Wednesday, March 28, 2007

Things To Remember About The B.C. Ferries Investigation


Update: Mar 28/07 5:30pm - Dave, who again knows of what he speaks, has an excellent, and much more succinct, post on this issue up at the Galloping Beaver. He also left us a comment on the thread attached to this post that is absolutely must, and I mean must, reading for anyone who is, in good faith, trying to truly understand what's happening with BC Ferries in general and what happened on the QOTN specifically.

(please note: this is a long one because I really wanted to get it all down in one place - if you just want the punchline skip on down to points six and seven at the bottom)

BC Ferries released the results of their own internal investigation into the year-old Queen of the North sinking Monday (pdf).

According to the Globe and Mail, they concluded that the sinking, which occurred after the vessel crashed into Gil Island at speed, was caused by human error.

They have also made much about the fact that two of the crew members that were on the bridge that night did not participate in the investigation.

They have also made much of the 'casual culture' that existed on the bridge.

They have also made much of the fact that the company investigators did not believe that the Quartermaster could not find the autopilot switch when the other crew member yelled at her to turn it off as a prelude to try and alter the course of the ship at the last minute, because:

"this testimony is difficult to reconcile."

Or, as Gary Mason (behind the G&M subscription wailing wall for Mar 27/07) put it:

"company investigators found this difficult to believe, saying this is a procedure she would have prevously done many times"

Now, this does sound bad for the folks who were in control of the vessel on that fateful night.

And my Dad, who spent his entire adult life travelling up and down the Westcoast towing logs and everything else imaginable, has said from the beginning that there very likely must have been a considerable element of human error in something like this.

But when you read the C.E.O.'s latest statements you would think it was a slam dunk that the entire thing was 110% the awful, terrible crew's fault:

"To go on to hit an island is quite stunning," said David Hahn president and CEO of B.C. Ferries.

However, before we all rush to judgement there are a number of points that I would like to remind everyone of:

First...... B.C. Ferries managed to get their internal investigation out this past Monday, just one day ahead of an interim draft report from the independent Transportation Safety Board which has now been sent to all parties involved to get their input before the latter report is finalized and made public in a few weeks.

Second.....All of the crew members that were on the bridge at the time of the accident have co-operated with the Transportation Safety Board's independent investigation, which something you very rarely hear through through the din of the cranked-up, one-day-ahead-of-the-game, internal investigation-assisted Whirlitzer. Regardless:

"according to (BC Ferries) company sources, their (the crew members') statements did not illuminate or explain why vital course corrections weren't made"

This also comes from Gary Mason's column. Now it is important to consider that these 'sources' are not named and it is also worth considering the 'how do they know anyway?' - type question. For example, it might be that they found this out from reading the draft of the TSB investigation and are now leaking it to their advantage, or, alternatively, they could have gotten it from someone friendly to them on the TSB, or, they could even just be making stuff up (ie. we don't know which of the three alternatives, or other alternative it is because it is not sourced which, of course, is just one more example of that rumour and innuendo thing again that we've been fussing about so much of late). Regardless, the floating of this non-verifiable, anonymous account to a high profile local pundit at the very least smacks of a spin dial set to 'eleven' .

Third..... When the P.R. outcome doesn't look so good the Corporation doesn't always act so quickly or as efficiently to get things out to the public. Case in point, B.C. Ferries sat on the internally commissioned system-wide safety report from George Morfitt for weeks through the late fall/early winter of 2006 all the way through into the New Year of 2007 before they finally dumped it, late on a Friday, just before the Pickton trial was to begin. Despite this blatant attempt at newscycle blunting, a few people did actually notice that the report made no less than 41 specific safety recommendations, two of which were that:

BC Ferries should carry out a comprehensive review of the Safety Management System (SMS) to determine
which areas are functioning effectively and which areas need improvement

BC Ferries should improve existing training and orientation processes to ensure they are sufficient to increase
knowledge and awareness of the SMS (safety management system) across the organization, especially among vessel
Officers and Terminal Directors and Managers to ensure they have “bought into” the SMS;

Now, there was nothing that could be spun there. Mr. Morfitt, who was chosen by BC Ferries themselves, told the Corporation that they should review the systems management plan (which would indicate that there were concerns about its overall effectiveness) and that they should then implement it system-wide to improve training and orientation. Interestingly, Mr. Hahn was NOT available for comment after the release of the Morfitt report which was, at least on the face of it, surprising given that, as was pointed out above, and as will be pointed out below, he always seemed to be available at every other other opportunity.

Fourth....Instituting such a comprehensive safety plan and stepped-up training was something that former B.C. Ferries safety officer Darin Bowland had apparently been asking for since before the Queen of the North sank for which he was, also apparently, rebuffed by B.C. Ferries management at the time. Bowland also claimed that he said that if such changes were not instituted that there would be a 'strong likelihood of catastrophic incidents'.

For his part Mr. Hahn had this to say:

"We reject all of his (Bowland's) allegations," Mr. Hahn said. "I think what's interesting [is] he never set foot on the Queen of the North during his time here, never was on the Queen of Prince Rupert [a sister ship], was never in Prince Rupert or Port Hardy on any business from B.C. Ferries.

Fifth......Mr. Bowland then began proceedings for a wrongful-dismissal suit in the summer of 2006 that was eventually dropped in the fall.

This does, indeed, mean that it is important to take Mr. Bowland's previous claims with a grain of salt (and why it is important to always keep the Morfitt report in mind).

