A Transportation Safety Board of Canada accident investigation found that a combination of inadequate risk assessment, informal practices, and insufficient supervision led to two crew members falling overboard from one of the rescue boats on the Spirit of Vancouver Island.

The incident took place on the 31st of August, 2018 at the Swartz Bay ferry terminal. Two crew members fell from a rescue boat into the water below as it was being slewed out during an emergency drill.

The crew members were rescued from the water and transported to hospital. One was uninjured, and the other was treated for minor injuries.

In its report the TSB investigators determined that the rescue boats onboard the vessel were replaced with craft that had different physical characteristics from the original, including having a greater overall height.

However, the existing davits were not changed.

The changes to the system resulted in the brake release line being out of adjustment, and following a previous incident, some of the crew responsible for the launching and retrieval of the boats had developed an informal practice to compensate.

The TSB investigation found that the chief officer’s high workload and tasks at multiple locations meant he was not available to supervise the drill. Although the coxswain of the rescue boat assumed the duties of officer in charge, his ability to supervise was limited as he was actively engaged with his own duties.

The informal work around allowed the brake release line to snag while the rescue boat slewed out from the davits. The rescue boat dropped suddenly, hit the edge of the deck, and tipped outboard—resulting in both crew members falling into the water.

Following the occurrence, BC Ferries made a number of changes to policies and procedures related to rescue boat operations.