........................................................................................................ 14

2.5.1

Loss of Lives ............................................................................................................................. 15

2.6

Lifejacket, Personal Flotation Devices (PFDs) and Survival ................................................... 15

2.6.1

PFDs with Inflatable Pillows/Collars and Inflatable Lifejackets ............................................. 16

2.6.2

Regulatory Overview ................................................................................................................ 16

2.7

Care, Maintenance and Inspection of PFDs.............................................................................. 17

2.8

Practice of Wearing Rain Gear Over Coverall PFD Suits ........................................................ 18

2.9

Reboarding the Vessel............................................................................................................... 18

2.10

Accessibility and Suitability of Emergency Signalling Equipment ......................................... 19

2.11

Survival and Marine Emergency Duties (MED) Training ....................................................... 19

2.12

Pre-departure Safety Briefings and Communications............................................................... 20

2.13

Regulatory Regime and Safety ................................................................................................. 20

2.13.1

Scope of Small Passenger Vessel Operations and Industry Standards..................................... 20

2.13.2

Self-imposed Local Industry Standards .................................................................................... 21

2.13.3

Dissemination of Safety Information ........................................................................................ 21

2.13.4

Federal Regulatory Initiatives ................................................................................................... 22

2.13.5

Provincial Initiatives ................................................................................................................. 22

2.13.6

Regulatory Overview and Safety .............................................................................................. 22

3.0 Conclusions .................................................................................................... 25

3.1

Findings ..................................................................................................................................... 25

3.2

Causes........................................................................................................................................ 26

4.0 Safety Action ................................................................................................. 27

4.1

Action Taken ............................................................................................................................. 27

4.1.1

Whale-Watching Industry Standards ........................................................................................ 27

4.1.2

Safety Concern Respecting Small Passenger Vessel Operations ............................................. 27

4.2

Action Required ........................................................................................................................ 28

5.0 Appendices
Appendix A - Sketch of the Occurrence Area ............................................................................................. 29
Appendix B - Photographs ........................................................................................................................... 31

iv

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Appendix C - Glossary ................................................................................................................................. 33

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vi

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FACTUAL INFORMATION

1.0

Factual Information

1.1

Particulars of the Vessel

AOCEAN THUNDER@

Licence Number

13K107700

Home Port

Tofino, B.C.

Flag

Canada

Type

rigid hull inflatable

Gross Tonnage

under five

Length

6.4 m

Breadth

2.5 m

Built

1994, New Westminster, B.C.

Propulsion

twin Mercury outboards, 135 horsepower each

Crew

Passengers

Owner

Ocean Pacific Whale Charters Ltd. doing business as Jamie=s

Whaling Station
Tofino, B.C.

1.1.1

Description of the Vessel

The boat is an extended version of a ATitan@ class 5.5 m, designed by a naval architect in Vancouver, B.C. The
deep AV@ aluminium hull with longitudinal stiffeners, watertight compartments and modular fuel tank is
designed to withstand rough conditions associated with whale watching on the west coast of Vancouver Island,
which is exposed to the Pacific Ocean swell. The deck is self-draining, with cable routing and a battery
compartment under deck. Two inflatable sponsons (chambers), one on either side, provide buoyancy and
stability to the boat. Attached to the chambers on the inboard side of the boat are grab lines, which provide
additional grip for the passengers. These grab lines do not extend to the waterline on the outside of the
inflatable chambers.

See Glossary at Appendix C for all abbreviations and acronyms.

Units of measurement in this report conform to International Maritime Organization standards or,
where there is no such standard, are expressed in the International System of units.

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On deck, four benches with tubular framing seat backs provide seating for 12 passengers. The seat backs also
provide hand holds for persons seated behind. There is no additional restraining device. Astern of the last bench
is a small wheel-house booth, which houses navigation equipment, steering and propulsion controls. The
operator stands in the booth, steering and navigating.
Mounted at the transom were two new Mercury outboard engines, with only about 60 hours of recorded running
time on them. Two throttles mounted in the wheel-house provided remote control for the engines. Each engine
was fitted with an emergency cut-off switch.

1.1.2

Stability of the Boat

The boat had never undergone a formal stability test, nor was one required. However, extensive sea trials were
conducted in the presence of the owner=s naval architect in Vancouver, to verify the boat=s performance and
seaworthiness.
Rigid hull inflatable (RHI) boats are widely used as rescue boats because of their good range of stability and
their seaworthiness in bad weather conditions. The AOCEAN THUNDER@ had a high degree of residual
stability such that it would return to the upright even from large angles of heel. This is depicted in a video
showing the boat undergoing sea trials while skimming over wave crests at high speed and undergoing a forced
roll.

1.2

History of the Voyage

3

On Sunday, March 22, three passengers were booked for the 1200 Pacific standard time (PST) departure to go
on a whale-watching trip from a prominent whaling station in Tofino. The trip was scheduled to last about three
hours. The boat arrived from the 0900 trip and began disembarking passengers. The investigation revealed that
the boarding passengers were made aware that, on the previous trip, the boat had been partially swamped while
transiting a channel and that some passengers had been frightened by the experience. The boat operator assured
the waiting passengers that it was safe to make the trip and instructed them on how to don the coverall personal
flotation device (PFD) suits (locally referred to as floater suits). No other safety information was provided.
All three passengers donned coverall PFD suits. The passengers tightened the ties around the ankles and wrists
and wore rain gear over the suit. The passengers observed that the operator had only donned his suit loosely and
did not zip it up fully, leaving part of his chest and head exposed. The boat then departed from the wharf at
1215.
The operator steered the boat through the myriad channels forming Clayoquot Sound to the open Pacific Ocean
where he slowed down upon encountering heavy, confused swells in the vicinity of reefs known as the La Croix
Group, Foam Reefs and Plover Reefs. The passengers then spent about half an hour looking at whales before
the operator decided to show them some marine life in the vicinity of Plover Reefs.
3

All times are PST (Coordinated Universal Time minus eight hours) unless otherwise stated.

