Marine transportation safety investigation report M23C0032

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The starboard and port forward mooring stations have controls that allow for the forward mooring equipment to be operated from either station. The controls for the combination anchor windlass and mooring winches have 2 speed settings, with the slower speed typically used to handle the anchor and the faster speed used to handle the mooring lines.

At the time of the occurrence, the starboard-side controls for the starboard combination windlass and mooring winch would only operate on the slower speed setting, and the handle for the controls had been removed to prevent use until repairs were completed (Figure 5). The port-side controls for the starboard combination windlass and mooring winch still worked at both speeds. There was no direct line of sight from these controls to the winch due to the vehicle ramp at midship.

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The mooring lines on the Atlantic Vision consist of 12-strand polyester blend ropes that are 44 mm in diameter. Each mooring line has an eye at either end that is covered with a 2.4 m-long protective sleeve of industrial nylon to guard against chafing. The lines have a certified average strength of 120 000 kg and minimum strength of 108 000 kg.

1.3 Les Méchins dry dock

Les Méchins dry dock is located on the south shore of the St. Lawrence River about 46 km east of Matane, Quebec (Figure 6). It is privately owned and operated by Groupe Océan, which acquired it from Verreault Navigation in 2022. Due to the design of the dry dock, vessels can only enter and exit during a specific window of time around high tide. Once a vessel has navigated into the dry dock, it is carefully positioned on blocks, the gate is closed, and the water is pumped out. The window to enter the dry dock is no later than 2 hours after high tide. In this occurrence, the Atlantic Vision was unmooring at around 1500, and high tide was at 1620. This meant there was a window of approximately 3 hours and 20 minutes for the vessel to enter the dry dock. The process normally takes 1 to 2 hours. 

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Some vessels moor at the public wharf while awaiting their turn in the dry dock. There are no line handler services available at the public wharf, but vessels can request assistance from the Les Méchins dock master, who will assemble a shore team consisting of various dry dock workers to help with mooring operations. Typically, some of the shore team members board a vessel if it is moored at the public wharf so that they are in position to take over mooring operations once the vessel reaches the dry dock gate. If the vessel’s crew is not proficient in French, the shore team members selected to board the vessel are chosen based on their working knowledge of English.

If the bridge team is unfamiliar with the area or not proficient in French, they can request the assistance of a local adviser who will board the vessel. The local adviser provides manoeuvring advice and helps with translating and relaying information between the vessel and shore when it is entering and exiting the dry dock. The local advisers are self-employed and work on an on-call basis. They perform a variety of services, including assisting vessels with docking at various docks (e.g., Sept-Îles [Quebec], Matane, etc.) as well as entering and exiting Les Méchins dry dock.

1.4 History of the voyage

On 22 March 2023, the Atlantic Vision departed from North Sydney bound for the dry dock at Les Méchins for its planned periodic survey. At 0730All times are Eastern Daylight Time (Coordinated Universal Time minus 4 hours). on 23 March, the vessel arrived off Les Méchins and waited outside the port area for the local adviser. At 1010, the local adviser boarded, and the vessel proceeded to the public wharf to wait for the dry dock to be available.

Because another vessel was preparing to leave the dry dock, the waiting time at the public wharf would be short, so the bridge team and dock master agreed to moor using 3 lines forward to secure the vessel’s bow and no lines at the stern. The vessel’s stern would be kept alongside with the stern thruster and the help of a tug. At 1110, the Atlantic Vision was secured alongside the public wharf.

While the Atlantic Vision waited for the vessel occupying the dry dock to vacate it, the master, the local adviser, and the dock master developed a plan for unmooring the Atlantic Vision and moving it into the dry dock. The plan was for the head line to be winched back onto the vessel and for the shore team to walk the breast line and spring line over to the dry dock.When the shore team walks lines over to the dry dock, they hold on to the end of the mooring lines once they are released from the bollards and then carry the lines from bollard to bollard as the vessel proceeds at slow speed into the dry dock. As it is a short distance from the public wharf into the dry dock, this process avoids the vessel having to winch in all the lines and then redeploy them shortly after arriving in the dry dock.

