DI #815-06-01 Divisinal Inquiry Incident Queen f the Nrth Grunding and Sinking March 22, 2006 Chair Executive Vice President New Vessel Cnstructin & Industry Affairs Investigatin Dates March 24, 2006 April 20 & 21, 2006 May 24 & 25, 2006 June 22, 2006 Queen f the Nrth Grunding and Sinking DI #815-06-01
DIVISIONAL INQUIRY QUEEN OF THE NORTH #815-06-01 Date f Incident: March 22, 2006 Lcatin f Incident: Type f Incident: Queen f the Nrth in Wright Sund Grunding and Sinking DIVISIONAL INQUIRY OUTLINE PANEL MEMBERS... 2 LIST OF INTERVIEWEES... 3 GLOSSARY OF TERMS... 4 SYNOPSIS... 5 HISTORY OF VESSEL... 5 ANNUAL REFIT... 5 ANNUAL INSPECTIONS... 5 BACKGROUND INFORMATION... 6 SUMMARY OF EVENTS... 9 INCIDENT STAGES... 10 FINDINGS... 18 CONCLUSIONS... 23 RECOMMENDATIONS... 26 ATTACHMENTS... 28 PANEL MEMBERS Executive Vice President, New Vessel Cnstructin & Industry Affairs (Chair) Operatins Vice President, Engineering Vice President, Emplyee Relatins Ships Officer s Cmpnent, BCFMWU Queen f the Nrth Grunding and Sinking DI #815-06-01 2/28
LIST OF INTERVIEWEES Interviewees have been identified by jb descriptin r EDN (Emergency Duty Number) where apprpriate. Master EDN #1 Chief Officer EDN #2 2 nd Officer EDN #3 4 th Officer EDN #5 Deckhand EDN #6 Deckhand EDN #7 Deckhand EDN #10 Deckhand / OFA EDN #11 Chief Engineer EDN #12 1 st Engineer EDN #13 2 nd Engineer EDN #14 3 rd Engineer EDN #16 Chief Steward EDN #19 Ck EDN #24 Night Steward EDN #32 Familiarizing Chief Officer EDN #41 Directr, Business Develpment Manager, Terminal Operatins Marine Superintendent Prject Manager Senir Master Terminal Operatins Supervisr Captain, F/V Lne Star Captain, F/V Sandra M Captain, Tug Castle Lake Queen f the Nrth Grunding and Sinking DI #815-06-01 3/28
GLOSSARY OF TERMS 1/O First Officer 2/O Secnd Officer 3/O Third Officer 4/O Furth Officer Call in pints CCGS CHS COG COLREGS CSA ECDIS ECS EDN EPIRB F/V IMO Knts (kn) MCTS M/V nm OOW PFD QM Radar SOG TCMS As directed by Transprt Canada, at varius psitins alng the Inside Passage. Vessels f certain tnnage are required t ntify MCTS f their lcatin and ETA at upcming pints. This is a frm f vessel traffic service advising mariners f ther surface traffic they might encunter alng their track. Canadian Cast Guard Ship Canadian Hydrgraphic Service Ship s curse ver the grund Cllisin regulatins are the regulatins fr the preventin f cllisin at sea als knwn as the rules f the rad Canada Shipping Act The Electrnic Chart Display and Infrmatin System is an integrated bridge system which indicates the ship s current psitin n the current chart and is IMO apprved The Electrnic Chart System is a digital chart display system which is nt Internatinal Maritime Organizatin (IMO) apprved. Emergency duties number Emergency Psitin Indicating Radi Beacn Fishing Vessel Internatinal Maritime Organizatin Nautical measure f speed. One knt is equivalent t ne nautical mile per hur. The Marine Cmmunicatins and Traffic Services centre is the Canadian Cast Guard vessel traffic management system n specific VHF radi channels fr specific gegraphic areas. MCTS tracks cmmercial vessel traffic by radi (calling in pints) and is usually supprted by radar. Mtr Vessel Nautical Mile 6,080 feet r 1,852 metres (equivalent f ne minute f latitude) Officer f the Watch Persnal Fltatin Device Quartermaster (Frm radi detectin and ranging) A radi system which measures distance and usually directin by a cmparisn f reference signals with the radi signals reflected r retransmitted frm the target whse psitin is t be determined. Ship s speed ver the grund Transprt Canada Marine Service Queen f the Nrth Grunding and Sinking DI #815-06-01 4/28
SYNOPSIS On March 21, 2006, the Queen f the Nrth departed Prince Rupert at 2000 hurs bund fr Prt Hardy. There were ne hundred and ne (101) passengers and crew abard. At apprximately 0022 hurs n March 22, 2006 the vessel struck bttm at 17.5 knts alng the nrth side f Gil Island in Wright Sund sustaining significant hull damage. The vessel lst prpulsin and drifted fr apprximately eighty (80) minutes befre sinking in apprximately 430 metres f water in Wright Sund at a psitin f 53 19.917 N 129 14.729 W (refer t Attachment 4 Chartlet 3742). Passengers and crew abandned ship and were evacuated by BC Ferries lifebats and liferafts befre the vessel sank. Sme f the passengers and crew were taken t the village f Hartley Bay by fishing vessels frm the cmmunity and by the F/V Lne Star. Hartley Bay is apprximately seventy-five (75) nautical miles (nm) suth f Prince Rupert and apprximately six (6) nm frm the scene f the sinking. Others were taken abard the Canadian Cast Guard vessel, Sir Wilfred Laurier. Eleven (11) passengers and selected crew were transprted t Prince Rupert via helicpter frm Hartley Bay. All remaining passengers and crew were then transprted t Prince Rupert via the Canadian Cast Guard vessel. Tw (2) passengers are missing and presumed t have been n bard when the vessel sank. Vessel Traffic Services, The Transprtatin Safety Bard, Transprt Canada, the RCMP, the Canadian Cast Guard, Federal and Prvincial Envirnmental agencies, and the Prvincial Gvernment were ntified f the incident. HISTORY OF VESSEL Particulars f Queen f the Nrth and its histry with BC Ferries are set ut in Attachment1. ANNUAL REFIT The Queen f the Nrth underwent its annual refit and maintenance perid at Deas Pacific Marine Inc. frm Octber 3, 2005 t February 27, 2006. Details f the refit are fund in Attachment 2. The ttal expenditure fr the refit including drydcking was $3,339,000. Within this perid the vessel was drydcked at Vancuver Drydck frm Nvember 9 t Nvember 25, 2005. ANNUAL INSPECTIONS During the refit and at its cmpletin, there are numerus inspectins cnducted by Transprt Canada, Llyd s Register f Shipping and a variety f authrized service agents and ship s crew befre the vessel returns t service. Bridge equipment was inspected during refit as detailed in Attachment 2. The final inspectin by Transprt Canada leads t the issuance f the vessel s license t sail, als knwn as a Steamship Inspectin Certificate (SIC-16). On March 2, 2006 Queen f the Nrth Grunding and Sinking DI #815-06-01 5/28