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FACTUAL INFORMATION

The area consists of numerous reefs with white water around them. The waters were turbulent and the sea and
swell were confused. As the boat made its way through the turbulent waters near the reefs and the operator
negotiated a channel between rocks, a wave from the stern swamped the boat. Immediately thereafter, the boat
was broached (broadsided) and another large swell wave struck the boat from the port side. This raised the port
side to a near vertical angle and then the wave broke over the boat. The suddenness of the roll to a large angle
and the breaking wave caused the passengers and the operator to be thrown over the starboard side and into the
sea. No Mayday message was transmitted.
There is conflicting information as to whether the boat capsized. One account was that the boat had rolled
suddenly to a large angle throwing all occupants overboard.
The operator and two passengers, one male and one female, found themselves together in the turbulent waters.
They could not see the boat, which had drifted away from them. The male passenger, who was a non-swimmer,
panicked and was soon lost. His body was recovered later.
The operator cast off his boots and floated with the surviving passenger, providing encouragement, and advised
her not to go close to the rocks. After more than an hour, the operator was observed to be getting cold and
lapsing into bouts of unconsciousness. The surviving passenger (from this group of three) then saw the boat,
which was upright and had drifted within sight. She swam towards the boat and hung onto it. By now, she was
weak and her attempts to board the boat were unsuccessful. When she saw a rescue plane overhead, she found
the strength to board the boat and was rescued by a vessel that had been directed to the area by the search
plane. The operator=s body was recovered from the water nearby.
Meanwhile, the third passenger, who was also thrown off the boat, found herself carried some distance away
from the group of three and alone in a lagoon of calmer water. She could not see the others or the boat. She
floated, without exerting herself, with her face up; after an hour, she drifted off into unconsciousness. She was
rescued sometime later.

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1.3

Injuries to Persons
Crew

Passengers

Others

Total

Fatal

Missing

Serious

Minor/None

Total

The two female survivors and the operator were swimmers, while the male passenger was a non-swimmer. The
male passenger and the operator lost their lives due to drowning.
When rescued, the survivor who had made her way back to the boat was suffering from mild hypothermia. She
was treated at a local hospital and later released.
When the rescuers found the other female passenger, who was unconscious, she was suffering from severe
hypothermiaCthere was no pulse and her body temperature was low. Artificial respiration was begun and she
was revived. She was rushed to the hospital in Tofino where she was admitted and treated; she was released a
few days later.

1.4

Damage

1.4.1

Damage to the Boat

Upon recovery, an examination of the boat revealed, amongst others, the following:
$
$

The throttles of both engines were found set at the half-ahead position.
The port engine had a smashed lower cowling and a cracked upper cowling, its air filter was found
soaked with water, and water was found on top of the air intake throttle plates. The number four
cylinder was full of water and, in the other cylinders, there was indication of water on the spark
plugs.
The starboard engine was tilted up past its limit. There was damage to the cowling and the starter
solenoid battery connection had deposits of green verdigris corrosion. Water was found throughout
the cowling. All cylinders showed signs of water ingestion and cranking the engine expelled water
from the spark plug holes.
The tachometers, port hour meter, very high frequency (VHF) radio, Global Positioning System
(GPS) and radar were found to be damaged by sea water; however, all other instruments and wiring
on the main instrument panel were functional. The ignition safety cut-off lanyard was missing.

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FACTUAL INFORMATION

$
$

The battery connections were green and corroded.

The operator=s cabin window pane was broken, and scratches and scuffs were found on the port side
of the hull. On top of the operator=s cabin, the radar dome, the antenna and lights were intact.

1.4.2

Damage to the Environment

There was no pollution as a result of the accident.

1.5

Certification

1.5.1

Vessel Certification

1.5.1.1

Transport Canada Regulatory Requirements and New Initiatives

Currently, a vessel under five gross tons and carrying 12 or fewer passengers is not required by the regulations
made pursuant to the Canada Shipping Act to be inspected by Transport Canada Marine Safety (TCMS).
At the time of the occurrence, Transport Canada (TC), in conjunction with industry stakeholders, was reviewing
the Construction Standards for Small Vessels (TP 1332E). For the purposes of inspection of small vessels, be
they fishing vessels or passenger vessels, it is the intention of TC to raise the tonnage limit of uninspected
4
passenger vessels to 15 gross tons. The proposed standards are divided into two segments for application: one
for commercial vessels and the other for pleasure craft. The standards are nearing the final stages; however,
there is resistance from the stakeholders to incorporate minimum stability criteria for small vessel commercial
operations. Following the development of the construction standards, additional initiatives addressing crew
certification, safety equipment carriage requirements, and voyage limitations will be developed.
Currently, no construction standard exists for RHIs used for carrying passengers and engaged in operations
similar to whale watching, which tend to be operated by a single person and make trips in exposed areas of
open waters. However, a TC standard entitled Standards for Rescue Boats
5
(TP 7322E) does exist for RHIs used as Arescue boats.@ These rescue boats, also referred to as Afast rescue
craft,@ are designed for use in rough weather conditions similar to those found on the west coast of Vancouver
Island. The standards require, in part, that:

Ministerial response to TSB Recommendation M96-04 (TSB report No. M93L0004)

The hull design of the AOCEAN THUNDER@ is similar to that of a rescue boat.

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FACTUAL INFORMATION

$
$
$

the boat meet stability criteria;

becketed lifelines be fitted inside and outside the boat, giving person(s) in the water a hand-hold so
they may stay with the boat; and
the boat be equipped with a boarding ladder to help persons boarding from the water.

1.5.1.2

Industry Initiatives

At the time of the occurrence, the British Columbia Whale Watching Society of Victoria Harbour, an industry
association, had been reviewing the operational practices for whale-watching boats with a view to establishing
standards. The proposed (local) industry standards, entitled Standards for Victoria Area Whale Watching
Companies Operating Vessels of Less Than 5 Gross Tons and Carrying 12 or Fewer Passengers, deal with
vessel construction, safety equipment, communication equipment, navigation equipment and operator
proficiency. These standards call for equipment in excess of that currently required under TC regulations, and
include the following:
$

that open boats should carry a full-length Minister of Transport (MOT/CCG)- approved flotation
suit for each adult and a correctly sized, approved lifejacket for each child. Suits and lifejackets
6
must be worn by passengers and crew;
that three additional flares be on board to fit the pocket of operator=s floater suit;
that open vessels operated by a single operator be fitted with an engine kill switch and
lanyard/emergency engine shut-off;
that the vessel be fitted with a waterproof VHF Channel 16 emergency transmitter with long-life
battery secured to a float and tethered to the boat, or an emergency position indicating radio beacon
(EPIRB) of a type suitable to the boat=s activity and operating range (manually activated);
that an emergency calling decal with Mayday instructions be on board for the benefit of persons
other than the operator; and
that the vessel be fitted with a GPS for navigation.