Because 2 different languages were in use, radio communications to coordinate the vessel’s manoeuvres into the dry dock would be transmitted on 2 different channels, with the vessel’s crew communicating in English on a vessel channel and the shore team communicating in French on a shore channel. The crew confirmed with the local adviser that he would facilitate communications between the 2 teams by listening to both the vessel and shore channels and relaying information between the master and the dock master as needed. The crew also finalized preparations to enter the dry dock, which included deballasting the vessel to reduce its draft forward to 4.96 m to allow it to go up on the blocks in the dry dock.The vessel’s normal operating draft forward was between 6.1 and 6.3 m.

At 1402, the shore team that would be assisting the Atlantic Vision was called to their stations, as were the Atlantic Vision’s mooring teams. The forward mooring team on the Atlantic Vision consisted of 5 crew members: the second officer, a carpenter, and 3 deckhands. The bridge team at that time consisted of the master, chief officer, a quartermaster, and the local adviser.

The shore team consisted of 8 dry dock workers and the dock master. The director of operations for the dry dock was also on the wharf to observe the operation. The plan was for 4 of the shore team members to board the vessel so they could take control of mooring operations once the vessel had entered the dry dock. Four shore team members were to remain on the wharf and tend to the mooring lines with the dock master supervising.

Around 1440, the 4 shore team members boarded the vessel. Two proceeded to the starboard aft mooring station and 2 proceeded to the starboard forward mooring station. The 2 who proceeded forward noticed that all 3 mooring lines in use were secured on the starboard forward mooring winch (winch M5),When the shore team is walking lines over to the dry dock, the preferred arrangement is to have the lines on separate winches. This is so that the lines can be controlled separately and so that, in the event of a problem with the winch, both lines are not compromised. with the head line on the warping drum.

The forward mooring team informed the 2 shore team members that the combination anchor windlass and mooring winch on the forward starboard side (winch W1) was not working properly and therefore could not be used. The shore team members inquired further about the state of winch W1 and were informed that the winch would pay out normally, but would only winch lines in on slow speed. The shore team members shared this information with the dock master, who then discussed the situation with the bridge team.

Between 1440 and 1500, the master, the local adviser, and dock master began discussing a revised plan for unmooring the Atlantic Vision from the public wharf in light of the problem with winch W1. During this discussion, the dock master used numbers to refer to the mooring lines, and the master used the names of the lines. At 1502, the master asked for clarification about the plan for the spring line. The local adviser explained that the spring line was line number 2, the term the shore team utilized, and the master and local adviser then continued to discuss which lines were on which winch.

At 1503, the dock master requested that an extra line be made standby on winch W1. One of the shore team members at the forward mooring station subsequently confirmed that the line had been made standby. The dock master then informed the local adviser that the shore team was ready for the unmooring operation to begin and that the shore team would walk with line number 2.

At 1504, the local adviser indicated to the master that the unmooring operation could begin with the breast line. The master told the second officer to begin the unmooring operation with the breast line and, shortly after, added that it was okay to proceed with the head line as well. The local adviser relayed on the shore channel that the vessel was beginning the unmooring operation with the breast line and the head line. The vessel’s 2 bow thrusters were operating. The pitch on the forward bow thruster was set at an angle intended to keep the vessel’s bow alongside. The pitch on the aft bow thruster was set to 0. The stern thruster was also still in use.

The second officer went to his post at the aft-most opening of the starboard forward mooring station from where he was visible to the rest of the forward mooring team as well as the shore team and could direct both with hand signals. On the second officer’s signal, the carpenter activated winch M5 and created slack on all 3 of the lines to facilitate releasing them from the bollards on the wharf. Suddenly, winch M5 stopped working. The second officer left his post and went to winch M5 to investigate the problem. He also informed the bridge. This information was relayed to the dock master by one of the 2 shore team members at the forward mooring station.

At 1505:30, the chief officer ordered an electrician to attend to winch M5, but at approximately 1507, it suddenly began operating again. The master then informed the second officer that the spring line did not need to be winched in because the shore team was going to walk it over.

The second officer remained beside winch M5 and began disengaging the drum holding the spring line so that only the breast line and head line would winch in. The carpenter was at the winch controls, 1 deckhand was forward near the roller fairlead used by the head line, 1 deckhand was tending to the head line on the warping drum, and 1 deckhand was coiling the slack from the head line on the deck (Figure 7). The unused portion of the head line was stored in the rope locker under the deck. The 2 shore team members at the forward mooring station were standing near winch W1 underneath fan outlets that generated a significant amount of noise.

