News release

Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M22A0332) into an occurrence where a crew member on pilot boat A.P.A. No. 18 fell overboard near St. John’s, Newfoundland and Labrador.

On 26 September 2022, during the hours of darkness, the pilot boat set out with the master, a deckhand, and a pilot on board to complete a pilot transfer operation to an inbound vessel near the entrance to St. John’s Harbour. Shortly after the transfer, the deckhand fell overboard. The deckhand’s personal flotation device’s failure to inflate reduced the likelihood of his survival while he was immersed in cold water. He was recovered by the inbound vessel and was later pronounced dead.

The crew of A.P.A. No. 18 used a wire and tether system to reduce the risk of going overboard; however, it was determined that its design and installation prevented the crew members from being continuously connected to the wire as they moved on the vessel. The system design required crew members to disconnect their tether while transitioning from the side to the front of the wheelhouse, which contributed to the deckhand being untethered and subsequently falling overboard.

Masters and crew members were required to, and often did, conduct person-overboard drills, which were exercised in the calm waters of St. John’s Harbour and with a deckhand available to help. As a result, the drills did not reveal that a single person could not manoeuvre the vessel and rescue an unconscious person from the water using the available recovery equipment. This impacted the level of emergency preparedness and made it practically impossible for the master alone to retrieve the deckhand from the water.

The investigation also revealed that if a company’s safety management system does not facilitate the flow of safety information from the operational level to management, there is a risk of vessels operating with hazards that are known but without adequate defences.

As a result of the occurrence, the TSB issued Safety Advisory Letter 01/23. The Atlantic Pilotage Authority and Canship Ugland Ltd. took action by convening a special occupational health and safety meeting and making multiple safety improvements.

See the investigation page for more information.