1.5.2

Personnel Certification

$
$
$

Currently, there is no regulatory requirement under the Canada Shipping Act for boats the size and type of the
AOCEAN THUNDER@Cunder five gross tons and carrying 12 or fewer passengersCto have their operators
certificated. However, joint new initiatives currently under consideration by the industry and TC will address
the marine qualification and certification requirements.
In this instance, the operator of the AOCEAN THUNDER@ had a valid Certificate of Competency as Master of
Small Passenger Craft and a certificate to operate temporarily as an Engineer on two of the larger vessels
operated by the same company. He had also successfully completed courses in Simulated Electronic Navigation
I (which gives training in electronic navigation aids and radar), A1 Marine Emergency Duties (MED), Standard
6

TC=s participation in formation of the standards should result in proper terminology being used in the
final standard.

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FACTUAL INFORMATION

First Aid, Radiotelephone Operator=s Restricted Certificate (Maritime), Open Water Dive certification and Flat
Water Canoeing.
Of the three passengers, the two who survived had spent some time with recreational water craft, but none had
any formal training.

1.6

Personnel History

The operator of the vessel had been employed by the company for just over a year. His experience included two
year=s service as a deckhand on larger vessels at a different location in British Columbia and varied experience
in the outdoor recreation industry. He underwent the employer-sponsored training program, which comprised a
training course conducted by a local company and hands-on training and familiarization of the area by working
with other operators. Following an evaluation of his performance, he was employed as an operator of the
AOCEAN THUNDER@. The operator had made many trips in the vicinity of Plover Reefs.
His daily schedule varied depending on the number of trips that were required to be made. Generally, in the
peak tourist season, the day started with the morning trip at 0900 and ended before sunset after the third trip.

1.7

Weather and Current Information

1.7.1

Weather Forecast

The three-day weather forecast for the west coast of Vancouver Island issued by Environment Canada at 0624,
Saturday, March 21, included a gale warning. The forecast predicted a fairly intense system crossing the coast
on Saturday, bringing rain and wind. This would give way to cool unstable air and showers on Sunday, March
22, followed by another frontal system which would bring more rain and wind on Monday, March 23.
The 1030 forecast on Sunday, March 22, called for light winds rising to easterly, 15 to 20 knots (kn) overnight
and 20 to 30 kn on Monday morning. The skies were predicted to be mainly cloudy, with a few showers and 3
m to 4 m seas. The outlook was for strong to gale force winds.
At the time of the occurrence, the weather at the La Perouse weather buoy, south-west of Tofino, recorded wind
speeds of 10 kn, significant wave height of about 3 m to 4 m, and air and surface temperatures of 11.5C.
Reportedly, information from other vessels in the area indicated that the morning weather had moderated in the
afternoon.
On the evening of March 23, while the investigation into this occurrence was in progress, a frontal system
passed over Tofino cutting off power supply to most of the city. The severity of the system confirmed the
accuracy of the gale warning in the weather report.

1.7.2

Current Information

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FACTUAL INFORMATION

The Sailing DirectionsCBritish Columbia Coast (South Portion) Volume 1 warns that the tidal streams are
accentuated by the in-draught into the large sounds, especially during strong winds from south-east and
south-west. Low water at Tofino, on March 22, was at 1355.

1.7.3

Cold Water Survival

The sea water temperature was 11.5C. Studies of cooling rates for an average adult holding still in ocean water
of 11.5C (wearing a standard lifejacket and light clothing) show a predicted survival time of about 1.8 hours.
Extra body fat can increase survival time.
The operator was 1.79 m tall and weighed approximately 97 kg. He was wearing a coverall PFD suit, which
was not fully zipped, over seasonal clothing. The passenger who lost his life was 1.86 m tall and weighed about
147 kg. He was a non-swimmer and was wearing a coverall PFD suit which was fully zipped over seasonal
clothing.
The donning of the suits protected those on board from the harsh environmental conditions. According to the
manufacturer of the suit, the thermal protection afforded by the suit had the potential to increase their survival
time between two to four times.

TRANSPORTATION SAFETY BOARD

FACTUAL INFORMATION

1.8

Search and Rescue Issues

1.8.1

Sail Plan Monitoring

The vessel=s sail plan was left with the company

dispatcher but there was no established regular
calling-in procedure to keep track of the boat=s progress.
Rather, the boat was in contact with the dispatcher and
other boats as required. Communication was by way of
a VHF radiotelephone (R/T). The dispatcher had
observed, and the operator was aware, that the radio
reception from the AOCEAN THUNDER@ on the day of
the occurrence was such that they were frequently out
of touch when the boat was in the open waters. There
was no known problem associated with VHF coverage
or general radio reception in the area. The general
practice of the operator was to notify the dispatcher
when the boat was on her return trip.

1.8.2

Search and Rescue Operations

When the boat did not call in or return at the scheduled time, the dispatcher contacted other vessels in the area
at about 1450 and the owner some 15 minutes later. When it was established that no other vessels had sighted
the AOCEAN THUNDER@ at that time, the owner called Tofino Air and an aircraft was tasked to search for the
AOCEAN THUNDER@. The owner also requested other vessels in the area to assist in the search, and contacted
the Tofino Lifeboat to apprise the Lifeboat of the overdue vessel. At 1541, the Tofino Lifeboat apprised the
Rescue Coordination Centre in Victoria of the situation, setting in motion an official Search and Rescue (SAR)
response. The search was conducted by two aircraft and nine surface craft. The Tofino Air fixed-wing aircraft
was on scene at 1557 and saw the boat drifting in the vicinity of Plover Reefs with a person sitting in it. Other
boats belonging to commercial operators and to the Canadian Coast Guard (CCG), which had joined the search,
rescued the passengers and retrieved bodies of the other persons who had been on board the AOCEAN
THUNDER@.

1.9

Life-saving Equipment
7

The AOCEAN THUNDER@ carried life-saving equipment for a vessel of its size and type. In lieu of the
lifejackets, a one-piece coverall PFD suit was carried for each person on board, and each passenger and the
7

Following the occurrence, Board of Steamship Inspection Decision No. 6587, dated 16 July 1998,
permitted Acoverall PFD suits@ approved as PFDs to be carried in lieu of standard lifejackets on
vessels engaged on whale-watching operationsCprovided that the full-length PFD suits are worn
throughout the voyage.

TRANSPORTATION SAFETY BOARD

FACTUAL INFORMATION

operator wore one. Some of the suits were constructed to CAN/CGSB-65.11-M88 (Personal Flotation Devices)
8
standards, and carried a marking of AAnti-Exposure Suits.@ While the passengers had fully zipped their suits,
the operator had not. The six flares required by the Small Vessel Regulations, and a medical kit, were stowed in
the bow locker. None of the survivors knew where this emergency equipment was located, nor were they
instructed in its use. The flares became inaccessible when the occupants of the boat were thrown into the water.