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At 1507:45, a shore team member at the forward mooring station broadcast a message indicating that the lines were going to be released. This was followed by a conversation between the shore team on the wharf and the shore team member on the vessel about whether the vessel was ready to bring up the lines, and the shore team member on the vessel indicated it was.

At some point after the master’s initial order to release the lines at 1504, the head line was released into the water. The investigation could not determine the exact timing and the circumstances around its release.

At 1508:04, one of the bridge team members stated that there was a line stuck in the bow thruster. At the same time, one of the shore team members at the forward mooring station broadcast a message indicating that a line was getting close to the thruster. Between 1508:14 and 1508:16, one of the shore team members on the wharf broadcast messages that the line was dangerously close to the thruster and then in it. At 1508:23, the director of operations also observed the head line in the thruster’s tunnel and asked the local adviser to stop the bow thruster.

The local adviser, upon receiving the request from the director of operations, immediately told the master that there was a line in one of the thrusters and asked him to stop the thruster. The master set the forward bow thruster’s pitch to 0.

Meanwhile, at the forward mooring station, the head line had come under tension and started slipping on the warping drum. The deckhand who was holding the head line made an additional turn on the warping drum to stop the movement of the line. Around this time, the shore team members on the wharf observed the head line coming under extreme tension and ran to take cover in case the head line snapped back.

At 1508:51, the head line rapidly pulled through the warping drum and struck the deckhand on the head, destroying his hard hat and seriously injuring him (Figure 8).

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1.5 Environmental conditions

At the time of the occurrence, the air temperature was 0 °C and the skies were overcast with visibility of 10 nautical miles. The wind was from the east-northeast at 10 knots, and the swell was from the northeast with waves of 0.1 m in height. The tide was flooding and was low at 1008 (0 m), high at 1620 (3.2 m), and low again at 2223 (0.3 m).

1.6 Damage

The forward bow thruster was rendered inoperable until the mooring line wound around it was cut and removed (figures 9 and 10). 

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1.7 Vessel certification

The Atlantic Vision carried all the required certificates for a vessel of its class and intended voyage. Its last intermediate survey was carried out by DNV on 26 November 2021. The last time the vessel was in dry dock was at Les Méchins in November 2020.

1.8 Personnel experience and certification

1.8.1 Atlantic Vision

The master held a Master Mariner certificate and had been employed with Marine Atlantic Inc. for 34 years. He had held the position of master for 15 years and had become master on the Atlantic Vision in 2010. Prior to the occurrence, the master had gone into Les Méchins dry dock as master on the Atlantic Vision once before, in November 2020.

The chief officer held a Master Mariner certificate and had been employed by Marine Atlantic Inc. for 6 years. He had worked primarily as a chief officer for 2 years.

The second officer held a Watchkeeping Mate certificate and had been employed by Marine Atlantic Inc. for 20 years. He had worked as a second officer for 16 years.

The 3 deckhands at the forward mooring station all held bridge watch certificates and had each been employed by Marine Atlantic Inc. for at least 2 years.

The Atlantic Vision’s master and deck officers all held General Radio Operator certificates.

1.8.2 Local adviser

The local adviser held a Master Mariner certificate. He mainly worked in the Port of Sept‑Îles, but also contracted out his services to vessels docking in the region of Matane and Les Méchins. The occurrence was his second time boarding the Atlantic Vision to bring it into Les Méchins dry dock, having also been on board when the vessel went into dry dock in November 2020.

The local adviser also held a General Radio Operator certificate.

1.8.3 Dry dock personnel

The dock master had started working at the dry dock in 2017, becoming a superintendent in 2019 and dock master in 2020. Prior to starting work at the dry dock, the dock master had 18 years of experience, mainly as a bridge watch rating.

The 8 shore team members that were assisting with unmooring the Atlantic Vision were trained in various trades relevant to dry dock work (e.g., electricians, welders, mechanics, and painters). They regularly assisted vessels with entering and exiting the dry dock.

Verreault Navigation had originally provided the dry dock workers with a manual that was a copy of Principes de sécurité à l’amarrage developed by Institut maritime du Québec at Cégep de Rimouski.Institut maritime du Québec, Cégep de Rimouski, Principes de sécurité à l’amarrage (September 2012), at https://www.csmoim.qc.ca/public_upload/files/organismes-entreprises-maritimes/sante-securite/principes-de-securite-a-l_amarrage-guide-eleve.pdf (last accessed 09 September 2024). This manual gave an overview of shipboard mooring operations that was intended to familiarize seafarers with processes and equipment used on vessels during these operations. The shore team members were also given a 2-day training session that was based on the content covered in the manual. The first day of the training session focused on theory, and the second day focused on practice. Once a year, the shore team members had refresher training on elements of basic safety in mooring operations.