the vessel was issued a Steamship Inspectin Certificate SIC 16 with SI-07 (Marine Safety Ntices). (Refer t Attachment 20(a) and 20(b)) Marine Safety Ntices (SI-07) dated March 2, 2006 issued by Transprt Canada t the Queen f the Nrth fllwing the ship s annual refit have been reviewed during the curse f this investigatin. These Marine Safety Ntices are a listing f items the vessel and cmpany need t cmplete in a specified time, hwever n majr r n sail items were generated during the annual Transprt Canada inspectin, as evidenced by the full term Inspectin Certificate (SIC 16) issued n March 2, 2006. The utstanding Marine Safety Ntice issues did nt materially cause r cntribute t the incident. (Refer t Attachment 20(c)) BACKGROUND INFORMATION Crewing Arrangements The Queen f the Nrth was crewed as fllws: there were tw crews, each wrking tw (2) weeks n, tw (2) weeks ff. The deck (navigatinal) watch schedule n the Queen f the Nrth was divided int tw (2) watch sectins. The day watch std frm 0600 hrs t 1800 hrs while the night watch was in charge f navigatin frm 1800 hrs t 0600 hrs. The crew abard the Queen f the Nrth n March 21/22, 2006 was referred t as B crew. B crew wuld be assigned t wrk twenty-six (26) weeks per year less vacatin. The B crew had cme n shift abard the Queen f the Nrth at Prince Rupert n Wednesday, March 15, 2006 at 1200 hrs. B crew made three (3) rund trips t the Queen Charltte Islands (Skidegate) and ne rund trip t Prt Hardy via the Inside Passage, ttalling ver 1,100 nm, prir t the evening f March 21, 2006. There were fur (4) deckhands assigned t the night watch f B crew. While wrking in the wheelhuse, these deckhands were referred t as Quartermasters (QM), a title indicative f their membership in the navigatinal watch team. The fur (4) deckhands assigned t the twelve (12) hur navigatinal watch rtated thrugh varius duties: Deck (navigatinal) watch duties as QM (lkut r helmsman). QMs std ne (1) hur watches n the bridge each fur (4) hurs; Fire and security runds; Miscellaneus deck department wrk (Bsun lcker / deck maintenance / car deck lading and unlading). Crew were quartered in cmpartments belw the main car deck in tw areas: Frward berthing area (frames 95 t 148); After berthing area (frames 8 t 56). Queen f the Nrth Grunding and Sinking DI #815-06-01 6/28
Charts and Navigatin Charts 3772 / 3773 (frm the Sailing Directins published by the Canadian Hydrgraphic Service) Grenville Channel (53 22 N, 129 19 W), which leads 45 miles NW frm Wright Sund, is part f the main Inside Passage rute leading nrth tward Alaska. The channel is deep thrughut except near its NW end where sme shals lie alng the suth side f the fairway. The narrwest part f Grenville Channel is 0.2 mile wide in the vicinity f Ormistn Pint. Bth sides f the channel are muntainus and fr the mst part densely wded. Tides Tidal differences in Grenville Channel, frm thse experienced in Bella Bella, are given fr Lwe Inlet (Index N. 9195) in the Tide Tables, Vlume 7. Tidal streams fld frm seaward thrugh the NW and SE entrances f Grenville Channel and meet ff Evening Pint (53 40 N, 129 45 W); the separatin f the ebb tidal stream takes place abut 1 mile farther NW. These meeting and separatin pints f the tidal streams are subject t cnsiderable change, depending n the winds utside. At maximum tidal current cnditin, the current in the narrw prtin f Grenville Channel can attain tw (2) knts. The ebb current cntinue t run fr ne (1) hur thirty (30) minutes after lw water by the shre. Strng eddies can be encuntered abreast Lwe Inlet with the ebb stream. Chart 3772 (frm CHS Sailing Directins) Sainty Pint (53 22 N, 129 19 W) is at the SE end f Grenville Channel. Munt Pitt rises 2.2 miles NW. Sainty Pint light (665) is shwn at an elevatin f 15 feet (4.6 m) frm a white twer. Fleet Ruting Manual (refer t Attachment 8 Fleet Ruting, Rute 10) The Fleet Ruting Manual is a cntrlled dcument that utlines designated ferry rutes traveled by ships f the BC Ferries fleet. The manual further prvides rute guidelines fr the areas where BC Ferries vessels can be expected t transit under nrmal cnditins and states: The applicatin f these ruting guidelines shall be with full cmpliance f the Internatinal Regulatins fr Preventing Cllisins at Sea (1972) with Canadian mdificatins, the Canada Shipping Act and the Vessel Traffic Services system. Nthing in these ruting guidelines shall exnerate any vessel, r the wner, master, r crew theref frm the cnsequences f any neglect t cmply with the Internatinal Regulatins fr Preventing Cllisins at Sea (1972) with Canadian mdificatins, r any sectin r article f the Canada Shipping Act r f the neglect f any precautin which may be required by the rdinary practice f seaman, r by the special circumstances f the case. Any apparent cnflictin shall be reslved in favur f the Cllisin Regulatins r the Canada Shipping Act. Queen f the Nrth Grunding and Sinking DI #815-06-01 7/28
In cnstructing and cmplying with these ruting guidelines due regard shall be had t all dangers f navigatin and cllisin and t any special circumstances, including the limitatins f the vessel invlved, which may make a departure frm these ruting guidelines necessary t avid immediate danger. The specific curses thrugh the area in questin as set ut in the Fleet Ruting Manual are: Keeping t the centre f the channel, the base curse n the suth bund transit f Grenville Channel is 136 True. At Sainty Pint, the recmmended curse made gd changes t 118 True, being a curse change f 18 t prt. Chart 3742 (frm CHS Sailing Directins) Wright Sund (53 21 N, 129 14 W) is the junctin f seven channels and frms part f the main Inside Passage leading nrth tward Alaska. The Inside Passage is heavily used by castal vessels and cnsists, in this lcality, f McKay Reach, Wright Sund and Grenville Channel. Whale Channel, Lewis and Cridge Passages all enter the suth side f Wright Sund and are apprach rutes frm seaward; they are described in Sailing Directins bklet PAC 206 Hecate Strait, Dixn Entrance, Prtland Inlet and Adjacent Waters and Queen Charltte Islands. On the nrth side f Wright Sund, Duglas Channel leads nrth tward Kitimat and Verney Passage leads NE t the junctin f Gardner Canal and Devastatin Channel leading t Kitimat. Tidal stream charts are referenced abve. Tidal streams can be increased r decreased by as much as ne knt due t weather cnditins. Frm bservatins in Wright Sund, Duglas, Verney and Devastatin Channels, the range f tide appears t have little effect n the velcity f the stream, thugh there are large inequalities in the tidal stream rates. Due t the amunt f fresh water drainage int these channels, the subsurface current can, at times, flw in an ppsite directin t the surface current. Land masses n the Inside Passage nrmally prvide clear radar images. (Refer t Attachment 17) Queen f the Nrth Grunding and Sinking DI #815-06-01 8/28