1.10

Emergency Signalling Equipment

Emergency signalling equipment (ESE) can be categorized as Aself-activated@ and Asurvivor-activated,@ as

9
outlined in the following table.

MEANS OF EMERGENCY SIGNALLING

TYPE

DAY

NIGHT

self-activated

- international orange colours

- canopy lights

survivor-activated

- smoke signals
- rocket flares
- mirrors
- whistles

- flashlight/lanterns
- rocket flares
- flares
- whistles

self-activated

- EPIRB

- EPIRB

survivor-activated

- portable radio

- portable radio

SHORT RANGE

LONG RANGE

With the exception of a standard lifejacket, the terminology for various suits constructed under
different standards has changed.

Performance Recommendations for Marine Lifesaving Systems, The Society of Naval Architects and
Marine Engineers, Technical and Research Report R-27, 1983.

10

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FACTUAL INFORMATION

Short range ESE is primarily targeted at other craft that are within visible range, to initiate rapid rescue
response. In long range ESE, radio equipment is used. The longer radio range permits transmissions to be
targeted at a wide range of shipboard and shore-based radio stations for a rapid SAR response.
The AOCEAN THUNDER@ carried neither an emergency (portable) VHF radio nor an EPIRB, nor is there a
regulatory requirement for the carriage of such equipment. The rapidity with which the occupants of the boat
were thrown into the water precluded the transmission of a Mayday message.
There are various EPIRBs available on the market; their differences in position accuracy can affect SAR
response time and, hence, the eventual success of a SAR mission. Care should be exercised in determining
which equipment is best suited for operations.
The CCG has undertaken an initiative to upgrade the VHF radio distress system by providing VHF Digital
Selective Calling (DSC) services. This new digital radio transmits (either by hand-held or fixed radio) an
automatic, digital, all stations distress alert signal on VHF Channel 70. This distress alert includes vessel
identification, position (as obtained from GPS) and nature of distress. Commercial vessels larger than 8 m will
be required to carry this VHF DSC radio, but smaller vessels may do so voluntarily.

TRANSPORTATION SAFETY BOARD

11

FACTUAL INFORMATION

1.11

Safety and Record Keeping

Safety meetings were held by the company on a periodic basis, with the last meeting having taken place some
two weeks before the occurrence. The investigation revealed that the coverall PFD suits were maintained and
that they were periodically inspected by the owner=s representative. There is no regulatory requirement to keep
a maintenance record for PFD suits; however, the owner kept a record.

12

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ANALYSIS

2.0

Analysis

2.1

Impact of Weather in the Vicinity of the Occurrence

The weather was reportedly clear with a light breeze at the onset of the whale-watching trip. However, the
confused swell from the previous frontal system, and a new swell from the oncoming frontal system, likely
produced breaking waves across the channel in Plover Reefs, creating turbulent waters. A visit to the site of the
occurrence showed that, even in relatively calm sea conditions, there was a lot of breaking surf and white water.

2.2

Capsizing vs. Swamping

The boat, when found, was upright and was boarded by one of the survivors. The lack of damage to the mast
head and cabin-top structure, and the absence of shorting of the electrical system in the cabin is consistent with
the boat having remained essentially upright after attaining the large angle of roll that threw all of the occupants
into the water.

2.3

Decision to Operate the Boat

The decision of whether or not to make a trip rests with both the owner and the operator. However, in this
occurrence, the owner took a hands-off approach to decision making.
In the past, the owner of the boat had considered cancelling a trip when there were fewer than four passengers
on board and weather conditions were adverse. In this instance, while the boat was operated in a lightly loaded
condition in turbulent waters, there was no intervention from the owner. The operator, the on-site decision
maker, has the discretion to cancel a trip due to operating conditions.
While the owner or operator would not knowingly compromise safety, the dynamics of deciding whether or not
to make a trip can be influenced by the nature of the business. In a commercial enterprise, cancelled bookings
reduce revenues. An employee=s decision to make a trip would be influenced by the impact such a decision
would have on business.

2.4

Small Boat Operation and Safety

In the marine environment, because various components that affect the safety of a vessel are interlinked, there is
often a trade-off between them. Every vessel, irrespective of its size, has operating limitations and, in any given
circumstance, a smaller vessel such as an RHI is more prone to risk elements than a larger vessel. It is,
therefore, essential that an operator appreciates the limitations in the operation of the vessel. In this instance,
although the operator was not

TRANSPORTATION SAFETY BOARD

13

ANALYSIS

required to hold any formal qualification, he was certificated to operate a small passenger vessel. Part of his
ability to operate the vessel was gained from his practical experience. The operator had completed many trips in
the area.
On a previous trip, the boat had experienced turbulent waters in the vicinity of the reefs and had been partially
swamped, which had scared some of the passengers. As the area is known for its marine life, the operator
elected to return to it on the afternoon trip.
In a competitive marine environment with seasonal operations, customer service and satisfaction are essential
for the success of small businesses such as whale-watching operations. Passengers expect to see whales and
marine life. The operator, therefore, may have felt obliged to meet these expectationsCwhile operating the
vessel safelyCto ensure customer satisfaction and further clientele base. Observations by passengers who sailed
on the AOCEAN THUNDER@ depicted the operator as having confidence in his abilities to handle the boat and
in the boat=s ability to withstand severe operational conditions.
The weather had moderated before the start of the afternoon trip, and the operator decided to revisit the area of
Plover Reefs. Although the weather had somewhat abated, swell in the vicinity of the reefs would continue.
Despite this, the operator elected to revisit Plover Reefs. This would suggest that, although the operator was
trained and had experience, he did not fully appreciate the conditions the vessel would meet in the vicinity of
the reefs at the time of the accident, and the impact that operation of the boat in such waters could have on
passenger safety.
The operator=s decision to revisit Plover Reefs may be attributable, in part, to the abating of the weather, the
desire to obtain customer satisfaction, and confidence that the vessel could be operated safely in such waters.

2.5

Factors Affecting Survival

Instances have been recorded where people who have no medical problem, who are in good health and good
spirits, and who are good swimmers, drown. Any person who enters water rapidly or from a height may become
disoriented. Individuals faced with a rapidly developing adverse situation will react in different ways. An
individual=s ability to survive when immersed in cold water is influenced by a number of factors, including:

14

TRANSPORTATION SAFETY BOARD

ANALYSIS

$
$
$

the psychological effect of entry into the water,

the prevailing weather conditions, and
10
the individual=s ability to prevent drowning.

2.5.1

Loss of Lives

In this instance, the deaths were attributable to drowning.