1.9 Radio communications

The Innovation, Science and Economic Development Canada website provides general radio operating procedures for use by the public.Industry Canada, RIC-22 – General Radio Operating Procedures, at https://ised-isde.canada.ca/site/spectrum-management-telecommunications/sites/default/files/attachments/2022/ric22e.pdf (last accessed 09 September 2024). In the marine industry, masters and bridge officers are required to take radio communication training. This training is intended to standardize communication and reduce the risk of miscommunications.

There is no training required for day-to-day internal radio operations, such as those conducted at the dry dock, and the dry dock workers did not have training in radio procedures. Radio communications to coordinate a vessel’s manoeuvres into Les Méchins dry dock are typically transmitted on 2 different channels, a vessel channel and a shore channel. In this occurrence, the vessel’s crew was using ultra high frequency radios, and the shore team was using very high frequency radios. The local adviser on board was responsible for monitoring both channels and translating and relaying information between the master and the dock master when necessary.

During the unmooring operation, there were numerous messages being transmitted, at times simultaneously on both radio channels, using non-standard radio procedures. The context and relevance of information being transmitted were not always clear.

1.10 Safety management

A safety management system (SMS) is an internationally recognized framework that allows companies to identify hazards, manage risks, and make operations safer—ideally before an accident occurs. An SMS uses a documented, systematic approach and provides individuals at all levels of a company with the tools they need to make sound decisions in routine and emergency operations. The policies, procedures, practices, training, and safety culture of a company are the outputs of an SMS. Risk management within an SMS is an ongoing cycle that helps companies and vessel operators identify, assess, mitigate, and follow up on existing and potential risks to vessels, personnel, and the environment.

At the time of the occurrence, only Canadian vessels that operated on international voyages and were subject to Chapter IX of the International Convention for the Safety of Life at Sea (the International Safety Management Code) had to comply with the domestic Safety Management Regulations. Although not required by regulation, Marine Atlantic Inc. had voluntarily developed an SMS for its fleet that was audited and certified by Lloyd’s Register for compliance with the International Safety Management Code. Among other things, its SMS includes guidance for mooring operations, guidance on the use of personal protective equipment, and documents to support master–pilot exchanges.

On 03 July 2024, the new Marine Safety Management System Regulations entered into force. These regulations expand SMS requirements to the majority of Canada’s domestic commercial vessel fleet, including ferries. All impacted authorized representatives must be in compliance with the new requirements within 1 to 3 years, depending on their vessel’s size and type of operation.

1.10.1 Mooring and unmooring operations

Marine Atlantic Inc. had a variety of documents in its SMS that addressed mooring and unmooring operations, including a general procedure in the Fleet Operations Manual, as well as some vessel-specific documents, such as work instruction manuals and safe work checklists.

The general procedure was intended for the Marine Atlantic Inc. fleet as a whole. The procedure indicated that the vessel’s officers should familiarize themselves with the principles of mooring as per their vessel’s mooring equipment, lines, design loads, etc. It also gave some advice about bridge team communication and safety during mooring operations, noting that the officer in charge needs to be visible and easily heard when conducting mooring operations. The majority of the content covered in the procedure related to different types of mooring systems and considerations related to these systems. The procedure indicated that for unusual or non-standard mooring arrangements, a risk assessment form needed to be completed. A risk assessment form had been completed before the Atlantic Vision arrived in Les Méchins, which primarily covered concerns related to the vessel’s stability.

The Atlantic Vision’s Work Instructions Manual included a chapter that covered the steps involved in mooring. The chapter specified the personnel needed at a mooring station as well as considerations when securing mooring lines, such as ensuring that “slack mooring line is kept out of water.”Marine Atlantic Inc., Work Instructions Manual MV Atlantic Vision (revision WV-2016-001, issued March 2016), Chapter 11, p. 22.

The vessel also had a safe work checklist for mooring that was intended to be completed prior to each mooring operation. It included items to consider in mooring operations, such as making sure all persons have appropriate personal protective equipment and that the order of the lines for mooring operations is clearly understood. It also specified that the officer in charge was to keep a watch on the deck crew, the lines handlers, and the mooring lines. The investigation was not provided a copy of the safe work checklist that was completed prior to this occurrence.