SUMMARY OF EVENTS This Divisinal Inquiry Reprt has been prepared withut the benefit f an accunting by the 2/O (EDN #3) and 4/O (EDN #5) regarding the sequence f events which ccurred between Sainty Pint at the suthern end f Grenville Channel and the grunding n Gil Island. These fficers were frmally requested t prvide infrmatin but n the advice f their legal cunsel refused t answer the Panel s questins regarding the ccurrences during this critical time perid f apprximately furteen (14) minutes. Key events and activities are summarized belw in Table 1. Additinal infrmatin by Incident Stage fllws the Table. TABLE 1 Incident Stage Time Lcatin Situatin Refit Cmplete March 3, 2006 Deas Pacific Marine Queen f the Nrth leaves Tsawwassen terminal after Deas Pacific Marine annual refit. Transprt Canada SIC-16 Inspectin Certificate issued Senir Master psted new steering changever prcedures A crew n bard N bridge equipment defects reprted Crew Change March 15, 2006 1200 hrs Pre-Departure Prir t 2000 hrs n March 21, 2006 Departure March 21, 2006 @ 2000 hrs Transit March 21, 2006 Time unknwn Grunding Pst Grunding March 21, 2006 @ 2237 hrs March 21, 2006 Time unknwn March 21, 2006 @ 2350 hrs March 22, 2006 @ 0003 hrs March 22, 2006 @ 0008 0022 hrs March 22, 2006 @ 0022 hrs March 22, 2006 @ 0022 apprx. 0100 hrs Prince Rupert Prince Rupert Frm Prince Rupert Ormistn Pint Grenville Channel Pitt Island Light Msley Pint B crew n bard: Master s handver given Crew cmplement/ qualificatins cnfirmed t meet CSA requirements Pre-departure prcedures cmpleted althugh landed crew list nt signed by Master r designate Initial passenger staterm assignments cmpleted Queen f the Nrth departs with 101 passengers and crew Full away rder given 2/O (EDN #3) assumes cn; 4/O (EDN #5) t break QM (EDN #7) relieved fr lunch by QM (EDN #11) MCTS psitin reprting call made 4/O (EDN #5) returns t bridge, assumes cn frm 2/0 (EDN #3) 2/O (EDN #3) went t fficer s mess with a handheld radi QM (EDN #6) relieved by QM (EDN #7) Appraching Sainty 4/O (EDN #5) makes MCTS psitin reprting call Pint appraching Sainty Pint Sainty Pint t Gil ECS data indicates n curse alteratin r speed Island change until the grunding Gil Island Queen f the Nrth impacts bttm QM (EDN #7) leaves bridge t call Master Wright Sund Master arrives n bridge; 1/0 (EDN #2), 2/0 (EDN #3), 3/0 (EDN #4) already n bridge Wright Sund On-watch Engineer cntacts bridge after initial impact Wright Sund Annuncement fr passengers t prceed t uter deck Cabin search cmmences n decks 6 and 7 Master rders prt lifebat and rescue bat swung ut Queen f the Nrth Grunding and Sinking DI #815-06-01 9/28
Abandn Ship Time unknwn Wright Sund Master rders abandn ship March 22, 2006 @ Wright Sund Abandn ship cmpleted 0112 hrs Assistance frm Other Vessels Sinking Transprt f Passengers and Crew t Safety Passengers and Crew Return t Prince Rupert March 22, 2006 @ 0145 hrs March 22, 2006 @ 0150 hrs March 22, 2006 @ apprx. 0140 hrs March 22, 2006 frm 0156 hrs March 22, 2006 @ 0706 hrs March 22, 2006 @ 1016 hrs March 22, 2006 @ 1700 hrs Wright Sund Passenger cunts undertaken nce rafts and lifebats are marshalled tgether Wright Sund F/V Lne Star arrives n scene Wright Sund Wright Sund Wright Sund Prince Rupert Bats frm Hartley Bay start arriving n scene Queen f the Nrth sinks belw surface Fast rescue bat frm Sir Wilfred Laurier arrives 63 passengers and crew transprted t Hartley Bay by lcal vessels 36 passengers and crew taken abard Sir Wilfred Laurier 11 passengers and crew transprted frm Hartley Bay t Prince Rupert by helicpter All remaining passengers and crew frm Hartley Bay taken abard Sir Wilfred Laurier and Sir Wilfred Laurier prceeds t Prince Rupert Passengers and crew safely transferred ashre in Prince Rupert INCIDENT STAGES Refit Cmplete The Queen f the Nrth cmpleted refit at DPMI n February 27, 2006 and mved t Tsawwassen Terminal t lad stres and cnduct crew training. Transprt Canada issued the SIC-16 n March 2, 2006. The vessel sailed fr Prt Hardy n March 3, 2006. Bridge electrnics equipment there was a detailed system in place fr reprting and crrecting any deficiencies nted in any bridge electrnics equipment abard vessels f BC Ferries, including the Queen f the Nrth. The Senir Master reprted all bridge electrnic equipment perating prperly fllwing refit and initial peratin. (Refer t Attachment 2 - n defects nted) (refer t Attachment 13 Master s Handver Ntes.) The ship sailed frm Prt Hardy n March 3, 2006 with A crew n bard. Crew Change B crew relieved A crew n March 15, 2006 at 1200 hrs in Prince Rupert, BC. B crew sailed the Queen f the Nrth fr apprximately 1,100 nm between March 15 and the incident. This includes: three (3) rund trips t/frm the Queen Charltte Islands; ne (1) rund trip t/frm Prt Hardy. (refer t Attachment 12- Sailing Schedule) Queen f the Nrth Grunding and Sinking DI #815-06-01 10/28
The Master reprted all bridge electrnic equipment perating prperly during his cmmand f the vessel cmmencing n March 15 until incident n March 22, 2006 (i.e., n defects nted). Prir t the incident, there were n reprts f bridge equipment defects by the 2/O (EDN #3) r the 4/O (EDN #5). The Chief Engineer stated n defects were reprted t him cncerning bridge electrnics r electrical equipment during this shift frm March 15 t the time f the incident n March 22, 2006. The navigatinal night watch (1800-0600 hrs) cmplied with the Canada Shipping Act and Crewing Regulatins and cnsisted f the: Secnd Officer (2/O) as Senir Watch Officer (Officer f the Watch); Furth Officer (4/O), the additinal persn ; Fur deckhands f which ne wuld act as Quarter Master (QM) n a rtating basis, the secnd additinal persn. Deckhand/QM (EDN #7) n the deck (navigatinal) watch had been cleared as a deckhand abard the Queen f Prince Rupert and the Queen f the Nrth. QM (EDN #7) had furteen (14) mnths experience n the Nrth Cast ships (Queen f Prince