Findings from TSB investigation M20A0434 Sinking of the fishing vessel Chief William Saulis
Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the December 2020 sinking of the fishing vessel Chief William Saulis which resulted in 5 crew members missing, several factors led to the accident. The three findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made three findings as to risk and one other finding.
Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- Without a formal stability assessment, the crew made operating decisions that likely affected the vessel’s stability without sufficient knowledge of the vessel’s safe operating limits.
- The vessel departed the fishing grounds with unshucked scallops on deck and the freeing ports were likely covered either mechanically or by scallops so that water from the heavy beam sea also accumulated on deck. The resulting free surface effect from shifting scallops and water and the rolling motion from the heavy beam sea likely caused the vessel to capsize and sink.
- The ingress rate and cold temperature of the water, fatigue, being woken from sleep, darkness, stress response, and the difficult-to-access escape routes combined to significantly affect survivability.
Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If If a company does not identify hazards specific to the context and nature of operations and assess their risks using a guided process, then fish harvesters will be left without appropriate guidance and safe work practices for mitigating hazards effectively.
- If guidance provided by Transport Canada for written safety procedures required by the Fishing Vessel Safety Regulations, including templates, only partially covers regulatory requirements for effective safety procedures, there is a risk that organizations will not develop complete written safety procedures.
- If the vessel certification process does not identify gaps in safety procedures and provide education, there is a risk that masters, owners, and others filling the role of AR will allow vessels to operate without effective safe work practices.
Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- Yarmouth Sea Products Limited did not have an up-to-date crew list for the Chief William Saulis before the vessel departed for the fishing grounds. Yarmouth Sea Products Limited was unable to provide the Joint Rescue Coordination Centre with the total number of persons on board until 26 hours after the occurrence..
- Yarmouth Sea Products Limited did not have an up-to-date crew list for the Chief William Saulis before the vessel departed for the fishing grounds. Yarmouth Sea Products Limited was unable to provide the Joint Rescue Coordination Centre with the total number of persons on board until 26 hours after the occurrence..
Findings from TSB investigation M20A0434 Sinking of the fishing vessel Chief William Saulis
Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the December 2020 sinking of the fishing vessel Chief William Saulis which resulted in 5 crew members missing, several factors led to the accident. The three findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made three findings as to risk and one other finding.
Findings as to causes and contributing factors
These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.
- Without a formal stability assessment, the crew made operating decisions that likely affected the vessel’s stability without sufficient knowledge of the vessel’s safe operating limits.
- The vessel departed the fishing grounds with unshucked scallops on deck and the freeing ports were likely covered either mechanically or by scallops so that water from the heavy beam sea also accumulated on deck. The resulting free surface effect from shifting scallops and water and the rolling motion from the heavy beam sea likely caused the vessel to capsize and sink.
- The ingress rate and cold temperature of the water, fatigue, being woken from sleep, darkness, stress response, and the difficult-to-access escape routes combined to significantly affect survivability.
Findings as to risk
These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.
- If If a company does not identify hazards specific to the context and nature of operations and assess their risks using a guided process, then fish harvesters will be left without appropriate guidance and safe work practices for mitigating hazards effectively.
- If guidance provided by Transport Canada for written safety procedures required by the Fishing Vessel Safety Regulations, including templates, only partially covers regulatory requirements for effective safety procedures, there is a risk that organizations will not develop complete written safety procedures.
- If the vessel certification process does not identify gaps in safety procedures and provide education, there is a risk that masters, owners, and others filling the role of AR will allow vessels to operate without effective safe work practices.
Other findings
These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.
- Yarmouth Sea Products Limited did not have an up-to-date crew list for the Chief William Saulis before the vessel departed for the fishing grounds. Yarmouth Sea Products Limited was unable to provide the Joint Rescue Coordination Centre with the total number of persons on board until 26 hours after the occurrence..
- Yarmouth Sea Products Limited did not have an up-to-date crew list for the Chief William Saulis before the vessel departed for the fishing grounds. Yarmouth Sea Products Limited was unable to provide the Joint Rescue Coordination Centre with the total number of persons on board until 26 hours after the occurrence..