Marine transportation safety investigation report M20C0101

On 12 May 2020, 3 of the Manitoulin’s crew members were crossing over a submerged mooring line in the vessel’s workboat while proceeding to shore near Sombra, Ontario, when tension came on the line and it struck the workboat. The impact caused all of the crew members to fall overboard. One of the crew members swam to shore and the other 2 re‑boarded the workboat. No injuries were reported.

1.1 Particulars of the vessels

1.2 Description of the vessels

1.2.1 Manitoulin

The Manitoulin (Figure 1) is a River class self-unloading Great Lakes bulk carrier^{Footnote 1} of steel construction with the machinery space and accommodation located aft. The vessel has a self-unloading system with a boom that is located forward. On either side of the vessel, near amidships, there is a gangway that can be lowered to the waterline. The vessel has a rescue boat^{Footnote 2} located on the starboard side of the accommodation. The vessel also has a workboat that was stored on the main deck. At the time of the occurrence, the rescue boat was undergoing repairs and had been unserviceable since the morning of the occurrence.

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1.2.2 Workboat

The Manitoulin’s workboat is a 14-foot aluminum boat of open construction (Figure 2). It has been on the Manitoulin since 2015 and is used approximately 15 to 20 times a year for crew transfers and mooring operations. At the time of the occurrence, the workboat was powered by a 2-stroke 5 hp gasoline outboard engine that weighed 26.2 kg. The engine had a kill switch with a lanyard that was designed to be clipped to the workboat operator.

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The workboat has a Canadian compliance notice^{Footnote 3} posted on the hull that indicates the boat is a Category C, which is a designation for boats “designed to operate in typical steady winds of Beaufort force 6 or less and the associated significant waves heights of up to 2 m.”^{Footnote 4} The compliance notice also indicates that the workboat’s recommended safe limits are as follows:

• A maximum of 4 persons on board, weighing a total of 275 kg
• A maximum total weight of 468 kg, including all persons, gear, and the engine
• An outboard engine with a maximum power of 26 kW and maximum weight of 190 kg

The workboat is launched and retrieved using an electric winch that is hooked to the Manitoulin’s hatch crane davit.  

1.3 History of the occurrence

On 12 May 2020, at approximately 1500,^{Footnote 5} the Manitoulin was approaching a shoreline facility near Sombra, Ontario, to unload stone and carry out a crew transfer (Appendix A). At this facility, there is no dock, but there are mooring chains located on shore to facilitate securing of vessels.^{Footnote 6} As the Manitoulin neared the facility, the workboat was launched to help transfer the vessel’s steel mooring lines ashore. The Manitoulin then came alongside the river bank, approximately 50 m off shore, and maintained position while the mooring lines were being secured.

By 1530, the port anchor had been deployed, and 4 of the vessel’s mooring lines had been secured to shore (Figure 3, items 1, 2, 3, 6, and 9). The aft spring line was secured to shore but kept slack for emergency use in the event that the other mooring lines parted or detached from shore. The line had approximately 9 to 12 m of slack on it. Keeping the aft spring line slack for emergency use was common practice at this location.

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At 1536, unloading operations using the vessel’s self-unloading system (Figure 3, item 5) began. The chief officer was supervising these operations from the starboard side of the main deck. The second officer was assisting from one of the 2 unloading control rooms that are located forward.

Meanwhile, the workboat, which had remained in the water after the mooring lines were secured, was used to carry out a crew transfer. Two relief crew members who were waiting on shore were transferred from the shore to the Manitoulin on the workboat. The relief crew members and the workboat operator then boarded the Manitoulin using the starboard-side gangway,^{Footnote 7} leaving the workboat secured to the base of the gangway. 

Once these crew members had transferred aboard the Manitoulin, a watch handover was done, and a new workboat operator boarded the workboat in preparation for transferring 2 other crew members ashore. The new operator, wearing a personal flotation device (PFD), seated himself at the back of the workboat beside the engine. The operator started the engine without attaching the engine kill switch lanyard to himself.

