Wrong Equipment Cited in Drowning Investigation

The Transportation Safety Board of Canada's investigation found that the third officer used a rope ladder to read the seaward draft marks in the middle of the vessel. When resting flat against the vessel's hull, this ladder leaves little room for hand and foot holds, making it unsuitable for this task, and the rope ladder was rigged to the guardrail in such a way that there was no safe way to access the ladder from the deck.

The Transportation Safety Board of Canada released its investigation report Nov. 2 into a drowning that occurred in Quebec last year. The board found that unsuitable equipment and inadequate work procedures on the general cargo vessel Amazoneborg led to a crew member falling overboard and subsequently losing his life.

The cargo vessel was docked on Sept. 29, 2017, in the Port of Trois-Rivières, Quebec. The third officer was assigned to take the vessel's draft measurements as part of routine cargo operations. Some time after going to read the draft marks amidships on the seaward side, the third officer was reported missing. Search and rescue authorities conducted a search of the area without success. The third officer's body was found eight days later near Champlain, Quebec.

According to the board, the investigation found that the third officer used a rope ladder to read the seaward draft marks in the middle of the vessel. When resting flat against the vessel's hull, this ladder leaves little room for hand and foot holds, making it unsuitable for this task, and the rope ladder was rigged to the guardrail in such a way that there was no safe way to access the ladder from the deck. The third officer may have fallen while climbing over the vessel's guardrail to use the ladder or while using the ladder.

"While a permit was required to work overboard on the vessel, there were no instructions or procedures for taking draft measurements in the company or vessel manuals. The investigation found that no one was aware of the third officer's actions, no fall protection system or personal flotation device was used, and no one was present to initiate emergency response when the third officer went overboard," the board reported. "If routine tasks are not addressed in the shipboard operating procedures, there is a risk that these tasks will not be conducted safely and that unsafe practices will persist, endangering the lives of crewmembers."

After the death, the vessel's operator discontinued the use of rope ladders and replaced them with embarkation ladders. Use of a fall protection system and a personal flotation device and the presence of second crew member with access to lifebuoys and a communication system are now required for working overboard. The company also explained the various methods available for taking draft measurements to its crews.

Download Center

  • Safety Metrics Guide

    Is your company leveraging its safety data and analytics to maintain a safe workplace? With so much data available, where do you start? This downloadable guide will give you insight on helpful key performance indicators (KPIs) you should track for your safety program.

  • Job Hazard Analysis Guide

    This guide includes details on how to conduct a thorough Job Hazard Analysis, and it's based directly on an OSHA publication for conducting JHAs. Learn how to identify potential hazards associated with each task of a job and set controls to mitigate hazard risks.

  • A Guide to Practicing “New Safety”

    Learn from safety professionals from around the world as they share their perspectives on various “new views” of safety, including Safety Differently, Safety-II, No Safety, Human and Organizational Performance (HOP), Resilience Engineering, and more in this helpful guide.

  • Lone Worker Safety Guide

    As organizations digitalize and remote operations become more commonplace, the number of lone workers is on the rise. These employees are at increased risk for unaddressed workplace accidents or emergencies. This guide was created to help employers better understand common lone worker risks and solutions for lone worker risk mitigation and incident prevention.

  • EHS Software Buyer's Guide

    Learn the keys to staying organized, staying sharp, and staying one step ahead on all things safety. This buyer’s guide is designed for you to use in your search for the safety management solution that best suits your company’s needs.

  • Vector Solutions

Featured Whitepaper

OH&S Digital Edition

  • OHS Magazine Digital Edition - May 2022

    May 2022

    Featuring:

    • WEARABLE TECHNOLOGY
      How Wearable Technology is Transforming Safety and the Industrial Workplace
    • TRAINING: CONFINED SPACES
      Five Tips to Improve Safety in Confined Spaces
    • INDUSTRIAL HYGIENE
      Monitor for Asbestos to Help Save Lives
    • PPE: FALL PROTECTION
      Fall Protection Can Be Surprising
    View This Issue