Queen of the North - re-enactment and conclusions

In March of 2006 the Queen of the North, a BC Ferry, struck an island and sank. The route of the ferry was through channels those of you will be familiar with on your treks to and back from Alaska. The route is shown in the video which is approximately 45 minutes long.

I will make two comments then you can move onto the video. In the stress of the moment, the helmsman cannot turn off the autopilot, hold your judgement on that, what you will notice is that why she can't turn it off isn't addressed. In a follow up post I will get to that as addressed in the book "The Queen of the North Disaster - a Captain's story"written by Colin Henthorne.

Also hold judgement on radar use or non-use, again I will comment latter. And lastly, why wasn't there DSC on the bridge. VHF radio is used by many communities along the BC coast, particularly along the northern portion. Isolated home dwellings also use it as cell phone use in these areas is basically non-existent. Also there are VHF repeaters up and down our coast so the DSC would have been picked up.

Wow. That was an amazing investigation. Sad that 2 people had to die and even sadder is that we'll never learn what actually caused the accident.

I will comment further on what was in the video and what they left out. For example, a fishing boat or tug towing is mentioneed in the video but don't take that fact further, why mention it if its not important. In the safety investigation that boat which turns out to be a mystery boat, plays a bigger part in the disaster.

I just need time to go through parts of the book so I get an accurate rendition of material in it.

I remember when this happened and also remember seeing QOTN many times on the route to AK years ago. Really sad and it shows just how quickly things can go south if not paying attention. Sort of looks like No. 4 was shagging the girlfriend on watch. Been known to happen.
I know a fisherman who did the same thing some years ago, and piled up his boat on the rocks playing silly buggers with the cook!

Sadly those rumours didn't pan out, also the other rumour they were arguing on the bridge, high probability it wasn't true. I say sadly because the two crew members will be marked for the rest of their lives, even though it wasn't true.

Here is one item the video left out which I don't need to consult the book to verify, that boat the dispatcher told the Queen of the North officer about became the focus of his attention. The record shows his course was not straight as in the video (better tv I guess) but showed a number of alterations as the second officer was compensating for his estimation of where that boat was and where his ship was.

The second officer lost "situational awareness" as he focused on the distant boat. As we all know, boats even though proceeding straight can have a "skid" to starboard or port depending on wind, current, tide, combo of all and intensity. It appears he lost awareness, his ship was skidding sideways. This was revealed when the hard drive which contained the navigation history was studied.

And I can give you THE GOSSIP, NOT THE TRUTH, so readers beware. The gossip among BC Ferries employees was that the couple who died were most likely on an elevator trapped. When the safety recommendations came out and implemented by BC Ferries, one of them was better communications from the elevators to the bridge. So it sounds to me that BC Ferries also believed the rumours.

The only two people that know for sure kept quiet didn't they? We may never know what actually happened up there.


I thought it was the 4th officer on the bridge, while the 2nd was down eating. That's according to the video anyway.

Yes, my bad about the second and forth officer. You are correct.

The only thing readily apparent from this is simple. Nobody on watch in the wheelhouse was paying proper attention for whatever reason. Regardless all the other side issues, electronics, fatigue etc., there was 2 people on watch and their attentions were diverted elsewhere, or this would not have happened.

78puget, I agree with you about 97 %. Here's a mystery that doesn't make sense to me. The helms person on many ships only has the wheel, there are no MDF's including radar read out in front of them. This was the situation in the Queen of the North scenario.

In fact, I can give you an even more bizarre - to my mind - helm station location that wasn't that great. Many a decade ago I trained as a young Canadian Navy officer in Esquimalt BC (Victoria). My training ship was Chaudiere. The helm station in these destroyers were place amid and athwart ship, the center of the ship, a couple of decks down from the bridge.

I can understand the designers thinking, move the helm so that if the bridge is blown to smithereens you still have control over the ships steering. And it would have made sense to me if it had been a secondary steering station, but it wasn't, it was where the helmsman lived in a room that really was the size of a closet, large enough to hold the wheel and one person. If a friend dropped by to say hello, they had to stand in the door opening, no room inside. The only instrument was the compass mounted on a bulkhead close to the deckhead. All course instructions were piped down.

So we all take for granted as we use our helm, the plethora of electronics available to us. Why doesn't the helmsperson not have this same instrumentation in front of them as safety back. If this had been the case, I believe this accident wouldn't have happened. She would have seen the course deviation and responded appropriately informing the officer on the bridge.

