Marine transportation safety investigation M22C0005

TSB has completed this investigation. The report was published on 10 July 2024.

Table of contents

    Mooring accident
    Roll-on/roll-off ferry Madeleine II
    Cap-aux-Meules, Quebec

    The occurrence

    On 09 January 2022, the chief mate on the roll-on/roll-off ferry Madeleine II was fatally injured during a mooring accident while the ferry was docking at wharf No. 2 in the Cap-aux-Meules harbour, Quebec. There was no damage to the vessel, and no pollution was reported.


    Safety Communications

    Safety advisory

    Media materials

    News releases

    2024-07-10

    The TSB highlights the risks of mooring operations following the 2022 fatal accident in the Cap-aux-Meules harbour, Quebec
    Read the news release


    Investigation information

    Map showing the location of the occurrence

    M22C0005

    Mooring accident
    Roll-on/roll-off ferry Madeleine II
    Cap-aux-Meules, Quebec

    Investigator-in-charge

    Image
    Photo of Yevgen Lezhankin

    Yevgen Lezhankin joined the TSB as an investigator with the Central region of the Marine branch in 2018. Yevgen holds a Master Mariner certificate and has worked at sea for 22 years, navigating internationally and in Eastern Canada. Before joining the TSB, Yevgen was working as a Transport Canada marine safety inspector in Port-Cartier and Quebec City. Yevgen graduated from Odessa State Maritime Academy and has a bachelor’s degree in navigation.


      Download high-resolution photos from the TSB Flickr page.

    Class of investigation

    This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 days. For more information, see the Policy on Occurrence Classification.

    TSB investigation process

    There are 3 phases to a TSB investigation

    1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
    2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
    3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

    For more information, see our Investigation process page.

    The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.