The Transportation Safety Board of Canada’s (TSB) investigation into a passenger ferry collision in Québec, Quebec, highlights the need to better manage safety risks following changes to shipboard equipment and to require passenger safety management training for crew members of all passenger vessels.
On October 18, 2024, while the ferry Radisson was approaching a wharf at the Port of Québec, bridge personnel noticed that the engine control was not responding. Shortly after, the ferry struck the wharf, injuring four passengers and one crewmember.
In 2023, after Radisson’s engine and control system were replaced, a new procedure was developed to transfer engine control between bridge stations. The investigation found that the procedure did not provide sufficient guidance to support crew members during the transfer and that the system did not provide clear cues to confirm whether it had been successful.
Although a formal risk assessment had identified hazards associated with the change, crew training was the only step taken to reduce the risks. As a result, previously identified risks remained unmitigated, allowing unsafe conditions to persist.
The investigation also found that gaps in passenger safety management limited the crew’s ability to respond effectively to an emergency, including the absence of realistic emergency drills and the lack of an effective warning to passengers before impact.
The TSB has investigated similar occurrences that identified shortcomings in passenger safety management on ferries including the occurrence involving the passenger ferry Sam McBride, following which the board recommended that Transport Canada implement a requirement for crewmembers of all passenger vessels to complete appropriate training in passenger safety management.
Since the occurrence, the Société des traversiers du Québec, owner and operator of Radisson, has taken several safety actions, including posting remote engine control transfer procedures at control stations, reconfiguring control station panels, and introducing an aural signal that sounds when the transfer process is active.
More information can be found on the TSB investigation page.