The Queen of the North sank because the crew on the B.C. Ferries ship's bridge did not follow "sound navigational practice" while cruising down a narrow channel during a storm, according to Transportation Safety Board investigators.

"Essentially, the system failed that night. Sound watchkeeping practices were not followed and the bridge watch lacked a third certified person," said Wendy Tadros, chair of the TSB.

The TSB released a video simulation of the final moments before the Queen of the North hit Gil Island. Transportation Safety Board

The federal agency released its final report Wednesday morning at 10 a.m. PT into the March 2006 sinking of the ferry off the north coast of B.C. Two passengers died in the incident.

The report concluded that Karl Lilgert, the senior officer on the bridge, failed to order a course correction and that the quartermaster, Karen Bricker, never made any course corrections because they might have been distracted by three factors in the minutes before the crash:

• They were engaged in personal discussion.
• There was a squall making navigation difficult.
• They had lost track of fishing vessels in the area on the ship's radar.

The Transportation Safety Board report also found that a number of basic principles of safe navigation were not observed by the bridge team, including:

• Reducing speed when the vessel encountered an area of reduced visibility.
• Failing to call senior officers to the bridge when a squall hit the vessel.
• Failing to maintain an effective lookout.
• Failing to locate and identify navigation lights (on nearby islands).

While the report details the procedures not followed by the two crew members on the bridge that night, it still does not explain why the crew failed to steer the ship away from Gil Island on March 22, 2006.

"The investigation is unable to explain why the fourth officer and quartermaster did not follow basic watch-keeping practices, so as to keep the vessel on course — nor why the fourth officer failed to detect the vessel's improper course for up to 14 minutes," the report said.

The report listed several other contributing factors in the sinking:

• The navigation equipment was not set up to take full advantage of the available safety features and was therefore ineffective in providing a warning of the developing dangerous situation.
• The bridge watch team lacked an appropriately certified third person. This made it more likely that the missed course change would go undetected.
• The working environment on the bridge of the Queen of the North was less than formal, and the accepted principles of navigation safety were not consistently or rigorously applied.
• Unsafe navigation practices persisted, which, in this occurrence, contributed to the loss of situational awareness by the bridge team.

The Transportation Safety Board report also said there were further problems as the Queen of the North sank:

• Some watertight doors were left open.
• There was no accurate head count of passengers, preventing a focused search for missing persons, namely the two victims.

The investigation resulted in several recommendations, including:

• That all large vessels in Canada should have voice data recorders on the bridge.
• That better measures be put in place to ensure crews have an exact count of the number of people on board all ferries before and after any incidents.
• That a third officer be on the bridge at all times

Romantic relationship questioned

The report also dealt with the relationship between the female quartermaster and the male fourth officer, saying that during the time they were off course, the two were "engaged in a conversation of a personal nature." But it also suggests they haven't told the whole story, possibly because of an ongoing criminal investigation and civil court action.

The Queen of the North, a provincially operated ferry, sank off B.C.'s north coast after running aground on March 22, 2006. Transportation Safety Board

None of the crew members involved has spoken publicly about the event that night, but it was previously reported that the quartermaster and fourth officer had recently ended a romantic relationship. After the breakup two weeks before, the shift was their first night shift together.

But the TSB dismissed what investigators called "rumours and innuendo" that the two might have been engaged in inappropriate behaviour at the time of the crash.

The ship's second officer, who was also on duty at the time, was on a meal break in a staff room close to the bridge when the crash occurred, the report said.

All three crew members have since been fired for failing to co-operate with the B.C. Ferries internal investigation. A criminal investigation and civil lawsuits are expected to begin sometime in the future now that the investigation by the TSB has concluded.

The internal report released last year by B.C. Ferries has already concluded the Queen of the North sank after the three crew members in charge of the vessel that night failed to make a routine course correction and ran the vessel into Gil Island.

Following the crash, 99 of the 101 passengers and crew aboard the ferry managed to escape to safety on lifeboats. However, two passengers, Gerald Foisy, 46, and Shirley Rosette, 42, of 100 Mile House, B.C., are still missing and presumed dead.

The Queen of the North sailed between Port Hardy and Prince Rupert.