The operator waited as the 2 crew members (Crew 1 and Crew 2) boarded the workboat with their gear. Crew 2 was wearing a PFD. The operator assigned the 2 crew members to seats: Crew 1 on the middle seat on the centreline of the workboat, and Crew 2 at the front of the workboat facing toward the operator. Their gear, a total of 3 bags, was stowed on either side of the workboat. The estimated total weight on board was approximately 284 kg.^{Footnote 8}  

Before departing, the operator checked the position of the aft spring line, which dropped straight down the side of the Manitoulin with the remainder of the line submerged in the water. The operator also checked to see if the Manitoulin was moving in the current; it appeared stationary. The current was downstream at approximately 2 to 3 knots. Crew 2 released the painter line that had been securing the workboat to the gangway. The operator initially allowed the workboat to float backwards with the current. He then turned his visual attention toward the shore and used the engine to manoeuvre the workboat stern-first^{Footnote 9} toward the crew vehicle waiting on shore (Figure 3, item 10).

The most direct route between the gangway on the Manitoulin and the crew vehicle required the workboat to pass over the Manitoulin’s submerged aft spring line. The same route had been taken earlier by the previous operator when transferring the relief crew to the Manitoulin. The mooring winch for the aft spring line was unattended.

The workboat was halfway to shore when it passed over the submerged line. At that moment, the Manitoulin shifted and the line came under tension. Crew 2 shouted a warning as the line suddenly rose out of the water. It caught the workboat between the transom and the outboard engine, rapidly lifting the stern into the air and submerging the bow into the water. All 3 crew members were thrown into the water. The workboat filled with water but remained partially floating due to its reserve buoyancy.

Crew 2 was able to hold onto the workboat and climbed back on board. From inside the workboat, Crew 2 was able to help the operator climb back into the workboat as well. At this time, the workboat’s engine was still running. Crew 1 started to swim the approximately 20 m to shore using his backpack for flotation.

The chief officer observed the incident and used his hand-held very high frequency radiotelephone to broadcast a call about persons overboard on the vessel’s working channel. The master, who was on the vessel’s bridge, began to coordinate a response. A few crew members who were standing on the cargo deck were assigned to keep a watch on the crew members in the water.

Approximately two minutes after the swamping, Crew 1 had reached the shore, and the operator and Crew 2 had motored the swamped workboat to shore. None of the crew members were injured. The workboat was pulled out of the water and onto the shore bank with the assistance of a front-end loader.

1.4 Damage to the workboat

The workboat’s engine was a total loss, as it would not start after it was used to motor the swamped vessel to shore. The workboat itself was not damaged.

1.5 Environmental conditions

At the time of the occurrence, the sky was clear and the visibility was 25 nautical miles. The wind was 14 knots from the west. The air temperature was 5 °C, and the water temperature was 7 °C. The wave height was 0.3 m, and the current was 2 to 3 knots downstream.

1.6 Personnel certification and experience

The master on the Manitoulin held a Master, Near Coastal certificate of competency that was first issued in 2019. He had worked for Lower Lakes Towing Ltd. since 2011.

The workboat operator involved in the occurrence held a bridge watch rating certificate^{Footnote 10} issued in 2019 and had served as a deckhand and wheelsman on board the Manitoulin for approximately 1 year. He had been an ordinary seaman since 2015. The workboat operator had completed training on the operation of the Manitoulin’s workboat in June 2019. The training was provided by the vessel’s second officer at that time and consisted of familiarization with a company procedure for workboat operations and practice operating the workboat. 

1.7 Vessel certification

The Manitoulin carried all of the required certificates for a vessel of its class and for the intended voyage. The Manitoulin was a delegated vessel and had last been inspected by its recognized organization (RO) on 13 September 2019. The Manitoulin’s workboat was not required to be registered^{Footnote 11} or inspected.^{Footnote 12} Consequently, it was not registered with and had never been inspected by Transport Canada (TC).

TC is in possession of a Small Vessel Declaration of Conformity form that applied to the model of workboat on the Manitoulin. The form is a declaration from the importer that the workboat was built to comply with the construction requirements of the Small Vessel Regulations (SVR). The form had been submitted to TC by the importer in 2010.