Passenger
Because the passengers= suits were fully zipped, they would have provided thermal protection, delayed the onset
of hypothermia, and increased the chance of survival. The male passenger was a non-swimmer and the water
was turbulent. This, together with the anxiety associated with entering the cold water, would have lowered his
ability to resist drowning.

Crew
It could not be established whether the operator=s suit was fully zipped at the time he entered water. However, it
is known that the operator discarded his boots after entering cold water. Improper donning of the suits,
exposure of the head, limbs, chest and groin area would make a person in the water more susceptible to
hypothermia. One of the survivors observed that the operator became progressively weaker and slipped into
unconsciousness. This would have made him more vulnerable to swallowing sea water in the turbulent seas.

2.6

Lifejacket, Personal Flotation Devices (PFDs) and Survival

The coverall PFD suits worn by the passengers and the operator of the AOCEAN THUNDER@ were approved
11
by the Department of Transport/CCG. Coverall PFD suits are designed to reduce thermal shock upon entry
into cold water, delay the onset of hypothermia, provide acceptable flotation and minimize the risk of drowning.
These coverall PFD suits use a wet suit principle; the survival time for a person wearing such a suit is shorter
than for a person wearing a dry (immersion) suit.

10

Transport Canada study, entitled Thermal Protection Performance of Personal Flotation Devices:
Assessment of Representative Types by J. S. Mayward of the University of Victoria.

11

Department of Fisheries and Oceans, the agency responsible for PFDs, has advised the industry that
certificates of approval for PFDs will no longer be issued. Instead, these devices are tested by the
Underwriters= Laboratories of Canada as part of a quality assurance program.

TRANSPORTATION SAFETY BOARD

15

ANALYSIS

Standard lifejackets, unlike PFDs, must meet rigid buoyancy standards and have the ability to turn an
12
unconscious person to a face-up position in the water, but they provide poor thermal protection in cold water.
Their design makes them cumbersome and, consequently, they are worn only in an emergency. In contrast,
PFDs, such as coverall PFD suits, provide good thermal protection in cold water and have reasonable flotation
capabilities. Information provided by manufacturers shows that the minimum survival time for a person wearing
a coverall PFD suit is more than twice the survival time afforded by a standard lifejacket, and can be as much
13
as eight times greater, depending on the water temperature.

2.6.1

PFDs with Inflatable Pillows/Collars and Inflatable Lifejackets

Vessels under five gross tons and carrying 12 or fewer passengers, are required to carry one standard lifejacket
or a small vessel lifejacket for each person on board.
Approved PFDs such as coverall PFD suits with inflatable pillows or collars, which are designed to keep the
wearer=s head above water to reduce the risk of drowning, are available on the market, but they do not have the
ability to turn a personCunconscious in the waterCto a face-up position. TC draft standards for inflatable
lifejackets that would meet International Convention for Safety of Life at Sea, 1974 (SOLAS) standards are in
the final stages of review. Meanwhile, CCG-approved inflatable PFDs that have the ability to turn a
personCunconscious in the waterCto a face-up position are available on the market, but these do not provide
thermal protection. There is an expectation that inflatable lifejackets or inflatable PFDs with similar capabilities
to that of a lifejacket could then be worn over the coverall PFD suits. This is not without some disadvantage
and care should be exercised in determining the type of personal life-saving equipment best suited for the
intended purpose. While the suits provide support/buoyancy for the whole body, standard lifejackets provide
support/buoyancy to the upper section of the body. Thus, the righting ability of any PFD or lifejacket, be it of a
standard approved type or an inflatable type, will be diminished when that item is worn over a coverall PFD
suit.

2.6.2

16

Regulatory Overview

12

Transport Canada study entitled Thermal Protection Performance of Personal Flotation Devices:
Assessment of Representative Types by J. S. Mayward of the University of Victoria.

13

Where comparisons are made with exposure suits, they are for the design and type used by the
occupants of the boat.

TRANSPORTATION SAFETY BOARD

ANALYSIS

Under the current regulatory regime, a coverall PFD suit is only an aid to keep a person afloat; it is not a
substitute for, nor is it intended to function as, an approved lifejacket. Neither the regulations in force at the
time of the occurrence nor the new Small Vessel Regulations that came into force on 31 May 1998 (some two
months following the occurrence) require thermal protection for passengersCa key component in survival in the
cold waters of Canada. To maximize survival time for a person in the water, all personal life-saving equipment
for use in Canadian waters ought to incorporate both requirements: thermal protection and inherent buoyancy.
This need has been highlighted, for over a decade, in a number of marine investigation reports. The Board,
concerned about the high risk to survival faced by personnel in the cold waters of Canada, recommended to TC
14
that small boats be required to carry anti-exposure work suits or immersion suits.
While the recommendation was made with respect to small fishing vessels, the need for the provision of
thermal protection applies equally to all small vessels, be they small fishing vessels, small passenger vessels or
pleasure craft. Despite this, the new regulations, such as Small Vessel Regulations, that affect small vessel
safety, do not address the recommendation.
It is the position of TCMS that, to impose a regulatory requirement to carry a specific device, especially in the
absence of a Arequired to wear rule,@ would be expensive and counter-productive. In TCMS=s opinion, the
industry has always maintained that, in addition to the regulatory minimum carriage requirements for passenger
vessels, additional equipment may be carried based on the operator=s assessment of Arisk.@ At the same time,
Board of Steamship Inspection Decision No. 6587 allows vessels engaged in whale watching to use full-length
PFD suits in lieu of the carriage requirement of approved standard lifejackets, provided that the suits are worn
by passengers and crew for the duration of the trip.

2.7

Care, Maintenance and Inspection of PFDs

PFDs, when submitted for approval, have excess buoyancy built into them according to a formula and a factor
of buoyancy retention of the particular foam material(s) used. In theory, after five years of occasional
recreational use, the device will be at its minimum design buoyancy. The useful life of a suit will depend upon
the frequency of its use and the wear and tear it receives. Hence, barring inspection, it is difficult to determine
its life expectancy.
Coverall PFD suits that are in frequent use and exposed to the elements (particularly sunlight) tend to degrade
over time. Currently, TC does not have any requirement for retesting or replacement of old, frequently used
PFDs. TC and manufacturers, however, recommend that the suits be tested annually, be it by the owners of the
suit or by a manufacturer=s accredited representative. TC recommends that owners test the device in a pool to
determine if it still provides adequate flotationCthe only practical method to determine the buoyancy loss after
each season. Care and maintenance information is available from the manufacturers.

