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Safer vessels, safer waters, safer crews

By Marc-André Poisson
Director, Marine Investigations, Transportation Safety Board of Canada

This article was published online in the October 2013 edition of Marine Matters magazine.

On the evening of February 10, 2012, the large fishing vessel Katsheshuk II was heading toward Harbour Grace, Newfoundland. Its cargo hold filled with over 300 tonnes of shrimp, the vessel neared the end of another successful trip, and the crew was busy cleaning the trawl deck and the onboard factory.

Shortly after the evening meal, however, tragedy struck. A foreman, having just completed his inspection of a recently cleaned holding tank, was exiting the tank when a shutter door closed on his neck. He was killed instantly.

When investigators from the Transportation Safety Board of Canada (TSB) deploy to the scene of an accident, we seek to answer three key questions: what happened, why, and what can be done to prevent it from happening again? In the marine sector, for example, our investigations and recommendations have prompted international regulators to require survival suits for all crew members on commercial vessels. Domestically, small passenger vessels now need a float‑free liferaft, large vessels now carry voyage data recorders, and all passengers on Canada's ferries must receive a safety briefing before each voyage.

None of these improvements would have been possible without qualified, dedicated professionals. TSB experts come from such diverse backgrounds as airline pilots, rail and pipeline experts, computer technicians, journalists, lawyers, engineers, fishermen, marine nautical officers and engineers, and members of the Canadian Forces—to name just a few! Whether they are painstakingly putting together the pieces of a shattered airliner, computer modeling the inside of a lifeboat locking mechanism, or mounting convincing arguments for change, these men and women have worked diligently to ensure that the TSB's conclusions sit securely on a base of sound science and hard facts.

That's a big responsibility, and in order to carry it out properly, the Canadian Transportation Accident Investigation and Safety Board Act grants our investigators significant powers, including the ability to freeze accidents sites, restrict access, seize wreckage, and compel witness interviews. That doesn't mean we're out to point fingers—far from it. The TSB never assigns fault or determines civil or criminal liability. Moreover, the confidentiality of our interviews is protected by law, allowing witnesses to say what they need without fear of reprisal or prosecution.

Katsheshuk II
Katsheshuk II

(Click to view larger image)

The result of all this is a pretty good success rate: of the 147 marine recommendations we've issued since 1990, over 80% have received our highest rating of “Fully Satisfactory.” But there's still one key area where we have plenty of room for improvement: safety management systems (SMS).

Implemented properly, an SMS allows vessels and marine companies to proactively identify hazards, manage risks, and develop and follow effective safety processes. Having an SMS, in other words, helps you find trouble before it finds you.

Fortunately, the marine community has long recognized the value of SMS. For over a decade, in fact, all vessels over 500 gross tonnage that sail in international waters have had to meet the requirements of the International Safety Management Code and implement an SMS. These requirements, however, do not presently apply to all vessels that operate domestically in Canada—including the hundreds of passenger and commercial vessels over 500 tonnes.

In the case of the Katsheshuk II, the vessel's owners had in fact taken some initial steps before the accident. They implemented a rudimentary SMS, even though none was technically required. The TSB's investigation, however, found numerous concerns, including a lack of formal training for crew members, and no documented risk assessments for workplace operations.

Although many of these issues have since been addressed—including safety upgrades to equipment, a detailed hazard assessment, and new procedures for many onboard activities—the Katsheshuk II remains only one vessel. What's needed is for Transport Canada to require all commercial vessels to have SMS—and for each SMS to be certified and audited.

Such a move won't prevent every accident, of course, nor is that the goal. After all, even the most rigorous SMS must evolve to meet the ever changing nature of today's workplaces. But having an SMS does improve safety, giving crew members a formal, structured process to help find trouble—before trouble finds them.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. For more information, visit our website at