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Svanoy: A Ferry Master Watching the Wrong Screen, a Pleasure Craft Nobody Could See, and a Collision in Six Minutes of Fog

🕑 5 min read words Safety • Incident • Deck-operations

Vessels: Svanoy, passenger ferry (Canship Ugland Ltd., operating for Société des traversiers du Québec) and a pleasure craft, 4 persons aboard
Date & location: 2 July 2023, St Lawrence River between Saint-Joseph-de-la-Rive and L'Isle-aux-Coudres, Quebec
Outcome: Collision in dense fog – pleasure craft sank, all four occupants rescued and taken to hospital as a precaution; ferry sustained minor damage; no fatalities
Human factors: Attention Fixed on the Wrong Display · Silence Where a Signal Was Required · One Sensor Is Not Enough
Source: Transportation Safety Board of Canada, Investigation Report M23C0143 (published 10 July 2025)

8 decision points4 outcome paths~6 min read + Knowledge Checker

Six Minutes From Dock to Impact

Svanoy left her berth at Saint-Joseph-de-la-Rive around 1000 on 2 July 2023, the chief officer handling the departure before the master took the console at 1003 and the chief officer, with permission, left the bridge. The master, now alone, altered course to starboard and gradually built speed to 8.2 knots to compensate for the current. A pleasure craft with four people aboard had left a Quebec marina at 0700 bound for Tadoussac, crossing the ferry's path around 0950 as fog thickened over the passage. By 1003 the two vessels were about 1.4 nautical miles apart. Neither had sounded a fog signal. Neither had made a safety call to the shore traffic centre.

Watching the Chart, Not the Radar

Svanoy's radar – S-band set to a 1.5 nautical mile range, X-band to 3 – had the pleasure craft on it the whole time. But the master's attention was on the electronic chart display, tracking a different ferry, Félix-Antoine-Savard, working the same passage. The pleasure craft, meanwhile, had no radar switched on at all – its operator was relying on visual and audio lookout plus an AIS receiver that could see other traffic but, with no MMSI programmed, couldn't be seen by anyone else. At 1006:30, the master finally spotted the pleasure craft dead ahead, sounded one blast, and cut speed. Five seconds later, at 1006:35, the two vessels collided 0.35 nautical miles from the dock. The pleasure craft operator had heard a warning shout, seen the ferry's silhouette emerge from the fog, and pulled back the throttles and turned to port – too late to matter.

Two Vessels, Neither Sounding a Signal

Under the Collision Regulations, a vessel underway in restricted visibility must sound prescribed fog signals. Svanoy sounded none on departure and none through the transit – bridge personnel later described avoiding them out of concern for disrupting crew communication and disturbing passengers and nearby residents. The master was also alone on the bridge, in breach of Marine Personnel Regulations requiring an officer of the watch plus a dedicated lookout in restricted visibility, and no VHF safety call was made to the shore traffic centre on departure, contrary to the Navigation Safety Regulations, 2020.

What the Investigation Found

TSB's findings centre on detection, not seamanship under pressure once the vessels were already close – by the time either side had a clear appraisal of the other, there was no time left to avoid the collision. The master's attention was captured by the chart display showing an assumption (a known other ferry in the area) rather than the radar showing the actual threat. The pleasure craft operator's reliance on AIS alone, with no radar as a backup sensor, limited how early the threat could have been detected on that side too. And behind both: a Pleasure Craft Operator Card system that TSB found provides no meaningful preparation for exactly this situation.

Recommended Actions

From TSB's findings and the safety actions the ferry operator, Canship Ugland Ltd., has already taken:

Sound the prescribed fog signals every time a vessel is underway in restricted visibility – concern about disturbing passengers or crew communication does not override a Collision Regulations requirement written specifically for this situation.
Keep a dedicated lookout and a second person on the bridge in restricted visibility, as Marine Personnel Regulations require – a single person cannot simultaneously monitor a chart display, a radar, and visually scan ahead.
Make the required VHF safety call to the shore traffic/vessel monitoring service on departure into restricted visibility, every time, not only when traffic is expected.
Use radar actively as the primary detection tool in fog, not a secondary display running in the background behind an electronic chart – and cross-check both.
Small craft operators: don't rely on AIS alone. An unregistered or non-broadcasting AIS unit gives you a partial picture of traffic and gives commercial vessels no picture of you at all.

Separately, Canship Ugland Ltd. issued a fleet-wide Ship Safety Bulletin (SSB-09-2023) on restricted-visibility best practice, reinforced navigational procedures to bridge crews, evaluated and posted radar blind sectors on the bridge, replaced the ferry's X-band radar magnetron, and met with the ferry service authority to discuss safe-speed reductions and schedule-suspension discretion in heavy fog.

Human Element Analysis

Watching the wrong screen

The master wasn't inattentive – he was actively monitoring a display, just the one showing an assumption (a known ferry crossing the same water) rather than the one showing the actual approaching threat. In fog, the instrument you trust becomes the only picture you have. If it's not the instrument built to detect small, non-cooperative targets, you're navigating on a partial truth.

Silence for the sake of politeness

Neither vessel sounded the fog signals the regulations require. On the ferry, the stated reason was social – not wanting to disrupt crew communication or disturb passengers and nearby residents. A safety-critical signal being skipped for a courtesy reason is a pattern worth recognising in yourself before it becomes routine.

One sensor, and a training gap nobody had closed

The pleasure craft operator held a valid certification and still had, in TSB's words, limited depth of knowledge for navigating a high-traffic waterway in restricted visibility – because the course that certified them never covered it. This wasn't one operator's individual failure to prepare; it was a training system with a real, known gap.

Cross-Industry Parallels

Industry	Incident	The parallel
Aviation	Tenerife Airport Disaster (1977)	Two aircraft operating in dense fog, ambiguous radio communication, and neither crew achieving full situational awareness of the other before it was too late – the same fog-plus-communication-gap combination that put Svanoy and the pleasure craft on a collision course.
Nuclear/Process Safety	Three Mile Island (1979)	Operators fixated on an instrument reading that matched their existing assumption, while the actual developing hazard was visible on a different, unmonitored display – the same pattern as the master's attention on the chart display instead of the radar carrying the real threat.
Rail	Ladbroke Grove Rail Crash, UK (1999)	A known, previously flagged sighting/visibility problem at a specific signal was not addressed before it contributed to a fatal collision – echoing TSB's finding that pleasure craft operators' restricted-visibility training gap was already known (via a 2022 pilot survey) before this collision happened.

Try the Decision Simulator

You're the master, alone on the bridge, fog closing in, and a chart display showing a ferry you already know about. Do you trust what you know, or check what the radar's actually showing you? Play through the real decision points and see which ending you land on.

Test Your Knowledge

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