The Transportation Safety Board says BC Ferries did not conduct a comprehensive risk assessment in changes to safety procedures that led to a lifeboat falling off a vessel in June.
That was in the safety message of a Marine Transportation Safety Investigation conducted after a lifeboat fell an estimated 16 metres into the water off the Spirit of Vancouver Island while at Swartz Bay June 19.
The incident caused damage to the hull of the rescue boat, releasing 100 litres of fuel into the environment.
There were no injuries from this incident, which happened two months after a rescue boat with two members on board dropped off the Queen of Cumberland, injuring the crew members.
The report notes BC Ferries quickly changed its procedures to not allow anyone to be in the rescue boats during training exercises.
But the safety board says that change was made without looking at any new risks it might create.
BC Ferris has since rescinded that restriction.
The June incident involved service technicians boarding the Spirit of Vancouver Island for a call about intermittent jerking of a rescue boat davit.
After the lifeboat dropped off the vessel, an inspection found a spring-loaded safety latch on its hook was bent to the side, causing a gap.
The investigation report said the tempory safety procedure changes meant there was “no longer a way for the crew to verify that the lifting shackle was correctly positioned on the hook.”
Authorities say the rescue boat was lowered to the water and was there for about 50 minutes, which was uncrewed, and free to move in the water.
The TSB says this may have led to the lifting shackle being repositioned on the tip of the hook allowing it to slip off.