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A fractured fuel pipe made of copper instead of steel and the removal of a thermal heat shield in the engine room were identified as the main factors in a fire on the Queen of Surrey passenger ferry in May of 2003.

A Transportation Safety Board of Canada report released yesterday identified a number of other problems that increased the risk of fire on the B.C. Ferries vessel.

Flaws were discovered in the carbon-dioxide fire-smothering system on the ferry, as well as the inspection routine to verify that it was working properly. The report concluded that the quality of inspections by Transport Canada "may not be ensuring safe operational conditions."

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The safety board was also critical of the "safety management system" on the Queen of Surrey and said there was not adequate communication between the various shifts of engine-room employees.

The fire May 12, 2003, broke out on the ferry during its fourth trip of the day between Langdale, a Sunshine Coast village on the north side of Howe Sound, and Horseshoe Bay. No one was seriously injured. The ferry had to be towed to Langdale and it was nearly four hours after the fire started that the 318 passengers were able to disembark.

"A ship on a fire is very dangerous. You can't go anywhere. You can't run away," said safety board investigator Aloak Tewari.

During a technical briefing in Vancouver yesterday, he praised the work of the crew in quelling panic among the passengers after the fire started.

When the Queen of Surrey was built in 1981, it was equipped with a fuel oil pressure gauge pipe made of steel. That was later replaced with a copper pipe, which was more brittle and which eventually fractured, allowing pressurized fuel to spray onto the hot engine exhaust manifold.

"We don't know who did it," Mr. Tewari said of the decision to replace the steel pipe with one made of copper.

The thermal heat shield, which protected the engine exhaust manifold from spilled fuel oil, was removed in 1997. The report said it appeared to have been removed to make it easier to disconnect exhaust pipes from the cylinder heads.

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The copper pipe and the removal of the heat shield were not reported by ferry employees or discovered during annual Transport Canada inspections. The heat shield is "a big piece," Mr. Tewari said. "If an item is missing, it should be picked up," he noted.

Transport Canada spokesman Rod Nelson said "we are proud of our inspectors." He added that any inspection is "a snapshot in time," and it is also up to B.C. Ferries to maintain its vessels.

Transport Canada has 90 days to formally respond to the safety board report and Mr. Nelson said there will be a review of its findings and recommendations.

After the fire, B.C. Ferries replaced copper fuel lines with steel piping and implemented a number of other safety measures.

"Safety is non-negotiable," said president and chief executive David Hahn. He added the safety board findings about the Queen of Surrey fire did not differ from B.C. Ferries' internal investigation.

"We did not wait for the TSB. We came right out and tackled everything," he said. "We have senior chief engineers who work very hard to maintain these ships."

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Mr. Hahn suggested that previous safety issues were a result of underfunding, when B.C. Ferries was a Crown corporation.

"The problem was government. We should never be part of government again," he said. B.C. Ferries was made an independent commercial company in the spring of 2003.

Jackie Miller, president of the B.C. Ferry and Marine Workers' Union, disputed Mr. Hahn's comments about the quality of the safety-management system.

"We believe that B.C. Ferries has not yet seen its worst day," she said.

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