Finally, the vessel had a job safety analysis (JSA) specifically for unmooring.The job safety analysis was required to be reviewed and signed off by all participating crew once a shift. It had been signed by the occurrence crew but was not dated. The JSA identified steps involved in unmooring, as well as potential hazards associated with each step, and preventive measures to mitigate the hazards. The JSA identified a risk associated with the vessel engines and thrusters running when the lines were released. The associated potential hazards were listed as uncontrolled vessel movement, property damage, injury, death, or fouling of the mooring line in the vessel’s thrusters or propellers. The JSA identified 2 preventive measures: “proper communication between all parties prior to commencing unmooring” and for the “master to ensure proper vessel movements while unmooring.”Marine Atlantic Inc., Job Safety Analysis: Un-Mooring Operations (15 August 2018), p. 1.

1.10.2 Personal protective equipment

The chapter in the Atlantic Vision’s Work Instruction Manual that covered the steps involved in mooring specified that at all applicable personal protective equipment was to be worn at all times. The safe work checklist and the JSA also prompted crew to make sure they were wearing appropriate personal protective equipment. In this occurrence, the forward mooring team was wearing the required personal protective equipment, including approved hard hats.

1.10.3 Exchange of information between vessel and local adviser

The SMS included a pilot card to be filled out to facilitate the exchange of information between the master and pilots. The pilot card was intended to provide essential information about the vessel and its equipment, including the condition of the equipment.

In preparation for the local adviser boarding at Les Méchins on 23 March, the pilot card was filled out on 18 March, and no operational defects with any equipment were noted on the card. The issue with winch W1 had been identified on 17 March. Once the local adviser boarded, the problem with winch W1 was not communicated to him and therefore he was not aware of it when the initial plan for unmooring was developed. The local adviser was informed of this only when the shore team reached the forward mooring station.

1.11 Team situational awareness

When people operate in a team environment, team situational awareness is important for safe and effective operations. Team situational awareness involves having a shared perception and comprehension of the current situation in order to be able to project what will happen in the near future. Perception, comprehension, and prediction are driven by the information available to the team, the team’s experience and knowledge, and the overriding context. Effective team situational awareness allows team members to develop performance expectations and to understand how their individual roles support the team’s goals. As team members develop a shared understanding of a situation, they can communicate to cross-check their perceptions of the situation with each other.

For team situational awareness to develop and be maintained, the right information needs to get to the right person at the right time, which involves coordination among the team.K. T. Harris, C. M. Treanor, and M. L. Salisbury, “Improving patient safety with team coordination: challenges and strategies of implementation,” Journal of Obstetric, Gynecologic, and Neonatal Nursing, Vol. 35, Issue 4 (2006), pp. 557–566. A team’s effectiveness is often a reflection of the degree to which team members share information (e.g., questioning, cross-checking, coordinating, setting priorities, and contingency planning).C. A. Bowers, F. Jentsch, E. Salas, and C. C. Braun, “Analyzing communication sequences for team training needs assessment,” Human Factors, Vol. 40, Issue 4 (1998), pp. 672–679.

Team situational awareness can be compromised by breakdowns in communication. These breakdowns may result in information that is shared too late to be of use, that is not consistently complete and accurate, or that is ambiguous. They may also result in problems that are left unresolved until a point of urgency.A. Parush, C. Kramer, T. Foster-Hunt, K. Momtahan, A. Hunter, and B. Sohmer, “Communication and team situation awareness in the OR: implications for augmentative information display,” Journal of Biomedical Informatics, Vol. 44, Issue 3 (2011), pp. 477–485.

1.12 Mooring winches

The Atlantic Vision had 6 electric stand-alone winches and 2 electric combination anchor windlass and mooring winches. The mooring equipment was manufactured by Rolls-Royce in 2000 and installed on the vessel the same year. The equipment was designed and manufactured according to recognized industry standards at the time. Although the mooring equipment was designed by Rolls-Royce, the winches contained frequency converters that were manufactured by another company, Vacon.