1.8 Use of workboats on lake freighters

Workboats are common on lake freighters and tend to be used for various purposes, including vessel inspection and maintenance, transfers of crew and materials, and oil pollution emergencies. In addition to the Manitoulin, Lower Lakes Towing Ltd. has 8 other lake freighters, all of which have workboats on board.

1.9 Mooring line hazards

There are various hazards associated with mooring lines, primarily because of the large loads these lines carry. One type of hazard is the uncontrolled movement of slack mooring lines. Factors like wind, current, waves, and passing vessels can cause a vessel to move constantly if moored with slack lines, especially if the vessel is in an exposed location with a limited number of lines. As the vessel moves, slack mooring lines can rapidly come under tension and suddenly rise up, creating a slingshot effect. Being struck by a mooring line in such a situation can result in injury or death.^{Footnote 13},^{Footnote 14},^{Footnote 15}

Developing a mooring plan provides an opportunity to evaluate the vessel’s mooring arrangement and prevent the uncontrolled movement of mooring lines. A mooring plan typically establishes the number and position of lines required to prevent a vessel from moving, as well as other specific precautions that may be needed. Lower Lakes Towing Ltd. did not require its vessels to develop mooring plans, and the Manitoulin did not have a mooring plan for mooring at the shoreline facility near Sombra.

1.10 Effect of expectations on reaction time

For a person to interrupt what they are doing in order to react to a hazard, a condition or stimulus needs to be visible or detectable (available to the senses), perceived (assigned meaning), and recognized (as sufficiently important). Expectations about a situation can affect whether and how appropriately a person responds to hazards in the environment. When people receive information that they expect to receive, they tend to react quickly and without error. However, when they receive information that they do not expect, their performance tends to be slow or inappropriate.^{Footnote 16}

At the time of the occurrence, the workboat operator did not expect to see the aft spring line to come under tension and rise up and could not take action to avoid it.

1.11 Falling overboard

In Canada, falling overboard is one of the top causes of death in the marine industry. A person falling into water that is below 15 °C^{Footnote 17} experiences an initial cold shock, which can be fatal. If they survive the cold shock, exhaustion can quickly set in as they attempt to stay afloat. Exhaustion increases rapidly if the person is not wearing a PFD.

PFD use can minimize the adverse consequences of being immersed in cold water and increase a person’s chances of survival until help arrives. Not wearing a PFD when there is a risk of falling in the water is a safety issue that has been identified by the TSB on both commercial vessels and fishing vessels^{Footnote 18}.

Rapid recovery of the person from the water is also critical to increasing their chances of survival and can be facilitated by vessels having a person-overboard procedure and a rescue plan in place. Under the Maritime Occupational Health and Safety Regulations (the MOHS Regulations), ^{Footnote 19} when a hazard of drowning exists, employers are required to provide PFDs, emergency equipment, a written emergency response procedure, a qualified person ready to intervene, and a vessel that is ready to respond. ^{Footnote 20} The Manitoulin was subject to the MOHS Regulations.

PFDs were available in the workboat, but only 2 of the 3 crew members in the workboat were wearing one.

TC is responsible for enforcing the MOHS Regulations.^{Footnote 21} One of the ways it does this is through routine visits to workplaces, such as vessels.

1.12 Safety management system

The International Safety Management Code (ISM Code) provides an international standard for the safe management and operation of vessels and for pollution prevention.^{Footnote 22} Its objectives are to ensure safety at sea, prevent human injury or loss of life, and avoid damage to the environment and to property.

Under TC’s Safety Management Regulations, vessels that are subject to the International Convention for the Safety of Life at Sea (SOLAS) must comply with the ISM code, which requires companies and vessels to develop and implement a safety management system (SMS) that establishes safeguards against all identified risks. This involves establishing procedures, plans, instructions, and checklists for shipboard operations that concern the safety of personnel, the vessel, and the environment. The Code specifies that the various tasks should be defined and assigned to qualified personnel.

The ISM Code also requires companies to identify potential emergency shipboard situations and establish procedures to respond to them. For example, a potential emergency shipboard situation on any vessel is a person overboard. A procedure to respond to this situation should identify the equipment intended to be used for recovery purposes and measures to be taken by the crew.

