Human Error

"The ship never altered course at all. It never changed its speed; it just ran ahead into Gil Island."

“There’s nothing to indicate they ever tried anything. It’s just human error."

Those two quotes from BC Ferries CEO David Hahn, sums up the basic finding of the review, the ship just kept plowing through the waters of coastal BC, on its way to tragedy.

The review is not a full examination of events, with information on the fourteen minutes prior to the crash into Gil Island left unknown, as those officers involved on watch that night refused to provide any information to the reviews author. A key piece of the puzzle that needs to be known, but so far has not been provided in public testimony or explanation.

The internal review was conducted by BC Ferries shortly after the ill fated vessel sank to the bottom off the Island, the report was released on Monday, a twenty eight page document that outlines as best the Ferry Corporation could, the events that led to the sinking of the Queen of the North on March 22, 2006.

The Victoria Times-Colonist examined the report and found that there were many questions left unanswered about that night in the waters off of Gil Island

What does come across in the BC Ferries review is a complete lack of awareness of the ships position as it sailed to its destiny, or the danger it was sailing into until it was far too late to change course.

The report is but one piece of a long process, with the next much anticipated document to come being the Transportation Safety Board report which is still being compiled by the federal government department.

It’s not known if the watch officers have co-operated with that board of inquiry or not, but one thing seems certain, there will be no sense of closure to this tragic event, until those on watch that night explain fully what happened and how a normally routine course of affairs turned so horribly wrong.

Not far in the back of any passengers mind will be a sense of confidence in the Ferries that sail the coastal waters, a pact that will always be suspect until the truth comes out and British Columbians have the full story on those events that led to tragedy in the early morning hours off of Gil Island.


Ferry report puts blame on crew for sinking
But company's report leaves key question unanswered: Why?
Times Colonist
Tuesday, March 27, 2007

The fourth officer on the bridge of the Queen of the North failed to alter course, and the quartermaster at the helm couldn’t find the switch to turn off autopilot before the ferry crashed and sank, a B.C. Ferries’ investigation has found.

But the long-awaited probe that promised blunt answers doesn’t answer the most critical question of all. Why?

“Human factors were the primary cause of the sinking of the Queen of the North,” according to the report, which was released on Monday.

“The ship never altered course at all. It never changed its speed, it just ran ahead into Gil Island,” B.C. Ferries’ president David Hahn said Monday. “There’s nothing to indicate they ever tried anything. It’s just human error.”

The Queen of the North sank after it collided with Gil Island on March 22, 2006, during its route from Prince Rupert to Port Hardy. Ninety-nine passengers and crew were rescued; two passengers have never been found.

The report sheds some light on what happened on the bridge of the ferry that night, blaming three crew members - the second officer, the fourth officer and the quartermaster - for the vessel going off course, but if offers no explanation as to why the mistake occurred. It does, however, discard the idea that confusion over how to use new bridge equipment installed just a month prior to the crash had anything to do with the cause.

And, in an interview, Hahn poured cold water over the idea that the fourth officer and the quartermaster were distracted because they were engaged in sexual activities on the bridge. The two had a previous romantic relationship.

“Anything is possible but I don’t believe it,” Hahn said. “There were too many senior people from management aboard the vessel that could show up at any time. I’ve never felt that was an issue.

“But why they weren’t paying attention, I don’t know,” Hahn said.

The B.C. Ferry and Marine Workers’ Union would not comment on the report, instead waiting for the release of the Transportation Safety Board’s report, which isn’t due for several months.
The fourth officer, second officer, and the quartermaster aren’t identified in B.C. Ferries’ report, but are named in court documents filed by passengers suing B.C. Ferries.

Fourth officer Karl Lilgert and quartermaster Karen Bricker were on the bridge when the ferry crashed. Second officer Keven Hilton left for a meal break prior to the ferry exiting Grenville Channel at Sainty Point.

The report says the officers refused to provide information about what transpired during a crucial 14 minutes prior to the vessel’s crash into Gil Island at 12:22 a.m. Up until 12:08 a.m., the voyage was routine.

The report concludes the doomed ferry went down shortly after midnight partly because Lilgert, who had control of the ship from Sainty Point, “failed to make a necessary course alteration or verify such alteration was made.”

The report also concludes the navigational watch failed to maintain a “proper lookout.” Those who were on lookout maintained a “casual watch-standing behaviour,” investigators determined, partly because music could be heard playing on the bridge during radio calls.
Just before the crash, Lilgert screamed at Bricker, who was at the helm, to make a bold course correction - a 109-degree turn - and to switch off the autopilot. But she “stated not knowing where the switch was located.”

B.C. Ferries’ report questions the validity of this evidence “as the autopilot disengages simply with a single switch and would have been operated numerous times by the [helmswoman].”
However, the report states the master did find it necessary to post a note for navigational crew on how to operate the autopilot.

Evidence was given that Bricker didn’t know the location of the ship when she took over as lookout - or that the ferry was about to crash until she saw trees.
She said she was asked to make only one, maybe two small course changes as directed by Lilgert after she started her shift.

Creating even more questions, after the crash the helmswoman left the bridge to call for help and reported hearing Lilgert tell Hilton: “I’m so sorry, I was trying to go around a fishing boat.”
An earlier safety board advisory said bridge crew were confused about how to use a new steering mode selector switch — that amongst other things controls whether the ship is on autopilot or manual steering — installed in a retrofit in February 2006.

But B.C. Ferries’ report concludes bridge crew working the night of the disaster “chose” to use the newly installed steering controls in a way “different” than instructed. “This choice does not appear to have been causative of the grounding,” it concludes.

With files from CanWest News Service and The Canadian Press
© Times Colonist