Regardless, afterwards Mr. Bowland called on Mr. Hahn to release his previously stated safety concerns given that he, Bowland, could not due to a confidentiality agreement.

Mr. Hahn flatly refused to do so, and instead had this to say:

"If there was fact, if they were credible allegations, why would he drop the lawsuit? It's very clear that if someone had the smoking gun stuff he's talking about, they would continue with this."

Now, as we've already seen, Mr. Morfitt showed us at least the tip of the barrel, if not more, of such a potential 'smoking gun' a couple of months later. But it is even more important to understand that pretty much an entire, although metaphorical, Smith & Wesson had already been flashed around months before all of this 'stuff" came out. Which brings us to point number six, the.....

Sixth...... Late last spring (2006) Mr. Hahn received, well in advance of its public release, a letter from the Transportation Safety Board (the same independent, federal board that is now wrapping up the fullscale, independent investigation described above). When he was asked about this letter by Vaughn Palmer before it was publically released, Mr. Hahn made like a doctor of some kind and described the letter as 'benign'. It was anything but. Here's an excerpt of our report from that time (it's not short, but it is worth reading all the way through to the end - you'll see why):

Now, over the past couple of days I have read and heard Mr. Hahn say many times that the letter means little because it just reflects the grousing of a few BC Ferry workers after the fact. Additionally, I also heard him say yesterday that it doesn't matter anyway because the upgrades were trivial and were comparable to getting a new keyboard on a your home computer.


Perhaps we should go to the original document (ie. the TSB's letter) and see if Mr. Hahn is making an honest diagnosis or if he is playing the part of a quack bent on getting out his own spin.

We will excerpt it below, but the entire letter from the Safety Board can be found here (warning pdf file):

"......Early in March the Queen of the North had just completed a refit, which included the installation of a new sterring-mode selector switch at the main steering station. Although crew members who were involved with the refit had passed on information about the modifications to other crew members, not all crew members appear to have been adequately briefed.

Information gathered so far has revealed that some bridge team members were not familiar with the use of all of the bridge equipment and controls. For example, members of the bridge team had different understandings of how the recently installed steering-mode selector switch worked and what function each setting of the switch performed (that is, to select between the autopilot, jog, and the forward and main steering wheels)."


So, the Transportion Safety Board is telling Mr. Hahn (the letter was addressed specifically to him on May 11th, 2006, almost one month ago [ie. before the report was originally written - RossK] that there were members of the crew that may not have been adequately trained to operate a piece of equipment that controls the autopilot and the steering.

In case you missed it, please read that last bolded phrase above one more time before we move on to the last point which is the......

Seventh......And here we come all the way back around to the beginning. To refresh your memory, because it was so long ago, the 'company investigators' found it difficult to believe that the Quartermaster (ie. a member of the crew) would have had difficulty turning the autopilot off when the other crew member on the deck yelled at her to do so because 'she would have previously done so many times.'

But the Transport Safety Board told us months ago that they had concerns about this very issue. And they, specifically, did not back down after the fact. Again, from one of our reports at the time, also from last June:

"[But] our investigators turned up a safety deficiency . . . and we are telling B.C. Ferries about what we uncovered," he said.

"We don't wait for the final report if something needs to be done. We haven't drawn any conclusions, but we've seen this thing, and it's starting to quack like a duck."

Canadian Transportation Safety Board spokesman John Cottreau, June 7th, 2006

To which Mr. Hahn responded:

"I think that's a bunch of B.S."
BC Ferries CEO, David Hahn
Emphatically responding to employee safety concerns, June 08, 2006.

Now do you see why, perhaps, that the 'company investigators' are now, nine months later, so full of zeal in their suggestions to the media that no one should believe that the Quartermaster may have had difficulty turning off the autopilot in the heat of the moment.

Additionally, here's something you may not have known already, because it is not something that the company's investigators or the CEO have made much of a fuss about (unlike, say, their trumpeting of the playing of music on the bridge), and that is the fact the Quartermaster was really little more than a deckhand who was actually training for the bridge job at the time of the accident.

There's that word again - training - the word that Mr. Bowland, whose comments should be taken with a grain of salt, and Mr. Morfitt, whose comments can be taken straight up, both indicated the Corporation has had some difficulties with in the not so distant past (ie. during the period when the accident occurred).

Oh, yes, and of course, the Transport Saftey Board also raised the same concern forcefully as well, both in writing and orally - nine months ago.

All of which makes one wonder - do the members of the local media really and truly have difficulty moving things from short to long term memory, or is this actually an issue early-onset, whirlitzer-assisted memory loss?

Regardless, all I'm really trying to suggest here, especially given the ferry corporation CEO's documented track record of serial spin-doctoring, is that we would all be well advised to read the internal report with a skeptical eye and wait until the TSB's complete and independent report is made public before we make any final judgements of our own about where, and how, the blame should be apportioned in its entirety.


I believe it was important to raise the issue of Mr. Mason's unnamed 'company sources' because he also resssurects some vicious rumours, none of which were specifically alluded to in the company's own report. This type of thing becomes even more relevant when one is reminded of the lengths that Mr. Hahn has gone to in the past in an effort to win over local pundits to his POV, not to mention the fact that he has also been known to shut the door on those reporters who don't.
Finally (and I'm really going to stop now - promise), if anybody's interested you can read our entire series of BC Ferries posts, from top to bottom, here.


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