This article has been extracted from the much longer main report and covers specific aspects of marine transportation safety.
The TSB received 1209 reports of marine transportation occurrences in 2022 (241 accidents and 968 incidents), including seven fatalities.
The total of 241 marine transportation accidents represents an increase from the 220 accidents in 2021 but is lower than the 10-year average of 276. In 2022, 82% of accidents were shipping accidents (when a ship, for example, sinks, founders, or capsizes), the same as the previous 10-year average (82%). The remaining 18% of accidents in 2022 were aboard a ship (when a person was killed or seriously injured when, for example, boarding a ship or by falling overboard), also the same as the previous 10-year average (18%).
There were seven marine transportation fatalities in 2022, fewer than the 11 in 2021 and lower than the 10-year average of 15. Of the 7 fatalities, 2 involved shipping accidents. Over the previous 10 years, fatalities were fairly evenly divided between shipping accidents and accidents aboard ship.
As in previous years, the highest proportion of the fatalities (three of the seven) was related to commercial fishing (Canadian-flag vessels in Canadian waters). Due to this continuing trend, commercial fishing safety remains a key safety issue on the TSB Watchlist.
There were 229 vessels involved in the 197 shipping accidents that took place in 2022. In 2021, 200 vessels were involved in 177 shipping accidents. The increase was observed in all regions.
The 968 marine transportation incidents reported to the TSB in 2022 represent a 13% increase from 2021 and a 25% increase from the 10-year average of 776. As in previous years, most reportable incidents (82%) were related to the total failure of machinery or technical systems. The increase in incidents of this type is due largely to changes made in 2014 to TSB reporting requirements.
Accident rate: A measure of marine transportation safety
According to TC, 2022 marine activity (commercial vessel-kilometres) for Canadian commercial non-fishing vessels with a gross tonnage of over 15 (excluding passenger vessels and cruise ships) was 10% above the 2013-to-2021 average. The 2022 accident rate was 3.0 accidents per million commercial vessel-kilometres, lower than the 2013-to-2021 average of 4.0.
In 2022–23, TSB staff deployed to 12 marine transportation occurrences (five more than in 2021–22), began nine investigations, and completed 10.
Industry-wide surveillance issue related to written safety procedures
Following its investigation into the fatal 2020 sinking of the fishing vessel Chief William Saulis (M20A0434) near Digby, Nova Scotia, the TSB issued a recommendation to the Department of Transport to ensure that each inspection of a commercial fishing vessel verifies that each required written safety procedure is available to the crew and that the crew are knowledgeable of these procedures (M23-05). Both the Canada Shipping Act, 2001 and the Fishing Vessel Safety Regulations require a vessel’s authorized representative to provide written safety procedures that familiarize vessel crews with operational and emergency activities. While the vessel owner had provided a manual for vessel operations and safety, most of the safety procedures were based on templates provided by TC. The investigation found that these templates did not include all procedures required by regulation.
As seen with the Chief William Saulis, many company manuals may be incomplete if based mostly on these TC templates. Without TC oversight to validate that the written procedures required by regulation on board fishing vessels have been developed and that crew are knowledgeable of their content, there is a risk that fishing operations will continue without guidance critical to support the safety of the crew and the vessel.
The TSB has been monitoring commercial fishing safety since 1999, and this issue has been on the TSB Watchlist since 2010. Every year, the same safety deficiencies on board fishing vessels continue to put at risk the lives of thousands of Canadian commercial fish harvesters and the livelihoods of their families and communities.
The issue of fatigue management has been on the TSB Watchlist for rail transportation since 2016 and was expanded in 2018 to include air and marine operations.
A lack of timely and effective regulatory surveillance to ensure operators in all modes are compliant is an issue on the TSB Watchlist.
Safety management is an issue on the TSB Watchlist and is a concern in the air, marine, and rail transportation modes.
The ongoing lack of regulatory oversight means that fishing crews are routinely operating on vessels without even knowing how to stay safe or how to respond when things go wrong.
This occurrence raised concerns around four systemic safety issues identified on the TSB Watchlist: regulatory surveillance, commercial fishing safety, fatigue management, and safety management.
Enhancing the safety of tugs of 15 gross tonnage or less
Following its investigation into the fatal 2021 sinking of the tug Ingenika in the Gardner Canal, British Columbia (M21P0030), the TSB issued four recommendations aimed at enhancing the safety of tugs of 15 gross tonnage (GT) or less.
