Transportation Safety Board of Canada - Departmental Performance Report for the period ending 31 March 2005

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Departmental Performance Report

2.5 Marine Sector

2.5.1 Annual Statistics

In 2004, 491 marine accidents were reported to the TSB, a decrease of 10% from the 2003 total of 547 and of 8% from the 1999-2003 average of 536. Marine fatalities totalled 28 in 2004, up from 17 in 2003 but equal to the 1999-2003 average.

Shipping accidents, which comprised 90% of marine accidents, reached a 29-year low of 441 in 2004, down from 481 in 2003 and the five-year average of 475. Half of all vessels involved in shipping accidents were fishing vessels. Accidents to persons aboard ship, which include falls, electrocution and other types of injuries requiring hospitalization, totalled 50 in 2004, a 24% decrease from the 2003 total of 66 and an 18% decrease from the five-year average of 61.

Marine activity for Canadian commercial non-fishing vessels increased by 8% from the 1999-2003 average, resulting in a 3% decrease in the accident rate from 3.1 to 3.0 accidents per 1,000 movements. Although marine activity for foreign commercial non-fishing vessels remained relatively unchanged compared to the 1999-2003 average, accidents decreased, yielding a 26% reduction in the accident rate from 1.9 to 1.4 accidents per 1,000 movements.

In 2004, shipping accidents resulted in 22 fatalities, up from 9 in 2003 and the five-year average of 15. Accidents aboard ship resulted in 6 fatalities, down from 8 in 2003 and the five-year average of 13.

Twenty-one vessels were reported lost in 2004, down from 38 in 2003 and the five-year average of 41.

In 2004, 246 marine incidents were reported in accordance with TSB mandatory reporting requirements. This represents a 10% increase from the 2003 total of 223 and a 16% increase from the five-year average of 212. This increase consisted mainly of mechanical failures and close-quarters situations.

Figure 3.

Marine Occurrences and Fatalities[D]f3

One indicator of marine transportation safety in Canada is the Canadian-flag shipping accident rate. Although this accident rate has increased from 2.8 accidents per 1,000 movements in 2003 to 3.0 in 2004, there has been a decrease over the past 10 years. This downward trend, however, is not statistically significant.

Figure 4.

Canadian-Flag Shipping Accident Rates[D]f4

2.5.2 Investigations

Sixteen new marine investigations were started in 2004-2005 and 21 investigations were completed. This represents an increase in both the investigations started and completed during the past two years. The increase is directly linked to the allocation of incremental resources to help address the backlog of work in progress. The average duration of completed investigations dropped to 881 days compared to 953 the year before, but remained significantly higher than in previous years. This is attributable to the concentrated efforts made to complete older cases. It is expected that the average time in process will drop further in future years, once the caseload is more current. A complete list of all marine investigations started and all marine reports released in 2004-2005 is available on the TSB website.

Table 9: Marine Productivity
	2000- 2001	2001- 2002	2002- 2003	2003- 2004	2004- 2005
Investigations started	23	16	13	14	16
Investigations completed	31	18	15	18	21
Average duration of completed investigations (number of days)	639	817	703	953	881
Recommendations	9	5	5	7	4
Safety advisories	6	12	7	6	9
Safety information letters	12	11	14	11	8
Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

One of the investigations completed this year, the sinking of the Lady Duck amphibious vehicle, required a much higher level of investment and effort than average. The Lady Duck took on water while on the Ottawa River during a combined land and waterborne tour. The vehicle sank rapidly by the bow in eight metres of water. Four of the 12 people on board were trapped inside the sinking vehicle and drowned. The investigation revealed that, amongst other things, the watertight integrity of the hull was compromised due to continuous leakage from the drive shaft bearing, shell plating fractures in way of the forward and after wheel wells, and where the front wheel steering linkage penetrated the hull. The TSB issued four safety recommendations as a result of this investigation (see section 2.5.4.1 for details).

2.5.3 Link to Resources Utilized

Table 10 provides a picture of the net cost to Canadians of marine investigations. Although net costs have increased slightly compared to the previous year, the average net cost per investigation completed has dropped. The numbers of investigations started and completed per investigator have both increased slightly compared to 2003-2004.