Vessel operators that are required to have an SMS must go through an auditing process by a third party (an RO or a classification society) to ensure that their SMS meets the requirements of the ISM Code and that the company and the vessel are operating in accordance with the SMS. Both the company and its vessels must obtain certificates to indicate compliance (the company is issued a document of compliance [DOC] and the vessel is issued a safety management certificate [SMC]).

Operators for whom the ISM Code does not apply may choose to voluntarily adopt it. Companies that voluntarily implement SMS may opt to have their SMS audited by a third party. Upon verifying that the voluntary SMS meets the requirements of the ISM Code and that the company and the vessel are operating in accordance with the SMS, the third party will issue the company a DOC and the vessel an SMC. As a non-Convention vessel, the Manitoulin was not required to comply with the ISM Code. However, Lower Lakes Towing Ltd. had voluntarily implemented an SMS on the vessel. In 2016, Lower Lakes Towing Ltd. was issued a voluntary document of compliance, and in 2017, the Manitoulin had been issued a voluntary SMC issued by the American Bureau of Shipping. These certifications indicated that the company and the vessel complied with the requirements of the ISM Code.

The Manitoulin’s SMS contained a risk assessment on the operation of the workboats in the fleet, as well as a workboat operations procedure. Both the risk assessment and the procedure were developed in 2015. These documents were generic and applied to all of the workboats in the fleet. 

TC is in the process of amending Canada’s Safety Management Regulations. When the proposed amendments come into force, Canadian vessels of 500 gross tonnage or more and the companies that operate them will be required to develop, implement, and maintain an SMS in compliance with the ISM Code.

1.12.1 Risk management

Risk management under an SMS is a continuous cycle that involves identifying hazards, assessing their risk, implementing mitigation measures to reduce or eliminate them, and assessing the effectiveness of these measures. Effective mitigations not only help to reduce the severity and probability of a hazard, but also can help recalibrate the way that the hazard is perceived (i.e., a hazard with no risk mitigations in place can be perceived as not being a threat compared to one with risk mitigations in place). Risk management is a continuous process, and assessments should be reviewed regularly by all parties involved.  

Recognizing the importance of risk management, the MOHS Regulations require employers to develop, implement, and monitor a program for the prevention of hazards in the workplace.^{Footnote 23} Lower Lakes Towing Ltd. had developed a hazard prevention program guide that was revised in 2019, and each vessel in the fleet had a copy on board. For all policies, procedures, and risk assessments, the hazard prevention program made reference to Lower Lakes Towing Ltd.’s voluntary SMS. 

The risk assessment that Lower Lakes Towing Ltd. had completed for the operation of the workboats identified hazards of falling overboard, drowning, and slipping and falling. The overall risk for the operation of the workboats was initially evaluated as moderate. Mitigating measures were listed as adherence to the workboat operations procedure, crew training, and use of all appropriate personal protective equipment (PPE). The residual risk was assessed as tolerable.^{Footnote 24}

The risk assessment did not identify specific hazards associated with workboats transiting in proximity to mooring lines. As well, there was no requirement for masters to develop mooring plans or complete risk assessments at shoreline facilities where the use of workboats was necessary.

1.12.2 Workboat operations procedure

The workboat operations procedure provided instructions for how to prepare, launch, and recover the workboats, as well as how to safely embark and disembark (Appendix B). It also listed required PPE and safety equipment to be worn by persons in the workboats. Training provided to workboat operators was based on this procedure.

Among other things, the procedure instructed crew members to use extreme caution when navigating between the forward and aft ends of the vessel due to mooring line hazards and propellers. ^{Footnote 25} The procedure also mentioned that workboats need to be inspected before launching, but no specific crew members were assigned to this task and no record of maintenance for the Manitoulin’s workboat was found as part of the investigation. However the procedure did not include weather restrictions or information about the purpose and use of kill switches, nor did it inform operators of specific mooring line hazards that may be present. It also did not specify the workboats’ recommended safe limits.

In this occurrence, the operator’s understanding was that the maximum capacity of the Manitoulin’s workboat was 5 persons, although the compliance notice specified 4 persons.