Rupert and Queen f the Nrth). All f the QM s (EDN #7) ship time was as a deckhand and the QM (EDN #7) had enugh sea time t write the bridge watchman s exam, althugh at the time f the incident had nt yet written the exam and was cnsidered t be a rating under training. Prir t jining the deck department, the QM (EDN #7) was hired int BC Ferries in April 2001 and had wrked as a Terminal Attendant. The 2/O (EDN #3) was the senir deck fficer during the night watch abard the Queen f the Nrth. He started with BC Ferries in May 1980 and had varius psitins f increasing respnsibility. He was cleared as a Secnd Officer abard the Queen f the Nrth and Queen f Chilliwack and as a Chief Officer n the Queen f Prince Rupert. The 4/O (EDN #5) had the cn (cnduct f the navigatinal directin f the vessel) during the suth bund transit frm Sainty Pint until the eventual grunding. He started with BC Ferries in May 1990 and was cleared as a Third Officer and Furth Officer n bth Queen f the Nrth and Queen f Prince Rupert. Steering changever prcedures the Senir Master had apprved and psted a prcedure/prtcl t be fllwed by the deck (navigatinal) watch fr peratin f the autpilt cvering all peratins, including arrangements and prcedures fr changing mdes as well as nrmal perating prcedures (refer t Attachment 14 Steering Changever Prcedures). The Senir Master prepared written handver ntes fr the Master, which were received by the Master n March 15 at the time f the watch changever frm A crew t B crew in Prince Rupert (refer t Attachment 13 Master s Handver Ntes). Queen f the Nrth Grunding and Sinking DI #815-06-01 11/28
Pre-Departure Passenger cunts verified (nte: passenger manifests nt required by the applicable regulatins). Crew accunted fr. Clearance prcedures cmpleted except as nted belw. The landed crew list was nt signed by the Master r designate befre the Queen f the Nrth departed Prince Rupert at 2000 hrs n March 21, 2006 because the Master had nt received crew status reprts frm Department Heads. While a deviatin frm established practice, this was nt causative f the lss. Passenger cabins were assigned fr thse with cabin reservatins. If cabins were available, passengers withut cabin reservatins culd purchase cabin space n bard frm the Chief Steward. Sme passengers changed cabin assignments. Dcuments evidencing final cabin assignments were lst with the vessel. Departure The Queen f the Nrth departed Prince Rupert n schedule at 2000 hrs n March 21, 2006 bund fr Prt Hardy. She was carrying frty-tw (42) crew, fiftynine (59) passengers, sixteen (16) vehicles, and apprximately 220,000 litres f fuel il (marine diesel #2) and engine lube il. Included amngst the passengers travelling were five (5) BC Ferries emplyees nt assigned t vessel duties. The vessel departed Prince Rupert under Master s rders with the 2/O (EDN #3) and QM (EDN #7) n the bridge. The QM was hand steering the vessel. The QM gave evidence f being a bit nervus at the start f the watch regarding helmsman duties departing prt and in restricted waters arund the harbur. Therefre, anther deckhand (EDN #11) stayed with the QM (EDN #7) until Queen f the Nrth had departed frm Prince Rupert. Deckhand (EDN #11) departed the bridge at 2030 hrs. Bth the 2/O (EDN #3) and 4/O (EDN #5) stated t the Divisinal Inquiry Panel that they had cnfidence in the helmsman abilities f deckhand (EDN #7). Transit Within Prince Rupert Harbur limits, the Master handed the navigatinal watch ver t the 2/O (EDN #3). The 2/O (EDN #3) and 4/O (EDN #5) were n watch frm 1800 hrs n March 21, 2006 until 0600 hrs n March 22, 2006. Standard perating prcedure required ne f the navigating fficers t be n the bridge with a QM when the autpilt was in use. When n hand steering, the deck (navigatinal) watch cnsists f three. This is in accrdance with sectin 40(5) f the Crewing Regulatins. At 2237 hrs n March 21, 2006 the deck (navigatinal) watch made the MCTS psitin reprting call abeam Pitt Island Light. At 2250 hrs, Deckhand (EDN #6) reprted t the wheelhuse fr his watch as part f the navigatin team. The ship was transiting Grenville Channel n hand steering s his assignment was as helmsman. When interviewed, QM (EDN #6) described the QM handver prcedure. After allwing his eyes t adjust t the darkness, he Queen f the Nrth Grunding and Sinking DI #815-06-01 12/28
ascertained the vessel s current psitin, rdered curse t steer, current speed thrugh the water, bserved weather cnditins, whether steering with ne r tw steering pumps, lcatin and descriptin f any surface cntacts and ther watch team members. He then asked the Officer f the Watch fr permissin t relieve the QM n the rdered curse. Bth the 2/O (EDN #3) and 4/O (EDN #5), plus a deckhand serving as QM (EDN #6), were n the bridge in a cnditin f stand by, being ne f enhanced readiness, abeam Ormistn Pint n Pitt Island. This pint is in a restricted prtin f Grenville Channel where the channel is apprximately five hundred (500) yards wide. After passing Ormistn Pint, where the channel widens, the bridge went ff stand by, the 2/O (EDN #3) assumed the cn, and the 4/O went fr a break ff the bridge. Abut this time QM (EDN #6) was directed t change t autpilt n the base curse. While n autpilt his primary duty was lkut. At Msley Pint, the 4/O (EDN #5) returned t the bridge and tk ver the cn frm the 2/O (EDN #3). The 2/O (EDN #3) relayed t the 4/O (EDN #5) the curse, speed, lcatin, traffic, weather, and that there were n defects reprted. The 2/O (EDN #3) reprted a single suth bund vessel fine n the prt bw just suth f Sainty Pint. The vessel was visible by sight (single white light) and was acquired and was being tracked by the autmatic tracking feature f the ship s radar. The white light ahead was in all likelihd the masthead light f the F/V Lne Star. Wind was reprted as twenty (20) knts ff the starbard beam. The 2/O (EDN #3) testified the prt radar (X band) was n a three (3) mile range ffset and starbard radar (X band) was n half (0.5) mile range ffset. Bth radars were reprted as functining prperly. At apprximately 2350 hrs, Deckhand (EDN #7) came nt the bridge fr an hur navigatinal watch. QM (EDN #6) relayed all relevant navigatinal infrmatin (as described abve when he assumed the helm at apprximately 2250) t QM (EDN #7). The vessel was n autpilt and all systems were perating