Table 10: Marine Resources
	2003-2004		2004-2005
	FTE	$000	FTE	$000
Actual costs - Marine Branch	26	2,878	27	2,975
Internal professional and communication services costs	16	2,060	19	2,090
Corporate Services costs	10	1,324	14	1,315
Contributions to employee benefit plans		770		803
Services received without charge		681		748
Net cost of Marine investigations	52	7,713	60	7,931


Indicators	2003-2004	2004-2005
Number of Marine investigators	22	23
Average net cost per investigation completed	$428,500	$377,667
Investigations started per investigator	0.64	0.70
Investigations completed per investigator	0.82	0.91

2.5.4 Safety Actions Taken

Four new marine safety recommendations were issued in 2004-2005. To date, safety actions have been undertaken on three of these recommendations and an unsatisfactory response was received on the fourth one. The TSB has also completed an assessment of responses to marine recommendations issued in 2003-2004. The results of these assessments are contained in Appendix A.

2.5.4.1 Marine Recommendations Issued in 2004-2005

Ottawa River, Quebec - 23 June 2002 Sinking and Loss of Life - Passenger Vehicle Lady Duck		Report No. M02C0030
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN

M04-01
The Department of Transport take steps to ensure that small passenger vessel enterprises have a safety management system.	Transport Canada (TC) agrees with the intent of the recommendation. TC is reviewing the feasibility of implementing safety management systems for operators of Canadian domestic vessels and is supporting the voluntary adoption of such systems by domestic operators.	Satisfactory intent	The review is scheduled to be completed by mid-2005. If the results indicate that safety management systems are warranted and feasible for any given sector of the domestic marine industry, TC will in consultation with industry, determine the best approach to effectively implement such regulatory requirements.

M04-02
The Department of Transport expedite the development of a regulatory framework that is easily understood and applicable to all small passenger vessels and their operation.	TC agrees with the intent of the recommendation. The new Canada Shipping Act, 2001 and associated regulations are scheduled to come into force by the end of 2006. Several measures were taken by TC to facilitate the comprehension and application, by owners and operators, of small passenger vessel safety requirements; however, they had already been taken into consideration by the Board when its recommendation was issued.	Unsatisfactory	There is no indication that the development of a regulatory framework that is easily understood and applicable to all small passenger vessels and their operation will be expedited earlier than 2006.

M04-03
The Department of Transport ensure that small passenger vessels incorporate sufficient inherent buoyancy and/or other design features to permit safe, timely and unimpeded evacuation of passengers and crew in the event of an emergency.	TC agrees with the intent of the recommendation. TC commissioned a study on the design, construction and operation of the amphibious vehicles operating in Canada. TC will continue to promote and enforce existing requirements that aim to equip passengers and crew to respond quickly and effectively to emergencies.	Satisfactory intent	A February 2005 draft report of the study included 13 recommended ways to enhance the safety of amphibious vehicles. TC is examining the report and will share it with Canadian amphibious vessel operators to discuss and consider any future requirements.

M04-04
The National Search and Rescue Secretariat, in collaboration with local authorities and organizations, promote the establishment of a system to monitor distress calls and to effectively coordinate Search and Rescue responses to vessel emergency situations on the Ottawa River between Ottawa and Carillon.	NSS accepts and concurs with the recommendation. NSS will pursue meetings with the relevant authorities to implement the recommendation.	Satisfactory in part	A working group has been set up by NSS and meetings held with other authorities to review the monitoring of distress calls. However, the coordination of search and rescue has yet to be addressed.

2.5.4.2 Other Marine Safety Actions Taken

Canada submitted a paper entitled "Measures to Prevent Brittle Fracture in Ships" to the 48th Session of the International Maritime Organization Design and Equipment Sub-Committee. The paper brings attention to the risks to vessels constructed with steel of unqualified fracture toughness operating in cold water such as the North Atlantic and requests consideration of the development of a "goal-based" standard to ensure that steel vessels are constructed such that their side shells are of known toughness. The toughness of the steel would be adequate under all expected circumstances such that a reasonable damage tolerance could be predicted and relied upon.

The Canadian General Standards Board is considering an amendment to its current standard for a "Marine Abandonment Immersion Suit System" to emphasize, at the point of sale, that survivability depends upon the suit remaining watertight and that it must fit securely to prevent entry of water.

Transport Canada has indicated its intention to pursue an amendment to the Life Saving Equipment Regulations that all passenger vessels equipped with life rafts should have provision for such life rafts to float free in the event of a sinking.