1.12.2.1 Workboat safety equipment

As a power-driven vessel of less than 15 in gross tonnage, the Manitoulin’s workboatwas subject to the SVR, which required the workboat to carry approved lifejackets; a marine emergency first aid kit; a buoyant heaving line; a watertight flashlight; flares; oars; an anchor with chain, rope, or cable; a manual bilge pump; a sound-signalling device or appliance; navigation lights; and a magnetic compass.

The required PPE and safety equipment listed on the workboat operations procedure included helmets and PFDs for everyone in the workboat, as well as spare PFDs for persons transferring between the vessel and the shore or vice versa. The list also included oars, a painter line, and a hand-held very high frequency radiotelephone.

At the time of the occurrence, and in recent years, the Manitoulin’s workboat was equipped with PFDs, oars, a portable fuel tank, a bailer, buckets, a painter line and a hand-held very high frequency radiotelephone. The workboat did not have the following required items on board: a marine emergency first aid kit; a watertight flashlight; flares; an anchor with chain, rope or cable; a manual bilge pump; a sound-signalling device or appliance; navigation lights; or a magnetic compass. 

1.12.3 Guidance for owners and operators of small commercial vessels

To encourage owners of small commercial vessels to comply with regulations, TC has developed the Small Vessel Compliance Program (SVCP)^{Footnote 26} and a Small Commercial Vessel Safety Guide.^{Footnote 27} Both the SVCP and the guide include checklists that cover safety procedures, operations, crew training, equipment, maintenance, and emergency preparation. Among other things, the checklists prompt operators to

• ensure that the vessel has a procedure for the safe operation of the vessel and for dealing with emergencies,
• ensure that passengers are given a complete pre-departure safety briefing,
• ensure that the vessel has equipment and a procedure for dealing with hypothermia and cold water shock, and
• consider the maximum wave heights and wind speeds in which the vessel will be operating.

The workboats on the vessels operated by Lower Lakes Towing Ltd. were not enrolled in the SVCP, and Lower Lakes Towing Ltd. did not use the Small Commercial Vessel Safety Guide for its workboat operations procedure. As such, the company had not incorporated in its operations any of these considerations from TC.

1.13 TSB survey of companies operating lake freighters with workboats

In September 2020, the TSB sent a survey to 9 other companies operating lake freighters in order to collect data about their workboats. Five companies responded. One company had a procedure for the operation of its workboats. Two of the companies indicated that they had risk assessment sheets on board their workboats. These companies had identified hazards associated with the workboats that encompassed slip, trips, falls, engine trouble, malfunction of the appliances used to launch and recover the workboat, strong current or tide, high waves, poor visibility, traffic in proximity to the workboat, loss of communication, and hazards around mooring lines.

Three companies indicated that their workboats were not registered, nor were they part of the SVCP. One company indicated that the safety equipment carried on its workboats did not comply with the SVR.

1.14 Engine kill switch lanyard

The workboat’s engine had a kill switch with a lanyard that was designed to be clipped to the operator while the engine was in operation. If the lanyard was pulled from its connector switch, the engine would stop to prevent it from running with no one at the controls. At the time of the occurrence, the lanyard was tied to the side of the workboat, and the operator was not aware of how it functioned. Previous investigations by the TSB^{Footnote 28} and by the United Kingdom’s Marine Accident Investigation Branch^{Footnote 29} have noted that not using this safety device could lead to a situation where the engine continues to run with no one at the controls when people are in the water.

1.15 Supervision

Supervision can have a significant impact on many factors that influence employee behaviour in the workplace.^{Footnote 30} Supervision supports and reinforces compliance with procedures and priorities. It can also assist with employee engagement and motivation, the management of workload, the identification of workplace hazards, and the prevention of unsafe acts.

At the time of the occurrence, the senior deck officers on the Manitoulin were involved with self-unloading operations and were not supervising the crew transfer. No one instructed the crew members on board the workboat to wear PFDs, nor did anyone brief the operator about hazards related to the operation.

1.16 TSB Watchlist

The TSB Watchlist identifies the key safety issues that need to be addressed to make Canada’s transportation system even safer.