nrmally. QM (EDN #6) des nt recall any surface cntacts r passing n any infrmatin abut ther vessels. The relieving QM (EDN #7) culd nt cnfirm t the Divisinal Inquiry Panel that any surface cntacts were visible. The channel is apprximately 1200 yards wide at this pint. After exiting Grenville Channel, the F/V Lne Star subsequently turned nrth, runding Waterman Pint, and prceeded between Prmise Island and the mainland (refer t Attachments 3, 4, 5, and 6), in rder t gain shelter frm high crss winds in Wright Sund. The lights f the F/V Lne Star, after runding Waterman Pint, wuld nt have been visible t Queen f the Nrth while Queen f the Nrth was still in Grenville Channel. The F/V Lne Star s lights wuld nt have been visible again t the Queen f the Nrth until the Queen f the Nrth had prceeded sufficiently suth t be able t view up the channel between Prmise Island and the mainland. Prir t exiting Grenville Channel, the 2/O (EDN #3) went fr lunch t the Officers Mess. It takes less than thirty (30) secnds t walk frm the bridge t the mess (refer t Attachment 23 Plan View). The 2/O (EDN #3) carried a radi with him s he culd be cntacted immediately if needed. Queen f the Nrth Grunding and Sinking DI #815-06-01 13/28
At 0003 hrs, n March 22, 2006, at the suthern end f Grenville Channel, the 4/O (EDN #5) called MCTS ntifying the vessel s lcatin as appraching Sainty Pint, giving an estimated time f arrival (ETA) at the next call-in pint f Kingcme Inlet at 0100 hrs. The ECS data recrding shws the Queen f the Nrth abeam Sainty Pint at apprximately 0008 hrs. T this pint, the vyage had been uneventful and rutine. The 4/O (EDN #5) reprted calling in t MCTS (Prince Rupert Traffic) at Sainty Pint n CH 11 VHF-FM (156.55 MHz). Fr the perid frm Sainty Pint until the grunding n Gil Island, the 4/O (EDN #5) refused t answer questins frm the Divisinal Inquiry Panel as t the cnduct f the vessel r events n the bridge. Evidence was given that QM (EDN #7) did nt knw the lcatin f the Queen f the Nrth when assuming the duties f lkut and that until trees were sighted, neither the shre nr any lights were visible. QM (EDN #7) remembered making ne r pssibly tw small curse alteratins as directed by the 4/O (EDN #5) after taking ver the watch. QM (EDN #7) stated that, when suddenly rdered t steer 109 by the 4/O (EDN #5) in a lud vice, QM (EDN #7) questined the rder as it was a bld alteratin. QM (EDN#7) lked ut the windw and sighted trees. QM (EDN #7) stated that the 4/O (EDN #5) rdered the autpilt t be switched ff. The QM (EDN #7) stated nt knwing where the switch was lcated. As the autpilt disengages simply with a single switch (refer t Attachment 15) and wuld have been perated numerus times by the QM, this testimny is difficult t recncile. The deck fficers had previusly advised that they were cmfrtable with the helmsman s capabilities. Music is clearly audible during rutine radi telephne cnversatins between the vessel and MCTS (Prince Rupert Traffic) (refer t Attachment 19 MCTS Radi Recrding Transcriptin 21/22 March 2006) at: Grunding 2237 hrs, March 21, at Pitt Island light; 0003 hrs, March 22, appraching Sainty Pint. At apprximately 0022 hrs n March 22, 2006 the Queen f the Nrth ran agrund at a speed f apprximately 17.5 knts n the rcky shre f Gil Island (apprximately 53 19.2 N, 129 14.3 W) in Wright Sund. This psitin is ver ne nm frm the standard 118 True trackline (refer t Attachment 3 Chartlet 3742). The QM (EDN #7) left the bridge t call the Master fr help. QM (EDN #7) reprted hearing the 4/O (EDN #5) say t the 2/0 I m srry I was trying t g arund a fishing bat. The Master, then in his staterm (refer t Attachment 23), stated that he was awken frm sleep by shuting and screaming. The Master felt the ship grunding and gt ut f his bunk. He stated that it felt like they were n an icebreaker. He prceeded immediately t the bridge. The Master stated that when he arrived n the bridge, the 1/O (EDN #2), 2/O (EDN #3) and 3/O (EDN #4) were already n the bridge. The X band radar was n the half (0.5) nm range and bth the main engine cntrls were set at full astern. The Master Queen f the Nrth Grunding and Sinking DI #815-06-01 14/28
reprted seeing a steady white light t the suth abut tw (2) r three (3) nm away and that the main engines were silent. The grunding lcatin wuld allw a clear view up the channel t the west f Prmise Island. The n-watch engineering fficer gave evidence that he cntacted the bridge fllwing the first grunding t reprt the engine rm was bilged (flding). All watertight drs were rdered clsed as sn as the Master reached the bridge. The senir engineer f the watch accunted fr all f his crew, started necessary equipment and rdered the immediate evacuatin f the engine rm. All engine rm crew reached safety, clsing watertight drs behind them as they egressed. The general alarm was sunded in crew areas and shrtly thereafter the general alarm was sunded in the passenger areas fllwed by an annuncement ver the public address (PA) system instructing passengers t muster n the uter decks. There was a reprt f the signal fr bat statins, seven shrt blasts fllwed by ne lng blast, n the general alarm bell. Accunts vary regarding the exact wrding f the public annuncements and the frequency f the annuncements; hwever, thse interviewed recalled passengers being instructed ver the public address (PA) system t muster n uter decks. Bth anchrs were let g. The crew cmmenced a search f all cabins and public spaces t accunt fr all crew and passengers. Alarm bells were ringing and there were regular PA annuncements. Crew banged n all cabin drs with a shut f evacuatin instructins. Fifty-three (53) f fifty-five (55) cabins were cnfirmed as having been physically searched. Emergency generatr and emergency lights functined nrmally after the engine rm was flded. Red rcket flares were deplyed t indicate distress. A call was made n VHF-FM channel 11 advising MCTS f the grunding. Passengers and crew had lifejackets n when mustered. The deck lights were functining. Fleet Huse Crprate Operatins Centre (COC) was activated within twenty-five (25) minutes f ntificatin. Abandn Ship Passengers and crew were mustered n the bat deck (Deck 7) prt and starbard as the ship began t list t starbard (refer t Attachment 11 Fire and Bat Statin Muster List). All thse mustered n the starbard side were rdered t the prt side. When the crew thught all thse n bard were assembled n Deck 7 prt side, the Master gave the rder t swing ut the prt lifebat and rescue bat t embarkatin. He then gave the rder t abandn ship as water was up t the starbard side rubbing strake and the deck plates in the engine rm. Frm the prt side, three liferafts, the prt rescue bat and the prt lifebat were launched. In all, eighty-tw (82) persns were evacuated n the prt side. One raft that was inflated malfunctined and failed. This raft was cut away. The canpy f ne liferaft that was deplyed did nt inflate prperly. Queen f the Nrth Grunding and Sinking DI #815-06-01 15/28