My ship, an image of that class of Destroyer: https://www.google.com/search?sxsrf...687559&biw=1920&bih=937#imgrc=JJYvytPE6ugzcM:

Was there two people on the bridge with functioning eyeballs or not? No mystery here. Whomever was on the bridge, was not paying proper attention and the ship ran aground. No more complicated than that.

Watched the video earlier today. I think the cause was pretty clear. Shagging while on duty.

There was a known relationship between helmsman and officer on duty. And they missed a turn and never noticed it despite many, many indications that would have been present to an attentive crew. I’ve been through that area many times, and they forked up, big time, plain and
simple. The officer on duty did prison time, as deserved. And all others lost their jobs and probably carriers. Maybe a bit harsh on the captain, but the buck stops there, so owning it is part of the job.


Well done that they only lost two people.

rsn48 said:

In the stress of the moment, the helmsman cannot turn off the autopilot, hold your judgement on that, what you will notice is that why she can't turn it off isn't addressed.

Click to expand...

This was in fact mentioned in the video (37:10) “He asked her to do it and she was unfamiliar.” It was earlier stated the A/P was a new install.

TSB confirms QM1 was not versed in A/P usage.

TSB Queen of the North
Marine Investigation Report M06W0052 - Transportation Safety Board of Canada

The TSB also concluded QM1 and 4O were distracted but; “it is not known what they were doing; only what they were NOT doing.

I'm just being lazy, I have the book sitting here beside the computer but I haven't gone back in to read and do a short synopsis. What I can tell you, my boat with Garmin and latest radar, with simple AP is set up safer than what was on the Q of the N. Modifications added to past modifications made something simple not so simple.

One of my closest friends is a retired BC Ferry Captain. I was talking to him trying to decide between a joystick and a toggle switch to use with my bow thruster. He highly recommended a toggle switch. "Rick, when you have seconds to react in panic'd conditions, you want the quickest and easiest solution to a problem on the bridge of a ship or at the helm of your boat." I went with a toggle switch.

All the techie stuff is nothing but a distraction from the obvious and real cause of the incident, which is non attention to duty, plain and simple. If they had been paying attention with their eyeballs instead of something else.... this would not have happened, all the electronic issues are meaningless.

78puget-trawler said:

All the techie stuff is nothing but a distraction from the obvious and real cause of the incident, which is non attention to duty, plain and simple. If they had been paying attention with their eyeballs instead of something else.... this would not have happened, all the electronic issues are meaningless.

Click to expand...

While not paying attention may be the root cause, poor systems design can still allow a smaller mistake to cause a problem or accident. While better systems design may have been enough to prevent it given the same circumstances.

Smaller mistake?? LOL. It was huge. My dad used to tell me of dragging barges to AK thru the IP with nothing but a compass, a flashing sounder, a horn and his eyes, which weren't very good btw. No electronics can make up for not paying attention.
It was a failure of epic proportions and nothing is to blame but the watch standers.

There was a DSC VHF radio on the bridge but it was not used during the accident. Apparently forgotten during the mayhem and alarms happening after grounding. Would have helped locate the wreck site faster but probably not changed the outcome.

78puget-trawler said:

Smaller mistake?? LOL. It was huge. My dad used to tell me of dragging barges to AK thru the IP with nothing but a compass, a flashing sounder, a horn and his eyes, which weren't very good btw. No electronics can make up for not paying attention.
It was a failure of epic proportions and nothing is to blame but the watch standers.

Click to expand...

Yup, been guilty of that, inattention, myself. I was down in the galley fixing a sandwich when I should have been starting a slow course change. I ran back upstairs, hit the jog lever, and rolled the skipper out of his bunk.

I bet he was tickled pink right? LOL. Pulled similar stunts when working for WTB.

Transportation Safety Board investigation
https://www.tsb.gc.ca/eng/rapports-reports/marine/2006/m06w0052/m06w0052.html

Transportation Safety Board simulation
https://youtu.be/MC1GF95aPxk[/url]

So thanks for posting the safety investigation. I will high light some of the problems with the vessels set up. I have attended many safety seminars and one was on major disasters and why the occurred. Most big events almost always have more than one cause, in fact three or more major factors are usually at play. Such was the case in this disaster. Most think they are brilliant here on the forum saying not having situational awareness was the leading factor, and they would be right, but looking beyound that is also really necessary. And how electronics was set up, training after new installations, etc also came into play. Even us pleasure boaters can learn from this incident. For me as I noted earlier, it affected the decision as how I control my bow thruster.