Transport Canada and the St. Lawrence Seaway intend to establish a joint task force to address concerns associated with a number of incidents regarding tug and barge operations.

Transport Canada conducted visual inspections of the steering gears of two passenger hydrofoils, with a commitment to carry out further detailed inspections during the off-season.

Transport Canada will review with the owner of a passenger vessel the organization of the stowage area for adult and children life jackets to facilitate their distribution.

The owner of a small ro-ro ferry is looking at ways to better secure ferries to the dock when embarking and disembarking vehicles. Although not required by regulations to provide crowd control training, he has made preliminary arrangements with a nautical institute to do so, targeting on-board personnel.

Transport Canada intends to require persons who are assigned passenger safety-related duties on passenger and ro-ro passenger vessels (greater than 500 tons engaged in voyages beyond sheltered waters) to have successfully completed a training course in passenger ship safety management.

2.6 Pipeline Sector

2.6.1 Annual Statistics

Seven pipeline accidents were reported to the TSB in 2004, down from both the 2003 total and the 1999-2003 average of 21. All accidents in 2004 occurred at facilities such as pump stations, compressor stations and gas-processing plants. Pipeline activity is estimated to have increased by 4% over the previous year. The last fatal pipeline accident in the portion of the industry under federal jurisdiction occurred in 1988, and the last accident involving serious injury occurred in 2000.

In 2004, 70 pipeline incidents were reported in accordance with TSB mandatory reporting requirements, up from 38 in 2003 and from the five-year average of 37. Eighty-one percent of those incidents involved uncontained or uncontrolled release of small quantities of gas, oil and high-vapour-pressure products.

Figure 5.

Pipeline Occurrences[D]f5

One indicator of pipeline transportation safety in Canada is the pipeline accident rate. This rate decreased to 0.5 pipeline accidents per exajoule in 2004, down from 1.64 in 2003 and the 1999-2003 average of 1.72. The trend line also indicates a clear downward direction.

Figure 6.

Pipeline Accident Rates[D]f6

2.6.2 Investigations

There were no new pipeline investigations started in 2004-2005 and two investigations were completed. These investigations led to the identification of multiple safety concerns. The average duration of completed investigations has increased to 1,081 days, compared to 410 in 2002-2003. This is attributable to the complexity of the investigations completed and to the fact that one of the two pipeline investigator positions was vacant for the full year. A complete list of all pipeline reports released in 2004-2005 is available on the TSB website.

Table 11: Pipeline Productivity
	2000- 2001	2001- 2002	2002- 2003	2003- 2004	2004- 2005
Investigations started	3	1	2	0	0
Investigations completed	0	3	2	0	2
Average duration of completed investigations (number of days)	0	531	410	0	1,081
Recommendations	0	0	0	0	0
Safety advisories	0	2	0	0	0
Safety information letters	1	0	1	0	0
Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.6.3 Link to Resources Utilized

Table 12 provides a picture of the net cost to Canadians of pipeline investigations. The average cost per investigation completed is $264,000. No comparative cost data are available as no investigations were completed in 2003-2004.

Table 12: Pipeline Resources
	2003-2004		2004-2005
	FTE	$000	FTE	$000
Actual costs - Pipeline Branch	2	229	1	198
Internal professional and communication services costs	2	164	1	139
Corporate Services costs	1	105	1	88
Contributions to employee benefit plans		61		53
Services received without charge		54		50
Net cost of Pipeline investigations	5	613	3	528


Indicators	2003-2004	2004-2005
Number of Pipeline investigators	2	1
Average net cost per investigation completed	$0	$264,000
Investigations started per investigator	0.00	2.00
Investigations completed per investigator	0.00	2.00

2.6.4 Safety Actions Taken

No new pipeline safety recommendations were issued in 2004-2005. However, five pipeline safety concerns were issued.

Safety actions continue to be taken by industry based upon TSB safety information. For instance, the TSB investigated further to an explosion at the East Hereford Compressor Station on the Gazoduc TQM Inc. pipeline system. The investigation revealed that the current Canadian standards regarding sealing requirements for cables do not address safety issues associated with sealing cable ends against continuous pressure buildup. This led to the creation of a working group to amend the Canadian Electrical Code to address safety issues associated with sealing cable ends against continuous pressure buildup.

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Updated: 2005-11-01		Important Notices