Althugh the rder t abandn ship was given and acted upn, the ship s whistle was nt used t signal bat statins (that is, prepare t abandn ship). The starbard lifebat was the last survival craft t leave the Queen f the Nrth. Althugh ne f the lifebats was initially hung up by the tricing pennants in the chcks, the crew freed it and it was swung ut. Seventeen crew were abard when cast ff. Just prir t lwering the starbard lifebat, it was reprted the ship had a fifteen (15) degree list t starbard. The Master was last t bard. The abandn ship prcess was cmpleted at 0112 hrs. The ship s lgs were inadvertently left n the ship. The rafts were twed away abut ne-half mile frm the ship by the rescue bat and lashed tgether with the prt lifebat. Running cunts f passengers and crew were undertaken n several ccasins; hwever, they prved difficult. After a number f cunts, there was cnfusin as t whether there were ninety-nine (99) r ne hundred and ne (101) persns in the rafts and bats. The rescue bat went back t the ship t search in case there was anyne remaining n deck r in the water. Accrding t ship s fficers, the sea was nw calm with a light rain falling. Passengers in ne liferaft were cmplimentary regarding the leadership f the persn in charge. They were kept infrmed, felt safe and were kept in gd spirits. Passengers in the ther liferaft cmmented that they did nt feel as cnfident. Assistance frm Other Vessels The F/V Lne Star, a 37 ft shrimper with a Captain and ne deckhand n bard was prceeding suthbund in Grenville Channel ahead f the Queen f the Nrth n the evening f March 21. He culd nt see the ferry behind him. When he reached the suthern end f the channel, the weather deterirated and the Lne Star s Captain decided t turn int the channel between Prmise Island and the mainland. The Lne Star was almst at Harbur Rck light in Cghlan Anchrage when he verhead the call f the Queen f the Nrth at apprximately 0024 hrs reprting the grunding. At 0029 hrs, the Lne Star cntacted Prince Rupert Radi and ffered assistance. The Lne Star cntinued t circumnavigate Prmise Island in a clckwise fashin and was the first vessel t arrive n scene at the liferafts and lifebats at apprximately 0145 hrs, just after the sinking f the Queen f the Nrth. The Lne Star tk a number f survivrs abard fr transprtatin t Hartley Bay. Alert citizens frm the village f Hartley Bay almst seven (7) nm t the nrth heard the initial call frm the Queen f the Nrth. Residents quickly tk t all manner f vessels and prceeded t the stricken Queen f the Nrth. Shrtly after the arrival f the Lne Star n scene a number f small craft began arriving frm the village f Hartley Bay t ffer assistance t the survivrs f the sinking. On the evening f March 21, the F/V Sandra M (a 40 ft fibreglass shrimp dragger) was prceeding suth in Grenville Channel with a Captain and ne deckhand and was vertaken by the Queen f the Nrth. N radi calls were exchanged between the Queen f the Nrth and the Sandra M, althugh the Sandra M mnitred the radi Queen f the Nrth Grunding and Sinking DI #815-06-01 16/28
cmmunicatins between Prince Rupert Radi and reprting surface traffic. The Sandra M heard the radi call frm the Queen f the Nrth cncerning the grunding and cntinued t the scene ff Gil Island. The Sandra M arrived n scene at apprximately 0230 hrs, and vlunteered its services in the rescue effrt t the CCGS Sir Wilfred Laurier. The Sandra M stayed in the area patrlling the flat/debris line and recvered fltsam frm the sinking fr abut eight hurs. The Sandra M recvered PFDs and miscellaneus debris. Sandra M ffladed all recvered debris t the Sir Wilfred Laurier. N passengers r crew frm the Queen f the Nrth were transprted abard the Sandra M. The Captain saw n ther vessels that evening prir t the incident nr heard any ther vessels ther than the F/V Lne Star n the radi. At the time f the grunding (0022 hrs n March 22, 2006), the tug Castle Lake (a 29 ft tw bat with lg tw) was n a suthwest curse in Verney Pass, apprximately ne nm nrtheast f Mney Pint. The Captain reprted that it was a dark, cludy evening with seven knts f wind frm suth t sutheast. The seas in Verney Pass were calm. The tug Castle Lake was abut six (6) nm nrtheast frm the Queen f the Nrth at the time f its grunding n Gil Island. The Castle Lake was bund fr Prince Rupert with a large lg tw and was making abut 1.3 knts thrugh the water. The Master reprted seeing the deck lights frm the stricken Queen f the Nrth, and mnitred the radi transmissins f the incident. He ffered his assistance, if needed, but as there were numerus small bats, fishing vessels and the Canadian Cast Guard vessel enrute t the scene, his assistance was nt required. When the Queen f the Nrth sank at 0140 hrs, the Castle Lake was mid way between Mney Pint and Cape Farewell in Wright Sund. The tug cntinued its jurney t Prince Rupert. CCGS Sir Wilfred Laurier was perating in the area and was at anchr in Bernard Harbur. Upn hearing the call frm the Queen f the Nrth, the Sir Wilfred Laurier prceeded with due haste t the scene. The fast rescue bat frm the Sir Wilfred Laurier arrived n scene at apprximately 0156 hrs and the ship arrived at apprximately 0210 hrs. Sir Wilfred Laurier assumed n scene cmmander fr the rescue effrt and directed the search and perimeter cntrl. All remaining passengers and crew in the survival craft were transferred t the Sir Wilfred Laurier. The Canadian Cast Guard ship then gathered all survivrs frm the village f Hartley Bay and ultimately prvided fr their care and cmfrt while transprting them t Prince Rupert. Sinking The Queen f the Nrth cntinued t settle n an even keel, sinking t the level f Deck 5. At apprximately 0140 hrs n March 22, 2006 the Queen f the Nrth settled mre quickly by the stern and began t sink beneath the surface, stern first. The bw angled steeply upward, expsing apprximately the frward third f the ship, and then slipped beneath the surface, accelerating in the descent. As the ship sank, trapped air caused numerus windws n the passenger deck t explde utward, and a clud f dust was frmed at the scene. Transprt f Passengers and Crew t Safety The fast rescue bat frm the CCGS Sir Wilfred Laurier, arrived t assist just after the Queen f the Nrth sank. Thirty-six (36) passengers and crew were transprted t Sir Wilfred Laurier. Queen f the Nrth Grunding and Sinking DI #815-06-01 17/28