Safety management is a Watchlist 2020 issue. As this occurrence demonstrates, even when formal processes are present, they are not always effective in identifying all hazards or managing the risks in every aspect of a vessel’s operations. Furthermore, when an operator voluntarily implements an SMS, the system does not receive any oversight from TC to ensure that it is effective.

1.17 Previous TSB occurrences involving workboats on lake freighters

Since 2002, the TSB has received 4 reports of occurrences involving workboats on lake freighters:

M16C0222 – On 22 December 2016, the workboat belonging to the Mississagi capsized during launching and 3 crew members fell into the water in Sault Ste. Marie, Ontario. The crew members were immediately retrieved from the water and sustained minor injuries. There was no damage or pollution. The Mississagi is also owned by Lower Lakes Towing Ltd.

The TSB sent a marine safety information letter to Lower Lakes Towing Ltd. and TC noting that, in this occurrence, the guidance provided in the workboat operations procedure had not been followed. The company issued a memorandum to the vessel’s crew, but neither the procedure nor the 2015 risk assessment on workboat operations were revised following this occurrence.

M13F0027 – On 07 December 2013, the workboat belonging to the CSL Tadoussac capsized and 1 crew member fell into the water in Ashtabula Harbour, Ohio, U.S. The crew member swam to shore.

M10C0060 – On 04 August 2010, the workboat belonging to the Saginaw capsized and 3 crew members were thrown into the water in Sarnia, Ontario. No injuries were reported.

M02C0079 – On 25 November 2002, the workboat belonging to the Algomarine capsized while crew were preparing to disembark and 3 crew members were thrown into the water in Windsor, Ontario. The crew members were wearing lifejackets and were recovered with mild hypothermia.

All 3 crew members on the Manitoulin’s workboat were thrown into the water after the workboat crossed over a slack mooring line that suddenly came under tension. The investigation looked at the risk associated with the uncontrolled movement of mooring lines, the company’s process for assessing and mitigating risks related to the use the workboat, as well as the adequacy of the workboat operations procedure.

2.1 Factors leading to the occurrence

The Manitoulin was moored 50 m offshore at a facility that is not equipped with a dock, and so the vessel’s workboat was used to transfer crew members ashore.

After the workboat operator boarded and did the watch handover, and before departing, he checked for potential spring line hazards by looking at the position of the aft spring line, which appeared to be slack and submerged in the water. He also visually checked, and determined that the Manitoulin was not moving, which would make spring line hazards less likely. These observations were consistent with an expectation that the direct route from the Manitoulin to shore would be clear of hazards, and so the operator proceeded with the crossing.

However, it was very difficult to predict the vessel movements in the strong current with any reliability, and even a small shift in the vessel’s position could result in the uncontrolled movement of the mooring line. Additionally, from the operator’s perspective in the workboat, and with his visual attention primarily on the shore, it would have been difficult to detect any movement of the Manitoulin or of the aft spring line.

The speed at which the line rose out of the water and the fact that this event was unexpected meant that the workboat operator was unable to manoeuvre the workboat out of the path of the line in time to avoid the impact.

2.2 Uncontrolled movement of mooring lines

The uncontrolled movement of mooring lines poses a risk of injury or death to anyone working near or over them because they can come under tension quickly and unpredictably. The uncontrolled movement of lines must therefore be prevented at all times. This can be accomplished by keeping all mooring lines as close to taut as possible, or by carefully monitoring any lines with slack on them to reduce the consequence of any unexpected tension. Ensuring that crew working near mooring lines are fully aware of the risks and are following safe working practices can also prevent injury or death.

On the Manitoulin, it was common practice to leave the aft spring line slack in the water at locations without formal docking facilities. At these locations, there was no requirement in the safety management system (SMS) for the master to develop a mooring plan that considered the uncontrolled movement of mooring lines, nor was there a requirement to establish safety precautions for mooring lines. As a result, the aft spring line was left slack and obscured below the water without precautions to mitigate the risk of it rising out of the water without warning. As well, the Manitoulin’s mooring arrangement meant that there was no clear path for the workboat to cross from the starboard side of the vessel to shore.