First the moon phase that was occurring:

Wednesday, March 22, 2006
On this day the Moon was in a Third Quarter phase. Sometimes called a Last Quarter Moon, this phase occurs roughly 3 weeks after the New Moon when the earth is three quarter of the way through it's orbit around the earth.

Visibility was considered good, wind didn't appear to be an issue.

Electronic chart set up [This raises an issue I've never seen discussed here before on raster versus vector charts]

1.10.3 Electronic chart system setup on the Queen of the North
Unlike the electronic chart display and information systems (ECDIS) - for which monitors must meet strict international standards for factors such as brightness, contrast, and colour - the purchaser of an ECS system may use any monitor.

On the Queen of the North, some bridge officers on both shifts found the ECS display overly bright during the night watch. This problem is exacerbated when the system is displaying raster charts,Footnote33 because land is shown as yellow-orange in colour and water is shown in white, regardless of whether the ECS is in day or night display mode.Footnote34 As a result, raster charts are inherently brighter than vector charts when the system is in night mode.

To alleviate this, the crew in a previous season had placed a screen over the monitor. A rotary dimmer was later installed to let bridge officers dim the screen beyond the standard setup brightness option for the monitor, even if night-setting palettes had already been selected. Some officers had developed the practice of dimming the screen, using this dimmer, and brightening it only when they wanted to check their position.

At the time of the occurrence, the ECS was displaying a raster chart, and the display had been dimmed by the 4/O. In addition, the investigation revealed the following points regarding the setup of the ECS on board the vessel:

The chart portfolio for the areas being navigated by the Queen of the North was mostly in raster format.
The navigation-danger alarm was unavailable while the raster chart was loaded.
The cross-track alarm had been manually deactivated around the time of the refit.
The software was configured such that all alarm sounds were deactivated. As a result, active alarms would provide visual warning only.
To defend against the ad hoc modification of parameters, such as alarm settings, the system was provided with a password. However, this password was well known and easily accessible to any who wanted it. Furthermore, BC Ferries had no policies or procedures in place to define the desired configuration of the ECS safety features. This effectively left the system setup at the discretion of each operator.

The waypoint, cross-track, and navigation-danger alarm features available with the other electronic navigation equipment had not been set up or enabled.

This next issue was a biggy, the helmsman (woman) did not know how to turn off the autopilot. Nothing addresses what I am about to say but I think it was possible she had an idea of how to do it, but in the panic in the moments prior to the collision, that knowledge went out the window.

1.12 Steering-mode selector switch
The Queen of the North was in refit from January 2006 until 02 March 2006. Its steering system was modified, and the following items were modernized:

the steering wheel at the aft steering station
the steering-mode selector switch at the aft station
The new steering-mode selector switch, albeit a newer model, was for all intents and purposes physically the same as the original switch. However, the logic and the manner in which the steering system functioned were altered with the installation of the new steering-mode selector switch.

In situations where a replaced system is physically similar to the original system, but where changes have been made to the underlying logic of the system, usability issues may emerge. As a result of negative transfer,Footnote36 significant training can be required to overcome the automatic response associated with the original system logic. This can be particularly important in times of stress, where the original automatic response is evoked because of the physical similarity between the original system and the new system.

Throughout the refit, the C/O of the A watch had remained with the vessel. When the new steering-mode selector switch was installed, a procedure was developed for its use. The procedure and information on the functional characteristics of the new steering-mode selector switch were posted on a laminated sheet immediately aft of the steering wheel at the aft steering station. All deck crew of the A watch were familiarized with the operation of the new switch. The posted procedure did not highlight the fact that the rear steering station was no longer the "primary" station.

At the time of the handover, the C/O of the A watch informed the C/O of the B watch of the replaced switch and advised him of the instructions posted behind the aft steering station. Not all crew (including QM1) of the B watch were familiar with the changes in operation, nor with the rationale for the new system and procedure. The B watch's unfamiliarity with the changes in steering system functionality following the installation of the new steering-mode selector switch was demonstrated by the fact that, subsequent to the accident, various B watch deck crew provided investigators with four different explanations as to the interaction between the forward and aft steering station switches and which specific functions were available at various switch settings.

Following the change in watches, a number of crew members of the B watch challenged the new operational procedure. The master, in discussion with the crew and after testing the steering-mode selector switches en route, decided to use the steering selector system differently than the previous watch, and in a manner analogous to the original system. The B watch wanted the forward wheel to be active when the QM was at the forward station, and it was not active in the A watch system.

In developing their procedures, both the A watch and the B watch were attempting to maintain elements of the operation of the original steering system. However, the procedures for the original system and the procedures used by the A and B watches differed.