Currently, TC does not certify tugs of 15 GT or less, nor are these vessels required to undergo regular inspections. There were no records to indicate that TC had inspected the Ingenika at any point during its 50 years of operation.
Numerous TSB investigations have found that while vessel owners and operators have the primary responsibility to manage safety, it is vital that TC provide effective oversight. Although the TSB issued a safety concern to TC in 2016, the issue of regulatory surveillance for tugs of 15 GT or less persists and investigation findings continue to show that without adequate surveillance by the regulator, shortcomings in the safety management and operations of such tugs will continue to go unaddressed, leading to more accidents.
The TSB has also noted that there is currently no requirement for towing companies to assess any of the risks that might be present in their operations. This means that risks in towing operations will continue to go undetected and unmitigated, placing crews, tugs, tows, and the environment at risk.
Therefore, the Board recommended that the Department of Transport:
– expand its surveillance program to include regular inspections of tugs of 15 GT or less to verify that these vessels are complying with regulatory requirements (M23-01); and
– require authorized representatives of tugs of 15 GT or less to assess the risks present in their operations, including the suitability of their tugs for the specific towing operations they are undertaking (M23-02).
At the time of the occurrence, the Ingenika was operating in a compulsory pilotage area that falls under the responsibility of the Pacific Pilotage Authority, which is mandated to establish, operate, maintain, and administer safe and efficient pilotage services in British Columbia.
The Pacific Pilotage Authority has a system under which vessels may obtain pilotage waivers that exempt them from having to take a licensed pilot on board if the operators and vessels meet certain requirements. However, it does not verify that the information submitted meets regulatory requirements, which leads to an increased risk that non-compliance will go undetected and compromise safety in compulsory pilotage waters.
The TSB identified similar issues regarding the Pacific Pilotage Authority’s pilotage waiver process in occurrences involving the Ocean Monarch (M17P0244) in 2017 and the Nathan E. Stewart (M16P0378) in 2016.
Therefore, the Board recommended that the Pacific Pilotage Authority:
– verify that eligibility requirements are met before issuing pilotage waivers to companies operating tugs in compulsory pilotage areas (M23-03); and
– implement a process to verify ongoing compliance with waiver conditions by companies operating tugs in compulsory pilotage areas (M23-04).
Improving coordination between federal departments to improve the safety of commercial fishing in Canada
As a result of its investigation into the fatal 2020 sinking of the fishing vessel Sarah Anne in Placentia Bay, Newfoundland and Labrador (M20A0160), the TSB recommended that the Department of Fisheries and Oceans require all commercial fishing vessels to have a current and accurate TC registration (M22-01). Vessel registration gives TC the opportunity to provide safety oversight and guidance to fishing vessel owners. This recommendation is meant to push for improved coordination between the two primary federal departments that interact with the commercial fishing sector. Their combined efforts can work to increase the awareness and compliance with safety requirements among all commercial fish harvesters.
This investigation highlighted a number of systemic factors that were identified by the TSB’s 2009–2012 safety issues investigation into fishing safety in Canada (M09Z0001). These include vessel modifications and their impact on stability; the lack of, or failure to use, lifesaving equipment, such as personal flotation devices (PFDs), immersion suits, and emergency signaling devices; and inadequate regulatory oversight.
The investigation found that the vessel likely capsized suddenly, resulting in all crew members entering the water unexpectedly, before they had the chance to put on lifejackets, personal flotation devices or immersion suits, deploy the life raft, or make a distress call. Without critical pieces of lifesaving equipment, the crew would have remained in the cold water, likely unassisted, and drowned. Also, the Sarah Anne did not have a formal stability assessment, and there was no information available regarding its stability. Without this critical information, the crew made operating decisions without knowing the vessel’s actual safe operating limits. This may have negatively affected the vessel’s stability and led to it capsizing and sinking. The voyage of the Sarah Anne was not actively monitored by any external system and no distress signal was received. This resulted in a delay of several hours in the search and rescue response, severely reducing the crew’s chances of survival.
Regulators, vessel owners, and fish harvesters each must take ownership of safety to reduce accidents and preventable loss of life. Vessel owners can have their vessels assessed for stability, and equip them with the proper lifesaving equipment to survive a sudden capsizing. Crew members aboard fishing vessels can greatly increase their likelihood of survival by carrying a personal locator beacon, to signal for help to get out of the water as soon as possible, and by wearing a PFD to remain afloat until help arrives.