14

TSB Recommendation M92-07 (report No. M90N5017)

TRANSPORTATION SAFETY BOARD

17

ANALYSIS

The onus is on the owners/operators of the boats to ensure that these suits are well maintained and suitable for
use. There is no requirement that they be inspected nor that maintenance records be kept by owners/operators.
In this instance, the owner had kept maintenance records of the coverall PFD suits.

2.8

Practice of Wearing Rain Gear Over Coverall PFD Suits

The practice of some whale-watching boat operators is to have waterproof oilskins or rain gear worn over the
coverall PFD suits. This is reportedly based on their belief that the older types of suits are not very water
resistant; however, the new suits are treated with a waterproof coating that will prevent water from seeping
through the material. As the passengers are exposed to spray and water when sitting in the open boat, this
practice has evolved to provide passengers with greater comfort.
The difficulty arises when persons are in the water with the coverall PFD/rain gear combination. The coverall
PFD suits have velcro closures at the cuffs and ankles which, when properly used, will reduce the ingress of
water. These suits work on a wet suit principle whereby water, which enters the suit from the extremities, upon
reaching body temperature reduces the further loss of body heat. The suits, however, make it difficult to
negotiate ladders or board vessels. The practice of donning rain gear over a coverall PFD suit has the potential
to trap water between the suit and the rain gear causing the latter to billow out or bunch up, thereby further
reducing the mobility of the wearer. The rain gear, particularly a full-length rain coat similar to the one worn by
one of the passengers, is more susceptible to the forces of current and underwater turbulence.

2.9

Reboarding the Vessel

The nature of a whale-watching trip is such that the boats are crewed by one person and operate in open waters.
As such, some of the requirements in operating these craft are similar to those pertaining to rescue boats.
A person in the water can delay the onset of hypothermia and have an increased chance of survival by
reboarding a boat. The design of most small RHI passenger vessels makes reboarding from the water difficult.
The problem is compounded by the absence of a boarding ladder and/or other arrangement that is readily
accessible from the waterCitems that are essential for persons who find themselves in the water. While rescue
boats/fast rescue craft require a boarding ladder, there is no such requirement for small passenger vessels. The
absence of a boarding ladder decreases the chances of survival for a person in the water.

18

TRANSPORTATION SAFETY BOARD

ANALYSIS

The AOCEAN THUNDER@ had grab lines, but they did not extend to the waterline on the outside. The primary
function of such grab lines would be to provide a hand-hold for persons in the water to stay alongside the boat.
However, even if the lines extended close to the waterline, it would be difficult for most passengers to climb
over the sponsons to board the boat.

2.10

Accessibility and Suitability of Emergency Signalling Equipment

Once the vessel broached and the occupants were thrown into the water, the onboard emergency signalling
equipment (which was limited to flares) could only have been accessed by climbing back into the swamped
vessel. The vessel, which had drifted away, only appeared close to the survivors a few minutes before the
rescue units came within sight, and the use of rain gear over the coverall PFD suits made reboarding the boat
difficult.
As flares have a limited visual range, they can only be used to draw attention of other traffic in the vicinity.
Thus, the effectiveness of the flares in seeking assistance would have been limited.
The boat carried a VHF R/T which was used to communicate with the company office ashore. On the day of
the occurrence, the VHF aboard the AOCEAN THUNDER@ was not functioning satisfactorily and problems
were experienced in receiving transmissions from the boat. There is no known problem associated with VHF
coverage of the area. Because the vessel was not required to carry an EPIRB or an emergency waterproof
portable radio, the only means of communication on board was lost when the occupants were suddenly thrown
into the water.
Valuable time was lost as SAR operations began only after the boat did not return to the base at its scheduled
time. The carriage of a waterproof portable buoyant distress radio on the person of the operator and secured by
a lanyard to a suitable point on his coverall PFD suit would have allowed the operator (or, if incapacitated,
another person) to broadcast an immediate distress call. In circumstances such as this occurrence, it is possible
that an EPIRB would not float free and it is unlikely that there would be an opportunity to activate it manually.
In cold Canadian waters, the success of a SAR mission depends upon the prompt notification of SAR
authorities (of vessel position and other relevant information) and the prompt tasking of SAR resources. The
lack of emergency communication equipment can result in the loss of valuable time and adversely affect the
success of a SAR mission.

2.11

Survival and Marine Emergency Duties (MED) Training

Although not required to by regulations, the operator of the AOCEAN THUNDER@ had undergone MED
training. When the occupants of the boat found themselves in the water, the operator showed leadership in the
face of adversity and impending danger. While one of the survivors drifted away, the one who was with the
operator received direction and words of encouragement. The actions of the operator and the eventual survival
of one of the passengers can, in part, be attributable to the MED training received by the operator. The survival
of some of the passengers shows the value of MED training. The Board, concerned that a lack of such training

TRANSPORTATION SAFETY BOARD

19

ANALYSIS

compromises the safety of personnel in emergency situations, has expressed concerns in a number of reports
15
and made recommendations to the Minister of Transport respecting MED training. It is TC=s position that the
proposed amendments to the Crewing Regulations will require basic MED training for all persons on vessels
over five gross tons. The responsibility for MED training of uncertificated crew rests with the owners and
16
masters of these vessels.

2.12

Pre-departure Safety Briefings and Communications

The safety information provided to the passengers was limited to the instructions on how to don the coverall
PFD suits. Although the vessel was manned by a single operator, an appropriate pre-departure safety briefing
(as per Ship Safety Bulletin 4/95) was not given, in that information was not provided on the stowage and use
of pyrotechnics, emergency distress communication procedures or action to be taken by the passengers in case
of a mishap. A lone operator may become incapacitated in an emergency; hence, to ensure the well-being of
passengers, an explanation of emergency procedures is essential in preparing passengers for emergency
situations and in reducing the negative consequences of accidents. The Board, concerned about the safety of
passengers, recommended to the Department of Transport that pre-departure safety instructions be made
17
mandatory for such operations. In response to the recommendation, TCMS issued Ship Safety Bulletin 4/95
as an interim safety measure to be followed by regulatory initiatives (as amendments to the Small Vessel
Regulations). The bulletin advised operators to provide pre-departure safety briefings to passengers, including
the essential actions that passengers need to take in an emergency and the various means at their disposal to
attract attention and seek assistance.
In this instance, the poor VHF R/T performance precluded periodic reporting. However, action was initiated
when the vessel failed to return to the base at the expected time.