Sixty-three (63) passengers and crew were transprted t Hartley Bay by small lcal vessels. Passengers reprted that the peple f Hartley Bay prvided significant supprt and cmfrt. Passengers and Crew Return t Prince Rupert Eleven passengers and crew were transprted frm Hartley Bay by helicpter and were assessed and treated at the hspital in Prince Rupert. All ther passengers were landed at the Prince Rupert cruise ship terminal frm Sir Wilfred Laurier at apprximately 1700 hrs, then taken in hand by BC Ferries persnnel and accmmdated at lcal htels and their immediate needs were met. BC Ferries was assisted in this activity by the lcal Emergency Scial Services rganizatin and its vlunteers. Over the fllwing frty-eight (48) hurs, many f the passengers and crew were interviewed, claim prcesses initiated and critical incident stress cunselling services made available. Onward transprtatin was arranged and almst all passengers had left Prince Rupert by March 24. Investigatins were initiated by the Transprtatin Safety Bard, Transprt Canada, RCMP, BC Ferries, and BC Ferries underwriters. These activities necessitated interviewing many f the crew. BC Ferries established its Emergency Operatins Centre (EOC) at its Prince Rupert terminal, frm which the respnses t the varius issues were managed, including the envirnmental respnse, passenger supprt and claims, emplyee supprt and claims and service recvery. BC Ferries established its Crprate Operatins Centre (COC) at BC Ferries Headquarters (Fleet Huse) in Victria shrtly after 0100 hrs n March 22, t direct the verall respnse t the event, crdinating lgistic supprt, verseeing envirnmental respnse, liaising with investigatin agencies, and managing the multitude f human issues fr passengers and crew members. FINDINGS Transprtatin Safety Bard Deep Submersible Recvery Operatins On March 26, 2006, a Nuytc Research manned submersible, which had been cntracted by BC Ferries, lcated the sunken wreck f the Queen f the Nrth. The Transprtatin Safety Bard (TSB) bserved this peratin. On June 15, 2006, the TSB cntracted the services f a deep submersible remtely perated vehicle (ROV) t explre the wreck f the Queen f the Nrth (refer t Attachment 21 Reprt f a Marine Occurrence (TSB 1808)). The ship was discvered n the bttm in 420 meters (apprximately 1410 feet) f water, intact and sitting upright n an even keel, slightly dwn by the stern. Queen f the Nrth Grunding and Sinking DI #815-06-01 18/28
The ship had settled int the silt and ze cmmn n the seabed up t the rubbing strake at apprximately the main car deck. This silt prevented an examinatin f the lwer prtin f the hull. The main cmputer and hard drive frm the vessel s Electrnic Chart System (ECS) were successfully recvered frm the bridge during the June 15 ROV dive peratins and sent t TSB investigative labratries in Ottawa fr analysis. Electrnic data frm the ECS enabled recnstructin f the navigatinal situatin f the evening n March 21/22, 2006. On June 30, 2006, Captain Gerge Capacci f the Divisinal Inquiry Panel and tw ther members f BC Ferries management were shwn the recnstructed track infrmatin frm the night f March 21/22, 2006, recvered frm the vessel s ECS hard drives. The navigatinal data frm the ECS abard the Queen f the Nrth shwed evidence f the actual mvement f the ship thrugh Grenville Channel and Wright Sund. The plt shwed the vessel prceeding dwn Grenville Channel with a curse ver grund (COG) f apprximately 133 True. Speed ver grund (SOG) was indicated as 17.9 knts. The Queen f the Nrth was abeam Sainty Pint at the suthern extreme f Grenville Channel n substantially the same curse at apprximately 0008 hrs r eight minutes after midnight n March 22, 2006. Frm that pint, the recnstructin f the trackline shws the Queen f the Nrth hlding a steady curse ver grund f apprximately 132 /133 True and speed f apprximately 17.5 knts thrugh Wright Sund. N curse alteratin tk place abeam Sainty Pint as wuld nrmally have ccurred in accrdance with established tracks. The QM (EDN #7) gave evidence that ne r pssibly tw small curse alteratins were carried ut at the directin f the 4/O (EDN #5) shrtly after midnight. This is at dds with the bjective evidence frm the ECS data that n curse changes were made frm Sainty Pint t the pint f impact. The ship prceeded thrugh Wright Sund, maintaining a steady curse and speed until running agrund n Gil Island in the vicinity f Juan Pint at 0022 hrs r 22 minutes past midnight n March 22, 2006. Accrding t the QM (EDN #7), a curse change was rdered just befre impact, but frm the ECS data bserved the curse change des nt appear t have been executed prir t the impact. The SOG recrded by the ECS went frm 17.5 knts t zer in very shrt rder. The ECS data then shws the ship s heading fall ff t the nrtheast as the vessel appears t drift Dead in the Water (DIW) with the envirnmental cnditins f current and wind. The ship initially drifted t the nrth ff Gil Island (refer t Attachment 3 Chartlet 3742). The calculated set and drift fllwing the grunding is 326 True at a speed f apprximately 0.7 knts. Frm accunts at the scene, the vessel remained aflat until apprximately 0140 hrs r ne (1) hur and eighteen (18) minutes after grunding. Queen f the Nrth Grunding and Sinking DI #815-06-01 19/28
