(DARTMOUTH, Nova Scotia) — The Transportation Safety Board of Canada (TSB) has released its investigation report of an incident where a crewmember on a pilot boat died after falling overboard near St. John’s, Newfoundland and Labrador.
On Sept. 26, 2022, during the hours of darkness, the pilot boat A.P.A. No. 18 set out with the master, a deck hand and a pilot on board to complete a pilot transfer operation to an inbound vessel near the entrance to St. John’s Harbor. Shortly after the transfer, the deck hand fell overboard. The failure of the deck hand’s personal flotation device (PFD) 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 crewmembers from being continuously connected to the wire as they moved on the vessel. The system design required crewmembers to disconnect their tether while transitioning from the side to the front of the wheelhouse, which contributed to the deck hand being untethered and subsequently falling overboard.
Masters and crewmembers were required to, and often did, conduct person-overboard drills, which were exercised in the calm waters of St. John’s Harbor and with a deck hand available to help. As a result, the drills did not reveal that a single person could not manuever 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 deck hand 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 defenses.
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.
– Transportation Safety Board of Canada