2.13

Regulatory Regime and Safety

2.13.1

Scope of Small Passenger Vessel Operations and Industry Standards

There are some 30,000 to 40,000 small commercial vessels operating in Canada (excluding small fishing
vessels), many of which are engaged in carrying passengers. A large number of those carrying passengers are
engaged in sightseeing, whale watching, charters and sport fishing, using boats, other than those specifically
designed for passenger transportation, such as tow boats and small fishing vessels. The industry in British
Columbia is made up of a number of independent owners operating from urban centres and remote locations on
Vancouver Island, the islands in the Strait of Georgia and the mainland west coast of Canada. Similar
operations exist throughout Canada, including on the east coast, the St. Lawrence Seaway, and the Great Lakes.

20

15

TSB Recommendation M92-06 (TSB report No. M90N5017)

16

TSB report No. M93W0005

17

TSB Recommendation M96-05

TRANSPORTATION SAFETY BOARD

ANALYSIS

Whale watching, in particular, is a rapidly growing and loosely knit industry with a number of leaders who, in
view of the low tonnage/passenger requirements within the current regulatory regime, have implemented
carriage requirements that are in excess of the regulatory minimum. In Victoria, some 15 area companies are
signatory to the industry standards; however, the remainder, for the most part, do not belong to any such
18
parallel association.
While there are differing levels of safety among the operators across Canada, the voluntary standard developed
in Victoria can provide guidance elsewhere, with appropriate modifications for the type and area of operation.
However, in the diverse and far flung waters of the Canadian coastline, the influence of a voluntary association
is limited and localized; therefore, the dissemination and application of similar standards would benefit from the
support of a national agency or organization. In any event, until various standards are developed that address
the broad range of passenger vessel activity, passengers will be subject to varying levels of safety, depending
upon the safety culture of the owner/operator.

2.13.2

Self-imposed Local Industry Standards

Although not required by regulations, the industry (locally) has recognized the need for safety equipment that
provides thermal protection. Hence, some owners of whale-watching boats (including those of the AOCEAN
THUNDER@) provide coverall PFD suits, which are donned by all passengers and crew before a trip begins.
However, not all owners are members of the association/industry organization. Until such time as there is a
standard applied to all owners, only some (usually those who are members of industry organizations) will
assume the financial burden involved in the purchasing and maintenance required to operate safely. As a result,
there are differing levels of safety among operators. There is no system in place to make the public better aware
of these differences in safety standards.

2.13.3

Dissemination of Safety Information

TCMS uses Ship Safety Bulletins as a means to promote safety; the bulletins are widely distributed. However,
the investigation revealed that these bulletins do not always reach the target audience. In this case, some of the
small passenger vessel operators had no knowledge of

18

Standards for Victoria Area Whale Watching Companies Operating Vessels of Less Than 5 Gross
Tons and Carrying 12 or Fewer Passengers.

TRANSPORTATION SAFETY BOARD

21

ANALYSIS

the program or the existence of Ship Safety Bulletins. Further, these bulletins are not available on the TC web
site, and there is no alternative means available to access/receive this safety information.

2.13.4

Federal Regulatory Initiatives

Vessels under five gross tons and carrying 12 or fewer passengers, like the AOCEAN THUNDER@, are not
subject to inspection. Further, TC is currently amending the Canada Shipping Act to eliminate regulatory
inspection on all commercial vessels under 15 gross tons and carrying 12 or fewer passengers. Vessels entering
passenger service will not be required to report to TC, nor will an initial inspection be carried out. However, TC
will encourage operators to request a voluntary inspection of their vessels.

2.13.5

Provincial Initiatives

In the absence of mandatory inspection, there is a need to ensure that passengers are afforded a minimum level
of safety. That this is in the best interest of the tourism industry has been recognized by the province of
19
Quebec. In February 1998, Quebec passed a decree requiring all small passenger vessels under five gross tons
and carrying 12 or fewer passengers to be inspected (by a professional surveyor approved by TC) and to carry
at least one million dollars of liability insurance. The survey includes inspection of the vessel as well as
boarding and landing sites. The surveyor will issue a letter of compliance stipulating that the vessel meets TC
regulatory requirements and is appropriately equipped to operate a safe service (as described in the surveyor=s
report), and that the operating crew is knowledgeable to conduct the specified commercial activity in a specified
area/territory.
At the time of the occurrence, companies with the British Columbia Whale Watching Society of Victoria
Harbour had initiated action to set local industry standards specific to their type of operation. The initiative
covers a range of issues including: the carriage of safety, communication and navigation equipment; vessel
construction; and operator proficiency. Presently, the standards have been finalized and their implementation is
well underway.

2.13.6

Regulatory Overview and Safety

While inspection is not mandatory for all small passenger vessels, TCMS can inspect vessels that are signatory
to the voluntary standards. Most operators require a business license of some type, and the cooperation of city
licencing departments is essential. In addition, insurance and underwriters may require inspection/certification.
It is the position of TCMS that this type of licensing activity is an effective way to increase compliance and
TCMS will continue to encourage it as an alternative to prescriptive legislation. However, to date, there is no
formal arrangement among the local licensing systems, insurance/underwriters inspection requirements and
TCMS, nor is there in place a system similar to the one adopted in Quebec that will help ensure a level of
safety for all passengers.

19

22

Number 147B98, 4/2/98

TRANSPORTATION SAFETY BOARD

CONCLUSIONS

3.0

Conclusions

3.1

Findings

1.

The AOCEAN THUNDER@, in a lightly loaded condition, was being operated in breaking and
confused seas near Plover Reefs.

2.

In the past, the owner had considered cancelling trips when four or fewer passengers were booked
and the weather conditions were adverse; he did not do so on this occasion.

3.

An operator=s decision to cancel a trip can be influenced, in part, by the economic pressures of the
business.

4.

The operator=s decision to revisit the Plover Reefs may be attributable, in part, to the abating of the
weather, the desire to obtain customer satisfaction, and confidence that the vessel could be operated
safely in such waters.

5.

The operator may not have fully appreciated the persistence of the swell, or the conditions the
vessel would meet in the vicinity of the reefs.

6.

The AOCEAN THUNDER@ was swamped, rolled to a large angle and ejected its occupants, all of
whom were wearing coverall personal flotation device (PFD) suits, overboard into the sea.

7.

There was no established call-in procedure, and the pre-existing problem experienced with very
high frequency (VHF) transmissions from the boat precluded periodic radio contact with the
vessel=s base station ashore.

8.

The rapidity with which the occupants were thrown into the water precluded a Mayday transmission
from the vessel and the only means of communication was lost.

9.

The Search and Rescue (SAR) operation was initiated when the AOCEAN THUNDER@ failed to
return to its base at the scheduled time.

10.