The Queen f the Nrth ultimately drifted apprximately nine-tenths (0.9) f a nm in a nrth-westerly directin until the ECS data ceases t be recrded at apprximately 0140 hrs. In summary, the Queen f the Nrth failed t make any curse change at Sainty Pint after exiting Grenville Channel and the ship prceeded straight n a COG f apprximately 132-133 True fr apprximately fur (4) nm ver furteen (14) minutes, until the grunding n Gil Island. There were n apparent alteratins f speed at any time during this transit f Wright Sund and the Queen f the Nrth impacted Gil Island at 17.5 knts. Vessel Damage RCMP divers identified three distinct impact sites n the nrtheastern shre f Gil Island: 53 19.191 N, 129 14.296 W 53 19.160 N, 129 14.169 W 53 19.128 N, 129 13.995 W This equates t apprximately 1,158 feet (353 metres) alng the island (apprximately three ship lengths). At these sites, clear evidence f the impact f the Queen f the Nrth was as fllws: significant rck disturbance and scrapes f bttm paint frm the ship; a prpeller blade frm ne prpeller hub; a prtin f the steel structure frm the starbard A-frame r shaft supprt structure that extends frm the hull f the vessel. Reprts indicate the liferafts and bats were t far away frm the ship fr clse examinatin f the hull. Other reprts indicate the psitin f the liferafts and bats did nt permit a gd angle f view f the bttm f the ship as the bw rse at the time f the sinking. Hwever, the crew f the rescue bat that was circling the ship reprted seeing significant damage t the hull (bulbus bw and frward ne-third f hull) as the ship pitched up and sank. Vide f the wreck by submersible was nt helpful as the vessel s lwer hull is embedded in silt n the sea bttm, precluding direct bservatin. Bw Sectin Severe damage was reprted t the bw sectin f the vessel. Reprts varied between ne and tw hles lcated either in the side shell f the bw area r n the bttm (keel) area f the bw sectin. The track f the vessel was a glancing r side swiping actin striking the grund and witnesses reprted tw t three sequential impacts. These reprts are cnsistent with the bw grunding first, fllwed by aft sectins f the hull. There is a pssibility sme witnesses may have bserved the hull pening fr the bw thruster tunnel and described this as side shell damage. Even s, the reprts f tw Queen f the Nrth Grunding and Sinking DI #815-06-01 20/28
sequential impacts and several accunts f bw damage, including frm knwledgeable mariners, makes it mst prbable the bw sectin f the vessel sustained significant damage. There were n eye witness accunts f bw damage frm within the vessel at the time f impact as this prtin f the ship is nt nrmally visited except during crew runds. Machinery Spaces The vessel was steaming with tw watertight drs in the engine rm spaces pen n bridge cntrl fr the safe wrking f the vessel. The senir engineer f the watch reprted tw impacts, ne felt frm frward f the engine rm and ne frm aft. The machinery spaces began t fld very rapidly fllwing impact. Water was reprted entering the main engine rm frm aft, starbard side (the wrkshp and starbard shaft tunnel areas). The senir chief engineer reprted that the pumps culd nt keep up with the flding. Frm these reprts it appears the vessel was hled aft f the engine rm in the shaft tunnel cmpartment r wrkshp. The lcatin and rate f flding f the machinery spaces indicates the vessel sustained massive damage in the after starbard prtin f the hull. The after prtin f the hull was nt visible t liferaft bservers as the vessel reared and sank, s there are n exterir eye witness reprts f aft hull damage. After the incident, prtins f the starbard prpeller and the prpeller shaft supprt bracket were retrieved frm shallw water alng the shreline f Gil Island. In this same area numerus rcks were stained with the bttm paint f the vessel, indicating the pints f cntact between the hull and the rcks. The nature f the damage t the prpeller indicates it was turning at the time f impact and als that it sustained a massive impact. This is supprted by reprts the engines stalled immediately upn impact, cnsistent with a large prpeller strike. The magnitude f the impact makes it likely the starbard shaft was dislcated within the hull such that watertight integrity may have been breached alng the shaft line int the stern cmpartments f the vessel. After Crew Quarters Based n evidence given by crew members in their quarters, the ship s hull between frames 8 and 56 was significantly hled during the grunding as demnstrated by rapid in-flding f sea water. Crew members reprted water depths up t tw t three feet as they evacuated. Damage Summary Based n witness reprts frm the engine rm at the time f impact and frm bservatins frm liferafts as the vessel settled, it is apparent there were at least three serius hull breaches in three separate cmpartments. The first, in the bw sectin, was caused by the initial impact with the island. The secnd, the wrkshp cmpartment r shaft seal cmpartment, likely ccurred when the hull in way f the wrkshp and/r the shaft seal cmpartment struck. The degree f damage t the salvaged prpeller parts als indicates it is likely the starbard prpeller shaft was dislcated within its stern tube by the impact. Thirdly, in the after crew quarters where the hull was breached causing rapid flding int this cmpartment. Queen f the Nrth Grunding and Sinking DI #815-06-01 21/28
It was reprted that the car deck flded frm water cming up via the casing and flded the aft sectin f the car deck first. The water tpped the subdivisin drs int the secnd sectin mid ship. Crewing While BC Ferries had implemented and intrduced a new cmputer-based scheduling system SmartStaff int varius peratinal areas, at the time f the incident the crewing fr Prince Rupert-based ships was still being effectively managed and scheduled using the histrical paper-based systems while technical issues related t the new system were reslved. Accurate and current persnnel infrmatin was used by the crewing ffices t dispatch the crew. Manifests Lgs Passenger manifests were nt required by regulatin. A landed crew list was sent ashre by the Queen f the Nrth but was nt signed by the Master r designate. An accurate passenger cunt was sent ashre. Shre-side management were nt prvided with final cabin allcatins fr passengers as n-bard changes can ccur. Shre-side reservatin lists did nt reflect an accurate list f thse n bard due t n-shws, changes, and nn-reserved arrivals. N fficial dcuments were remved frm the Queen f the Nrth: The fficial bridge lg was inadvertently left n the ship. The engine rm lgs were left in the engine rm. Queen f the Nrth Grunding and Sinking DI #815-06-01 22/28