2.3 Risk management

Effective risk management is an ongoing process involving individuals at all levels of an organization. It entails identifying hazards, analyzing and evaluating the risk associated with those hazards, and putting mitigating measures in place. Since operational risks are not static but can emerge and change over time, it is crucial that risk assessments be regularly evaluated and updated in order to address new hazards or identify existing hazards that may have been initially overlooked. It is also important that any mitigating measures put in place have adequate controls to ensure that the people performing the mitigation measures are monitored and complying with these measures. 

Although a risk assessment on workboat operations had been carried out in 2015, it had not been revisited since then. Even after an occurrence in 2016 where crew members on another vessel owned by Lower Lakes Towing Ltd. went overboard from a workboat, the risk assessment was not updated. This resulted in a missed opportunity to evaluate whether hazards associated with workboat operations were being addressed effectively.

The 2015 risk assessment looked at workboat operations in general and did not consider specific hazards associated with crew transfers. This meant that a number of factors that have the potential to affect the safety of crew transfer operations were not assessed, including

• whether the workboat is transiting near mooring lines and the hazards of doing so,
• whether there is a rescue plan in the event of a person going overboard, 
• whether the rescue boat is serviceable at the time for a crew transfer,
• whether the workboat’s outboard engine is sufficiently powered for the current, and
• whether the workboat is compliant with current regulations.

Effective and well-documented procedures for routine tasks on board a vessel help crew members to perform these tasks with an understanding of the associated risks and control measures. When followed, these procedures contribute to consistent and safe working practices on board a vessel. In this occurrence, there was no procedure in place to respond to and recover persons going overboard, the rescue boat was unserviceable, and not all of the safety equipment required by both regulation and company procedure was available or being used on the workboat. Because these factors had not been assessed, there were no mitigating measures in place, which may have contributed to a perception that the crew transfer was a low-risk activity. Without mitigations in place to recalibrate risk perception, the subjective evaluation of low personal risk may lead to an increase in the performance of high-risk activities.^{Footnote 31}

Although there were some mitigating measures to address other risks that had been identified by the 2015 risk assessment, there were no controls in place to ensure that crew members complied with them. For example, although use of all personal protective equipment (PPE) was required, not everyone in the workboat was wearing a PFD, and there were no controls in place, such as supervision and inspections, to ensure that this was being complied with.

As a result, in this occurrence, the Manitoulin’s mooring location had not been assessed for the safety of a crew transfer, and the risks of navigating over a mooring line that could move unexpectedly and rapidly were not fully appreciated.

2.4 Workboat operations procedure

Effective documented procedures can contribute to consistent and safe working practices on board a vessel, as well as compliance with applicable regulations. It is important that procedures provide key information to ensure that operators are informed about any hazards or limitations that impact safety.

Given that the Manitoulin and other vessels in the Lower Lakes Towing Ltd. fleet frequently moored at shoreline facilities without traditional berths and that their workboats were regularly used for crew transfers and transporting mooring lines ashore, it was important that the workboat operations procedure provided information to operators about the hazards of navigating near mooring lines.

The investigation determined that, although the Manitoulin’s workboat operations procedure mentioned that operators should use extreme caution due to mooring line hazards, it did not specify the nature of these hazards or provide options to mitigate their risks. The operator of the workboat may have benefitted from information about the hazard of slack mooring lines suddenly coming under tension and the comparatively slow speed of human reaction time. Options to mitigate the risk of this hazard could have included a requirement for a mooring plan that prevented the uncontrolled movement of mooring lines or a prohibition on navigating over slack mooring lines.

The investigation also identified that the workboat operations procedure did not include some key information necessary for the safe operation of the workboat. For example, it did not prompt the operator to provide a safety briefing to personnel on board and to ensure that they wore PPE. It also did not cover the workboat’s recommended safe limits (maximum total weight and number of persons), waves and wind limitations, or the use of the kill switch lanyard. Training for the operators, which was based on the workboat operations procedure, did not cover any additional information about these items. As a result, the workboat operator did not know the workboat’s safe limits and was not aware of how the kill switch lanyard functioned. The lanyard was not clipped to him in this occurrence, and so the engine remained running in proximity to the crew members in the water, posing a risk of injury.

