The Printing of This Publication Has Been Approved by the Director of the Bureau of the Budger March 17, 1949 Cover Picture: The S. S. President Harrison in San Francisco Harbor, Courtesy American President Lines. Photo by PALMER PICTURES. A: a, b, c, d (2 ea.); remainder (1 ea.). B: e (35 ea.); c (14 ea.); g, 1 (5 ea.); f (4 ea.); h (3 ea.); d (2 ea.); Rear Admiral HALERT C. SHEPHEARD, Chief, Office of Merchant Marine of Ottawa on the 21st day of Novem- Many witnesses were called to give evidence and ample opportunity was I think I may say without fear of contradiction that the Investigation The Judgment of the Court was pro- Statement of the Minister of Transport on Tabling the Report of the Court of Investi- gation Into the Loss of the S. S. Noronic On September 17th last I informed the House that under the provisions of the Canada Shipping Act I had ap- pointed the Hon. Mr. Justice Kellock of the Supreme Court of Canada to act as a Commissioner to hold a for- mal investigation into the loss of the S. S. Noronic by fire in Toronto Har- The Commissioner sitting as a Court of Investigation was assisted by Cap- tains H. S. Kane and Robert Mitchell as nautical assessors and Mr. Neil B. Counsel appeared for the Depart- Steamship Lines, Limited, and Offi- cers, for the Attorney General of Ontario, for the Attorney General of the State of Ohio, and for the Sea- farers' International Union. Mr. W. K. Campbell acted as Registrar of The Court held hearings in the City of Toronto on eighteen days in Sep- This matter coming on for hearing Captain JAMES C. WENDLAND, 1. This Court Doth Order and Adjudge that the certificate of William Taylor, being Passenger Inland Waters' Certificate No. 6703 be, and same is hereby suspended until and including the 21st day of November, 1950. 2. AND This Court Doth Further Order and Adjudge that the costs of the Department of Transport of this investigation be taxed upon the scale of the Exchequer Court of Canada and be paid by Canada Steamship Lines Limited. 3. AND This Court Doth Not See Fit to make any further or other order touching the costs of the said investigation. (Sgd.) R. L. KELLOCK, Commissioner. (Sgd.) HUGH S. KANE, Assessor, (Sgd.) R. MITCHELL, Assessor. (Sgd.) NEIL B. GEBBIE, Assessor. The Commissioner's report, concurred in by the Assessors, is embodied in a separate document and has been forwarded to me by the Commissioner in accordance with the provisions of the Canada Shipping Act. I will table a copy of the report and copies will be available for all members of the House. The report of the Court of Investigation is a lengthy document as befits an investigation of major importance and should be carefully read by all those who are concerned in preventing a recurrence of such a terrible disaster. I shall not attempt in this statement to review the contents of the report at length but will endeavor to point out to members of this House some of the more important observations and findings of the Court. In the first part of the report the Commissioner reviews the legislation and regulations to which the ship and its owners were subject. He finds that the Noronic was built in 1913 and was constructed without fire-resisting bulkheads. Under the regulations the ship, as an existing ship, was exempted from compliance with the regulations which came into force in 1939 and which require new ships to be constructed with fire-resisting bulkheads. The Noronic was equipped with a fire alarm system which was mechanically in good order, with fire extinguishing equipment consisting of hydrants, hoses, fire extinguishers, pumps, smoke helmets and lamps which had been inspected by the Canadian Steamship Inspection Service on April 23, 1949, and had been approved by the Steamship Inspector. The Commissioner expresses the opinion that the laxity of the inspection in requiring compliance with the regulations could only induce or encourage a similar laxity on the part of the owners and officers of the ship with respect to the vital matter of preparedness for fire. Pursuant to United States legislation, the provisions of the Canadian regulations were considered by the United States authorities as approximating those in the United States, and a certificate was issued on April 28, 1949, by the Inspection Office of United States Coast Guard admitting the Noronic to the exemptions and benefits provided by United States Statutes relating to the inspection of boilers, machinery, hull and equipments. This meant that compliance with Canadian regulations was considered sufficient. The certificate issued by the Canadian Steamship Inspection Service permitted the ship to carry 600 passengers and 200 crew. At the time of the casualty the ship carried 524 passengers and 171 crew. There are no regulations applying to Canadian passenger ships on the Great Lakes with respect to the maintenance of any fire patrol system or as to fire drills for either passengers or crew. However, the Commissi ner states, that, in his opinion, it is implicit in the regulations relating to fire extinguishing equipment that there shall be provided by the shipowner men trained to use the required apparatus and so organized that the presence of fire on shipboard may be learned at a sufficiently early stage as to make the use of the required apparatus in the hands of such men effective in its control. So far as patrolling for detection of an outbreak of fire is concerned that is a duty which, it was decided as long ago as 1910 by the Supreme Court of Canada in the case of the Dominion Fish Company V. Isbester, is incumbent upon the shipowner for the protection of sleeping passengers in the case of a ship lying at dock. In a ship equipped with neither auomatic apparatus for detecting an outbreak of fire on board nor an automatic sprinkler system to extinguish it if it did break out, as was the case with the Noronic, an efficient patrol for the detection of fire at the earliest possible moment would appear to be essential The fire patrol actually employed on the ship was inadequate for the purpose. The report deals with the organization, or lack of it, of the officers and crew of the ship to meet a situation such as occurred. Only 15 crew members were required to be on the ship at the time of the fire, the remainder being free to go ashore. After reviewing the evidence of certain witnesses, the Commissioner finds that, in his opinion, no one in a responsible position in connection with the ship, either on the ship or ashore, had applied his mind in any serious way to the handling of a situation such as arose on the outbreak of fire on the night in question, although such an eventuality could not be considered otherwise than as one that might occur at any time. Moreover, complete complacency had descended upon both the ship officers and the management. The fire which actually occurred found officers and crew without any organization designed to deal with such a situation. The Commissioner further states that, in his opinion, it is clear there was no training of the crew with respect to fire or its detection, or what should be done after detection, apart from what might be picked up by attendance at fire drills. The lack of any effective system of patrolling for the purpose of fire detection and the lack of any system by which, when fire was detected, the information of its presence and location could immediately be sent to some central locality, where personnel trained in methods of dealing with fire were available to be sent to the spot immediately, accounts in the Commissioner's opinion, for the loss of life which ensued. The Commissioner points out that the outbreak of fire on a ship at a time when it has a large number of sleeping passengers on board requires of necessity a prearranged plan for rousing and getting them off the ship. The Noronic had no such plan. Any organization which the ship did have was designed to function in other circumstances with a complete crew on board. Accordingly the fire found the ship totally unprepared to deal with the situation. Such efforts as were made to fight the fire were scattered and ineffective, and the heavy loss of life shows clearly the failure of the crew to rouse those sleeping passengers who were unable to escape from the burning ship. The report states that the evidence establishes the origin of the fire to have been in a small linen closet located just forward of the women's washroom opening onto the port corridor on "C" deck. The actual cause of the fire was not established but there was no evidence of the fire having been deliberately set. The procedure followed in formal investigations of this kind is for the Department of Transport to propound certain questions for the opinion of the court. The report of the Com |