News release

The Transportation Safety Board of Canada (TSB) published its investigation report (M22C0005) on the fatal mooring accident on board the Madeleine II, a Coopérative de Transport Maritime et Aérien (CTMA) ferry, that took place on its arrival at the Îles de la Madeleine, Quebec.

On 9 January 2022, as the Madeleine II was moving astern to dock at wharf no 2 in the Cap-aux-Meules harbour, Quebec, the chief mate was in the snap-back zone and was fatally injured from the first spring line that released abruptly when the mooring bollard failed due to the tension on the mooring line. The situation developed very quickly, and the master was not notified in time to bring the vessel to an emergency stop.

The investigation found that before the Madeleine II arrived at the harbour, the master and chief mate had agreed to use a second spring line during the dynamic phase of the mooring operations. While this practice requires three deckhands and one officer, only two deckhands and one officer were involved in this operation. As the vessel was moving astern, the first spring line became stuck on the winch drum. At that moment, the chief mate had stopped paying attention to the situation outside because he had left his post to handle the second spring line. He therefore did not see that the tension was increasing, nor that the winch operator was trying to inform him of the situation.

The investigation also found that the CTMA safety management system did not include procedures specific to the Madeleine II. Without a formal written procedure for mooring the vessel, the crew did not have decision-making guidelines, and the risks of the procedure for 2-spring-line mooring without a third deckhand were not well understood.

Between May 2017 and March 2022, 12 occurrences (including this occurrence) involving serious or sometimes fatal injuries during mooring operations in Canada on domestic and foreign-flagged vessels were reported to the TSB.

Following the accident, Transport Canada did an inspection and required that mooring procedures be implemented for the Madeleine II at both Cap-aux-Meules and Souris, Prince Edward Island. The CTMA produced an internal investigation report, took action to mark the hazard zones at the mooring stations and displayed a mooring procedure on the vessel.

In October 2022, the TSB sent Marine Transportation Safety Advisory Letter 03/22 to Transport Canada and the CTMA regarding safety during mooring and unberthing operations, particularly the effect of the phenomenon known as “snap-back” and the marking of hazard zones on mooring stations.

See the investigation page for more information.