The passenger who was a non-swimmer was seen to panic and to quickly drown. The operator,
whose coverall PFD suit was not properly closed at the time of boarding the boat, later succumbed
to hypothermia and drowned.

11.

The passenger who was successful in reboarding the vessel some time later was suffering from mild
hypothermia when rescued. The passenger who was rescued from the water, unconscious, was
suffering from severe hypothermia.
The regulatory regime does not include thermal protection criteria for personal life-saving
equipment for passengers or crew.

12.

24

TRANSPORTATION SAFETY BOARD

CONCLUSIONS

13.

Although not required to by regulations, all occupants of the boat were wearing coverall PFD suits
of approved quality, substantially increasing their chances of survival.

14.

Although not required to by regulations, there was a regime in place to record inspection results of
the life-saving equipment.

15.

A safety briefing was given to the passengers but it was limited to instructions in donning coverall
PFD suits. Information on other safety equipment and emergency procedures was not provided.

16.

The absence of a requirement for the carriage of an emergency position indicating radio beacon
(EPIRB) or an emergency VHF radio transmitter on the AOCEAN THUNDER@ may have precluded
a timely SAR response and so adversely affected the success of the SAR mission.

17.

The absence of a boarding ladder hindered access to the vessel, to the detriment of passenger and
crew safety; a ladder was not required by regulations.

18.

The survival of one of the passengers can be attributed, in part, to the operator=s Marine Emergency
Duties training. The survival of the passenger who was unconscious can be attributed to the prompt
first aid rendered by the rescuers.

19.

The province of Quebec and Transport Canada have reached a formal arrangement to provide a
level of safety for small passenger vessels under five gross tons and carrying 12 or fewer
passengers. However, there is no similar arrangement with any other province.

3.2

Causes

The AOCEAN THUNDER@ was swamped and rolled suddenly to a large angle, throwing all occupants into the
cold water. A factor contributing to the occurrence was that the operator did not fully appreciate the conditions
the boat would meet at the time of the accident in the turbulent waters in the vicinity of reefs. Contributing to
the loss of lives were: anxiety associated with sudden immersion in cold water, the lack of effective
communication equipment, and the absence of emergency (medium range) communication equipment, which
resulted in a delay in initiating a Search and Rescue response.

TRANSPORTATION SAFETY BOARD

25

SAFETY ACTION

4.0

Safety Action

4.1

Action Taken

4.1.1

Whale-Watching Industry Standards

Following the occurrence, and at the request of the industry, Board of Steamship Inspection Decision No. 6587,
dated 16 July 1998, permits Acoverall PFD suits@ approved as personal flotation device (PFDs) to be carried in
lieu of standard lifejackets on vessels engaged in whale-watching operations, provided they are worn
throughout the voyage.
Also, the draft Standards for Victoria Area Whale Watching Companies Operating Vessels of Less Than
5 Gross Tons and Carrying 12 or Fewer Passengers has undergone further revision to more accurately depict
the type of safety equipment required to be carried on board vessels engaged in whale-watching operations. The
final draft also contains a provision that Transport Canada (TC) has the authority to inspect vessels for
compliance with these standards and, upon request, to test operators for knowledge and proficiency.
Transport Canada Marine Safety (TCMS), in consultation with the industry, is in the process of developing new
national standards for all whale-watching vessels and is considering operator certification to apply to all vessels
carrying passengers.

4.1.2

Safety Concern Respecting Small Passenger Vessel Operations

Subsequent to this occurrence, the Board reviewed its past safety recommendations made as a result of similar
occurrences involving small commercial vessels to determine the extent to which deficiencies identified in these
20
recommendations are being addressed. While there has been some remedial action taken to improve the safety
of small passenger vessel operations, the Board is concerned that several deficiencies remain unaddressed; to
highlight this concern, the TSB placed the ASafety of Small Passenger Vessel Operations@ on its list of Key
Safety Issues in 1999. The Board will continue to closely monitor the action taken by TC to address the
deficiencies identified in the Board=s recommendations and, where deemed appropriate, will make further
recommendations.

20

26

A total of 11 recommendations identified safety deficiencies concerning small commercial vessels:

M94-01, M94-02, M94-04, M94-05 (all issued February 1994),
M94-13 (issued August 1996), and M96-01 to M96-05 (issued April 1996).

TRANSPORTATION SAFETY BOARD

SAFETY ACTION

4.2

Action Required

Dispensation is given to the whale-watching industry to permit carriage of Acoverall PFD suits@ in lieu of
lifejackets. However, persons on many small vessels (including small fishing vessels) are not afforded similar
protection; i.e. both thermal protection and flotation. With respect to small fishing vessels, while TC is
attempting to address this issue, no concrete measures have been instituted. The Board is concerned that,
because the current regulations do not reflect the need for thermal protection, mariners and passengers on small
vessels and small fishing vessels may be exposed to undue risk of hypothermia. The Board will continue to
monitor the life-saving carriage requirements with a view to ensuring that these take into consideration both
flotation and thermal protection capabilities, and thereby provide mariners and passengers a reasonable chance
of survival in cold Canadian waters.

This report concludes the Transportation Safety Board=s investigation into this occurrence. Consequently, the
Board authorized the release of this report on 01 March 2000.

TRANSPORTATION SAFETY BOARD

27

APPENDICES

Appendix A - Sketch of the Occurrence Area

28

TRANSPORTATION SAFETY BOARD

APPENDICES

Appendix B - Photographs

30

TRANSPORTATION SAFETY BOARD

APPENDICES

TRANSPORTATION SAFETY BOARD

31

APPENDICES

Appendix C - Glossary
B.C.
C
CCG
DSC
EPIRB
ESE
F
GPS
immersed clo

kg
kn
m
MED
MOT
PFD
PST
RHI
R/T
SAR
SOLAS
TC
TCMS
VHF

32

British Columbia
Celsius
Canadian Coast Guard
Digital Selective Calling
emergency position indicating radio beacon
emergency signalling equipment
Fahrenheit
Global Positioning System
Values which depict the level of thermal insulation a garment provides through the rate
at which heat is lost from the body, as well as the difference in temperature between
skin and water. Once these values have been determined, predictions can be made of
the rate at which a person=s body temperature will drop in cold water.
kilogram
knot
metre
Marine Emergency Duties
Minister of Transport
personal flotation device
Pacific standard time
rigid hull inflatable
radiotelephone
Search and Rescue
International Convention for Safety of Life at Sea, 1974
Transport Canada
Transport Canada Marine Safety
very high frequency
degree

TRANSPORTATION SAFETY BOARD