Marine Atlantic Inc.’s SMS required critical equipment, such as winches, to be listed in the vessels’ planned maintenance systems and that periodic maintenance be monitored. The maintenance schedules for critical equipment were based on information provided by manufacturers in user manuals. At the time of the occurrence, the vessel had a user manual that covered the 6 stand-alone winches and the 2 combination anchor windlass and mooring winches. The manual included a statement on the first page to refer to the Vacon user manual for information regarding the frequency converters. The vessel did not have a copy of the Vacon user manual on board at the time of the occurrence. The TSB obtained a copy of the Vacon user manual and determined that it was mainly focused on how to program the converters and did not include any maintenance guidelines.

At the time of the occurrence, the Vacon frequency converter in winch M5 was the original converter (Vacon CX) dating back to when mooring equipment was first installed on the vessel in 2000. In 2005-06, a new generation of Vacon frequency converters was made available (Vacon NX). The CX generation became obsolete in 2012, and Vacon stopped supplying parts for this generation.

In 2014, winch M5 began having problems and a technician was called to look at it. The technician recommended that the frequency converter be upgraded during the vessel’s next scheduled service as there were no parts available to repair it. Another technician looked at the winches when the vessel was in dry dock in 2015. This technician confirmed that the software was obsolete and attempted to upgrade all of the winches but was unable to do so for 3 of them (W1, W2, and M5) for unknown reasons. It was decided to leave this equipment as it was since it had been working within set parameters.

On 17 March 2023, winch W1 was reported to not be working properly. This report triggered a series of emails between the vessel’s crew, company personnel, and external technicians aimed at troubleshooting the issue prior to the vessel’s arrival at the dry dock. However, despite troubleshooting attempts, it was not possible to get the winch fully operational prior to the occurrence.

A technician who visited the vessel after the occurrence could not determine exactly why winch M5 stopped working at the time of the occurrence, but he noted in his report that the frequency converter in the winch was an original Vacon CX and needed to be upgraded to NX for the winch to continue working safely. The technician noted that the expected life cycle for the circuit boards inside the frequency converter was 10 years. The technician also established that the problem with winch W1 originated from a connection between the control handle and the control block.

Following the occurrence, Marine Atlantic Inc. replaced the obsolete components in winches W1, W2, and M5, and repaired the issue with the winch W1 controls.

At the time of the occurrence, mooring winches were not typically covered by classification society surveys. They were also not covered by statutory inspections, which only check the connection of the winch to the deck.Post-occurrence, the Vessel Construction and Equipment Regulations were amended to include requirements for design, maintenance, and inspections of mooring equipment.

1.13 Previous occurrences

From 2013 to 2023, the TSB has received reports of 19 occurrences (including this occurrence) involving injury or death during mooring operations.Data on all marine transportation occurrences since 1995 is available on the TSB website at https://www.tsb.gc.ca/eng/stats/marine/data-6.html. It is updated monthly. As a result of these occurrences, 18 persons sustained serious injuries and 2 persons were fatally injured. In 2 of the occurrences, crew members were seriously injured by a mooring line fouling a propeller.

1.14 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 2022 issue. Some transportation operators are not managing their safety risks effectively, and many are still not required to have formal safety management processes in place. Moreover, those operators that have implemented a formal SMS are not always able to demonstrate that it is working and producing the expected safety improvements. As this occurrence demonstrates, not all vessel operators are required to have an SMS and even if safety management processes are in place, certain risks may not have been mitigated.

1.15 TSB laboratory reports

The TSB completed the following laboratory report in support of this investigation:

• LP102/2023 – Hard hat analysis

The TSB laboratory examined the hard hat worn by the crew member who was injured in the occurrence to determine if it met regulations and to estimate the forces required to damage it.

The laboratory analysis determined that, at the time of the occurrence, the hard hat was in a serviceable condition and was well maintained. The hard hat conformed with CAN/CSA Z94.1-15, a standard published by the Standards Council of Canada that applies to protective headwear. Conformance with CAN/CSA Z94.1-05 is required by the Maritime Occupational Health and Safety Regulations.CAN/CSA Z94.1-15 was the latest revision of the standard for protective headwear at the time of the occurrence. The Maritime Occupational Health and Safety Regulations reference an earlier version of this standard (CAN/CSA Z94.1-05).

The laboratory analysis could not conclusively quantify the force that was applied to the hard hat during the occurrence. However, the analysis could reasonably demonstrate that the whip velocity was likely over the maximum for an impact to the crown or side of the hard hat. As a result, the hard hat shell broke while absorbing a significant amount of energy (Figure 11). This reduced the energy that was transmitted to the hard hat suspension assembly.

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