Table 1.Procedural differences for switching from autopilot to aft steering station
A Watch B Watch
Original Procedure QM moves the switch at the aft station
from FWD to AFT QM moves the switch at the aft station
from FWD to AFT
Procedure After Change Aft station switch pre-set to AFT

OOW moves the switch at the forward station from AUTO to WHEEL Aft station switch pre-set to FWD

QM moves the switch at the aft station from FWD to AFT

OOW moves the switch at the forward station from AUTO to WHEEL
In the original system and the B watch system, the QM would normally only be required to operate the steering-mode selector switch at the aft steering station.

Next issue: Missed course change

2.1.1 Missed course change
When undertaking routine tasks, it is possible for a distraction to cause a sequential step to be missed and for persons in such circumstances to believe that the missed step and those that follow have in fact been accomplished.Footnote69

In this instance, between the time the 4/O announced to MCTS that the vessel was approaching Sainty Point and the time the course change should have been made (3.5 minutes), the OOW's routine sequence of making a course change was interrupted by several events that were taking place simultaneously, including:

the 4/O and QM1 were engaged in a conversation of a personal nature;
the vessel was encountering a rapidly moving squall, causing reduced visibility; and
a visual alarm indicating a loss of target.
In dealing with the immediate requirement to identify the position of the lost target, combined with the effects of entering the squall, the 4/O was likely distracted at some point between logging the radio communication and carrying out the course change. As a result, he believed he had called for and verified the course alteration.

In addition, the ECS display was dimmed and the audible alarms had been deactivated, thereby negating any warning that may have been provided by the waypoint alarm. As a result of these combined factors, the vessel continued past Sainty Point and into Wright Sound without changing course.

This discussion continues:

Typically, the passage through Wright Sound from Sainty Point to the next course change at Point Cumming is about 27 minutes of travel across deep, open water with few hazards. Crews normally consider that part of the voyage to be less difficult, particularly compared with the upcoming, more complex legs of the Inside Passage. It was in anticipation of transiting Wright Sound that the 2/O took a lunch break, leaving the 4/O and QM1 alone on the bridge.

Having entered the less difficult portion of the voyage through Wright Sound and believing he had made the course alteration at Sainty Point, the 4/O did not monitor the vessel's progress and failed to determine that the vessel was on an improper course.

The setup of the navigational equipment hampered effective monitoring, including:

The brightness on the ECS monitor had been turned down such that the display could not be read.
The ECS cross-track alarm, which would have alerted the crew to any substantial deviation, was turned off.
The navigation-danger alarm on the ECS, which could have indicated the close proximity of Gil Island, was unavailable because a raster chart was loaded.
Alarms available with other electronic navigational equipment (for example, radars) were not set up or enabled.
As well, a number of basic principles of safe navigationFootnote70 were not observed by the bridge team:

verifying the course after Sainty Point;
reducing speed when the vessel encountered an area of reduced visibility;
calling the senior OOW or the master to the bridge when visibility became reduced and the radar target (Lone Star) was lost;
maintaining an effective lookout;
posting a dedicated lookout during a time of restricted visibility;
communicating with the target vessel;
locating and identifying the navigational lights at Point Cumming, Cape Farewell, and Sainty Point;
monitoring the vessel's progress visually, via radar and with the ECS;
frequent plotting to determine the vessel's position; and
maintaining appropriate bridge team composition.
Many of these practices would have assisted in keeping the vessel on course or provided the cues necessary to determine that the vessel was not on course.

The TSB examined a number of plausible scenarios. In the absence of objective data, such as from a VDR, the investigation was unable to explain why the 4/O and QM1 did not follow basic watchkeeping practices so as to keep the vessel on course - nor why the 4/O failed to detect the vessel's improper course for up to 14 minutes.

The TSB rejects the suggestion that QM1 was alone on the bridge in the time leading up to the grounding. The preponderance of evidence leads to the conclusion that the 4/O and QM1 were both on the bridge throughout this period.

2.1.3 Striking sequence
When an individual's mental model of a situation differs from the actual, there is a period where contradictory information is rejected, followed by one where it is recognized that the mental model is incorrect and the individual or crew will need to work to reconcile the new information to form a more accurate picture. It is often only when very salient contradictory information is presented that they can realign their mental model.Footnote71

It is not known exactly when the 4/O began to be aware that the vessel was off course. However, approximately one minute before the striking, something prompted the 4/O to approach the window, and to move between there and the radar before subsequently ordering a course alteration to 109°, which would bring the vessel to a course for Point Cumming. As QM1 stood up and moved to alter course, both crew members saw trees ahead. The 4/O, now at the aft steering station, then gave the order to switch to hand-steering. This order was not complied with because QM1 was unfamiliar with the switch at the forward station.

