VICTORIA - The Transportation Safety Board says informal practices and insufficient supervision contributed to two crew members falling overboard during an emergency drill on a BC Ferries vessel.
The crew members fell from the passenger ferry's rescue boat into the water below on Aug. 31, 2018, while the boat was being swung out during a drill at the Swartz Bay terminal in North Saanich, B.C.
Both members were retrieved from the water and taken to hospital, where one was found to have minor injuries.
The safety board says the rescue boats had recently been replaced with a heavier version, but the davits, which are cranes that project over the side of a ship, had not been changed.
As a result, it says the brake release line was out of adjustment and after a previous incident, some crew had developed an informal practice to compensate while launching and retrieving boats.
At the same time, the board says the chief officer was busy with other obligations so the coxswain of the rescue boat was in charge, but his ability to supervise was limited by his own active duties.
"Without the chief officer or another deck officer present to supervise, the informal practice of compensating for the maladjusted brake release line allowed the line to snag while the rescue boat slewed out from the davits," the report says.
"The snag created tension on the brake line, to the point that the david arm brake released."
The rescue boat dropped suddenly, hit the edge of the deck and tipped overboard, causing both crew members to fall in the water, it says.
Although BC Ferries had voluntarily adopted a safety management system, the system failed to identify hazards related to the change in rescue boats, the safety board concludes.
It says passenger and crew safety can be compromised when risk assessments, reporting non-conformities, emergency drill planning and valid checklists aren't used.
Following the incident, the safety board says, BC Ferries changed a number of policies and procedures around rescue boat operations.