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People return to the mainland on a ferry at the Jack Layton Ferry Terminal in downtown Toronto on July 29.Laura Proctor/The Globe and Mail

An investigation into the 2022 crash of a fully loaded Toronto harbour ferry has found that there was not enough crew to deal with emergencies, they were not trained in crowd management and they did not know exactly how many people were on board.

However, the Sam McBride ferry was operating according to the rules at the time, leading the Transportation Safety Board to call for stricter regulations around such vessels in a report released Monday.

“If there had been a fire on board, or a need to evacuate the vessel, there [would] not be enough crew members to effectively respond,” TSB investigator Étienne Séguin-Bertrand told a briefing.

Transport Canada said its minister would respond to the TSB’s recommendations within the required 90 days, and noted it had already increased the crew size requirement on Toronto ferries.

The popular ferry service brings 1.4 million passengers per year from downtown docks to the islands that help define the city’s harbour, an archipelago known collectively as Toronto Island Park. On busy weekends, the boats have struggled to keep up with demand, leading to periodic calls from the public to build a bridge.

The ferries are also decades old, and plans to replace them have been repeatedly delayed. However, Mr. Séguin-Bertrand said old vessels can function well if properly kept up and that there were no concerns with the maintenance of the ferry that crashed.

The Sam McBride was carrying an estimated 916 people when it collided with the mainland ferry docks in August, 2022. Twenty people were injured, mostly from falling upon impact.

The TSB report paints a picture of a ferry service that could have struggled to handle a more serious incident. For example, procedures around launching the life rafts did not take into account the ferry’s design. There were not enough child-sized lifejackets on board during several voyages observed by TSB investigators. And emergency procedures required some crew to be in multiple places at one time.

Mayor Olivia Chow was not available to respond to the report but thanked the board in a statement issued by her office. Spokesperson Arianne Robinson said the mayor “believes it is imperative that we understand what happened in order to best prevent incidents and keep people safe while traveling to and from the island.”

According to the TSB report, the ship’s captain was running behind schedule prior to the collision. He came in faster than usual on his return to the mainland and was moving at around five knots, a bit more than nine kilometres per hour. Earlier in the day, he was making approaches at around three knots.

Toronto ferries typically move using their stern propeller. As they near land, the captain employs a second propeller at the bow to decelerate. On this day, when he tried to slow, he found that the second propeller didn’t engage.

However, the board was unable to replicate the conditions that preceded the crash. In their investigation, both propellers worked, leading the board to conclude that it had no evidence of malfunction. The report does not assign blame for the collision and notes that captains occasionally hurried their approach when running late or when large numbers of people were waiting.

The report notes that, prior to the collision, there were no written policies around approach speed. The city has since implemented them. Transport Canada has also issued rules requiring more staff on Toronto ferries, increasing the crew complement from six to 13.

In a statement, the City of Toronto’s media spokesperson, Russell Baker, said it had improved its ferry safety policies since the collision.

“The City has been and continues to be in compliance with Transport Canada’s requirements and regulations and has already implemented a number of these actions, while continuing to implement others,” he said.

The TSB made three recommendations. Specifically, it urged training related to crowd management, better oversight of evacuation procedures and an actual count of people on board.

“If there is no accurate method to count the passengers boarding a vessel, there is a risk that not all passengers will be accounted for in an emergency,” the report notes.

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