Analysis of the DGPS data recorded by the ECS data logs indicates that, during the final 30 seconds before the striking, the vessel's straight-line course changed by about six degrees to port. It could not be determined whether this course change resulted from the action of the QM1 at the autopilot or if the 4/O made the switch to manual steering and applied moderate helm. Interaction forces between the hull and the steep sides of the island may also have influenced the vessel's motion in those final seconds. Regardless, there is no indication that aggressive evasive action was taken, and indeed any action taken by the crew was too little too late to prevent the vessel from striking Gil Island.

This next one is a biggy and makes me wonder how pathetic is BC Ferry training. Before you go all out with a "feeling of superiority - you'd never be this stupid," how many here have radar and have rarely used it, don't really know how to use it, don't think they really need to know it and have never used silly things like a proximity alarm.

This guy didn't need to have his proximity warning on, you will notice he does have radar:


2.5 Navigation equipment alarm features
Analysis of the information obtained from the recovered ECS indicates that the system was functioning within its set parameters. However, the lack of policies and procedures to manage the configuration of the system meant that important safety features (alarms) that could have alerted the crew had been either deactivated or silenced. Additionally, the display had been dimmed in response to the overly bright monitor and raster charts. As such, the possibility of receiving a visual warning was also negated. Furthermore, alarm features available with other electronic navigation equipment were not set up or enabled.

The navigation equipment, therefore, was not set up to take full advantage of the available safety features and, as a result, the warnings that could have been provided with respect to the developing dangerous situation were not provided.

And finally some of the findings. Note I have only highlighted some of the issues that I think pertinent, there were other issues. My question as a person living on an Island is - how much tighter have the made the training and safety issues involved in this disaster scenario?

3.1 Findings as to causes and contributing factors
The fourth officer (4/O) did not order the required course change at the Sainty Point waypoint.
Various distractions likely contributed to the 4/O's failure to order the course change. Furthermore, believing that the course change had been made, the next course change was not expected for approximately 27 minutes.
For the 14 minutes after the missed course change, the 4/O did not adhere to sound watchkeeping practices and failed to detect the vessel's improper course.
When the 4/O became aware that the vessel was off course, the action taken was too little too late to prevent the vessel from striking Gil Island.
The navigation equipment was not set up to take full advantage of the available safety features and was therefore ineffective in providing a warning of the developing dangerous situation.
The composition of the bridge watch lacked an appropriately certified third person. This reduced the defences and made it more likely that the missed course change would go undetected.
The working environment on the bridge of the Queen of the North was less than formal, and the accepted principles of navigation safety were not consistently or rigorously applied. Unsafe navigation practices persisted which, in this occurrence, contributed to the loss of situational awareness by the bridge team.
No accurate head count of passengers and crew was taken before abandoning the vessel, thus precluding a focused search for missing persons at that time.

If you want to say that there were other issues, sure I buy that. But none of those would have become issues if everyone was doing their job with their own eyeballs and faculties. HUMAN ERROR.
Signed, one of the "brilliant" ones.

And a brilliant observation I say.

BC Ferries did an excellent job off "look over there" while management practices played a large part in sinking were not part of media frenzy.
Officers on northern routes starting with Queen of Prince Rupert in 1960's wanted extra officer on watch to cover breaks when underway...
4th officer, was Officer of the Watch, made many command errors and has death of 2 passengers, endangerment of survivors and loss of his ship on his conscious. To blame him solely for accident is ridiculous. This accident has been waiting for 40 years to occur. The ugly unsubstantiated rumor that circulates, is just crap. The bridge of ship underway is not private no matter the hour, crew members, come and go unannounced.
This is a company that still wants to reduce licensed crew.
After arm twisting Transport Canada and CCG, they were allowed to operate the new Salish class vessels with un-maned engine room.
https://www.timescolonist.com/news/...gine-room-safety-on-salish-vessels-1.23353999
Example of equipment change coupled with bridge management practices. Would another officer made a difference?
https://www.canada.ca/en/transporta...-on-the-spirit-of-vancouver-island-ferry.html
Lessons of QoN still have not penetrated...

For me the problems were not just insufficient crew, and I agree about the stupid rumours, but how modifications over other modifications were made creating small problems that became large problems in a crises when quick action was needed. And is that still going on?

If the gal at the helm had been able to get out of autopilot quickly, the accident may not have happened.