Safety advisories and safety information letters
The TSB issued three marine transportation safety advisories and information letters as part of its investigations in 2022–23.
Safety during docking and undocking operations
As part of Marine Transportation Safety Investigation M22C0005 into the fatal injury of a crew member on the Canadian-flagged roll-on/roll-off ferry Madeleine II in the Cap-aux-Meules harbour, Québec, the TSB issued Marine Transportation Safety Advisory Letter 03/22 to TC in October 2022. The letter identified that according to statistics from the TSB database, from January 2017 to March 2022, 13 occurrences (including the Madeleine II) were reported in Canada on Canadian- and foreign-flagged vessels. As a result of these occurrences, 12 people were seriously injured and two people were fatally injured.
The letter went on to explain that one of the main risks present during mooring operations is snap-back, which is the sudden release of built-up energy in a mooring line under tension. A common practice to mitigate this risk is to paint snap-back zones on the deck at mooring stations. The latest version of the UK Maritime & Coastguard Agency’s Code of Safe Working Practices for Merchant Seafarers now recommends considering the entire mooring deck be considered a snap-back zone and that clear and visible signage be posted to alert the crew. TC was provided this information for whatever follow-up action was deemed appropriate.
Safety issues on passenger vessels owned by the City of Toronto
The TSB conducted Marine Transportation Safety Investigation M22C0231 into the passenger ferry Sam McBride striking the dock while berthing at the Jack Layton Ferry Terminal in Toronto, Ontario. As part of the investigation, the TSB issued Marine Transportation Safety Advisory Letter 02/22 to the City of Toronto. Important safety issues were identified, relating to emergency preparedness, passenger safety management, and lifesaving equipment on one or more vessels operated by the city. For example, pre-departure safety briefings were not being consistently provided to passengers, the vessel’s crew complement for the maximum number of passengers did not allow tasks set out on the evacuation plan and muster list to be completed simultaneously, and passengers were counted using a hand-held tally counter. Furthermore, children, infants, and other passengers who may require extra assistance were not counted separately, and no infant lifejackets were on board.
The safety issues identified in this letter were communicated before the investigation was complete to ensure that those best able to take remedial action and effect change were made aware of the identified safety issues in a timely manner. Resulting from the communication of these safety issues, the City of Toronto’s website was updated to encourage caregivers to bring lifejackets for infants weighing less than 15 kg.
Failure of personal flotation devices to inflate
The TSB conducted Marine Transportation Safety Investigation M22A0332 into a fatality involving the pilot vessel APA No. 18 near St. John’s, Newfoundland and Labrador. A deckhand wearing an auto-inflating personal floatation device (PFD) fell overboard, but the device did not actually inflate. TSB laboratory inspection revealed that the inflator cap and body of the PFD were not mated, causing it to not be sealed and thus not inflate.
As a result, the TSB issued Marine Transportation Safety Advisory Letter 01/23 to the Atlantic Pilotage Authority in February 2023. The letter referred to TC’s Ship Safety Bulletin 12/2019, which highlighted the need to inspect and service inflatable lifejackets regularly and according to the manufacturer’s instructions.
Progress on outstanding recommendations
Of the 18 responses to marine transportation safety recommendations the Board assessed in 2022–23, none were closed, and no recommendations received a rating of Fully Satisfactory. The responses assessed were rated as Satisfactory Intent (six), Satisfactory in Part (nine), and Unsatisfactory (three).
In Recommendation M99-02, issued in November 1999, the Board recommended that the provinces review their workplace legislation with a view to presenting it in a manner that will be readily understood by those to whom it applies, and to help ensure that the enforcement mechanism and the regulatory regime complement each other. By 2021–22, all but two provinces had submitted responses that were assessed as Fully Satisfactory. In 2022–23, the Province of New Brunswick’s response was assessed as Fully Satisfactory with the passing of the bill An Act Respecting the Health and Safety of Fishers. This leaves the Province of Ontario, which continues to conduct consultations with stakeholders and partners to ensure that employers of the commercial fishing sector understand health and safety requirements but still does not have occupational health and safety regulations or guidance in place that is specific to the fishing sector. The Province of Ontario’s response was therefore assessed as being Satisfactory in Part.
For all active recommendations, the TSB will continue to monitor the progress of planned actions and call for action to reduce or eliminate these deficiencies.
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