Finally, the investigation identified that the list of safety equipment included in the workboat operations procedure did not include all of the items required under the Small Vessel Regulations. As a result, although the workboat carried the equipment listed in the procedure, it did not meet the requirements of the Small Vessel Regulations. Because a workboat is not part of a vessel’s lifesaving equipment and is not required to undergo external inspections, it can be overlooked by the crew, the company, and the regulator. In this case, Lower Lakes Towing Ltd. was not aware of the safety equipment requirements in the Small Vessel Regulations, and none of the workboats in the fleet were carrying the equipment necessary for compliance.

3.1 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.

1. While the Manitoulin was moored, the aft spring line was left slack, which meant the line could submerge and then unexpectedly rise out of the water with the vessel’s natural movements, posing a risk to anyone crossing near or over it.
2. Because of the way the vessel’s mooring lines were arranged, and the strong current on the port side, the route from the starboard gangway to the crew vehicle waiting ashore required the workboat to cross over the slack aft spring line, which was submerged.
3. The vessel’s senior officers were focused on unloading operations and did not brief the workboat operator or supervise the crew transfer, which resulted in a missed opportunity to consider the risk posed by uncontrolled movement of the aft spring line.
4. Given that the Manitoulin appeared to be stationary and that the aft spring line was submerged and not expected to rise up, the operator proceeded with crossing.
5. As the workboat was crossing over the aft spring line, the Manitoulin shifted in the current and the line rose up, catching the workboat by the stern and throwing all 3 of the crew members into the water.

3.2 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.

1. If precautions are not taken to mitigate the hazards associated with the uncontrolled movement of mooring lines, there is a risk that workers in the vicinity of mooring lines will be injured or killed if they are in the path of a line that suddenly comes under tension.
2. If hazards associated with the use of a workboat are not adequately addressed through risk mitigation measures and if compliance with these measures is not monitored, occurrences involving workboats will continue to happen.
3. If procedures for the use of workboats do not contain key safety information regarding operations, hazards, and limitations, there is a risk that workboats will be unknowingly operated in a manner that compromises the safety of those on board.

3.3 Other findings

These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.

1. At the time of the occurrence, Lower Lakes Towing Ltd. did not have a procedure for persons overboard, and the rescue boat on the Manitoulin was out of service for repairs.
2. The Manitoulin had not been subject to a maritime occupational health and safety inspection in the last 5 years. 
3. Some safety considerations that are included in Transport Canada’s guidance for small commercial vessel operators had not been addressed by the company’s safety management system.

4.1 Safety action taken

4.1.1 Lower Lakes Towing Ltd.

Following the occurrence, a due diligence report was completed by the master and crew. While completing the report, the master and crew discussed the incident, and the workboat operators on the Manitoulin were told to never cross slack mooring lines.

On 18 January 2021, Lower Lakes Towing Ltd. issued a policy on the prevention of falls overboard. The policy includes best practices and lessons learned to prevent falls overboard. It also includes descriptions of activities and hazards that may lead to falls overboard, critical activities for various crew members in the prevention of falls overboard, and a job hazards analysis. A memorandum was issued to all captains, engineers, and officers to inform them about the policy.

4.1.2 Smoker Craft Inc.

Following the occurrence, Smoker Craft Inc., the manufacturer of the workboat, performed a flotation test on a workboat of the same model. The test resulted in a change to the recommended safe limits for the power and weight of engines used with this model of workboat. The revised maximum power limit is 22 kW (30 hp), and the revised weight limit is 159 kg. Smoker Craft Inc. is in the process of notifying all relevant parties about these changes.

This report concludes the Transportation Safety Board of Canada’s investigation into this occurrence. The Board authorized the release of this report on 14 July 2021. It was officially released on 30 July 2021.

Appendix A – Chart of occurrence location, with inset image showing map of occurrence location

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Source of main image: National Oceanic and Atmospheric Administration, Chart 14852: Saint Clair River, with TSB annotations
Source of inset image: Google Earth, with TSB annotations

Appendix B – Workboat operations procedure

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Source: Lower Lakes Towing Ltd.