Marine transportation safety investigation M17C0232

This investigation has been completed. The report was released on 02 November 2018.

Table of contents

    Person overboard and subsequent loss of life
    General cargo vessel Amazoneborg
    Trois-Rivières, Quebec

    The occurrence

    On , the general cargo vessel Amazoneborg was docked at Section 19 in the Port of Trois-Rivières, Quebec. The third officer was assigned to take the vessel’s draft measurements. Some time after 2210 Eastern Daylight Time, the third officer went to read the amidships draft marks on the vessel’s seaward side; he was later reported missing. Search and rescue authorities were notified of the situation and conducted a search of the area without success. The third officer’s body was recovered on 07 October 2017 near Champlain, Quebec.


    Media materials

    News release

    2018-11-02

    Unsuitable equipment, inadequate work procedures led to 2017 person overboard and loss of life on the vessel Amazoneborg in Trois-Rivières, Quebec
    Read the news release

    Deployment notice

    2017-09-30

    TSB deploys a team to the Port of Trois-Rivières, Québec, following an occurrence involving the cargo ship Amazoneborg
    Québec, Quebec, 30 September 2017 — The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the Port of Trois-Rivières, Québec, following an accident involving the cargo ship Amazoneborg. The TSB will gather information and assess the occurrence.


    Investigation information

    Map showing the location of the occurrence

    M17C0232

    Person overboard and subsequent loss of life
    General cargo vessel Amazoneborg
    Trois-Rivières, Quebec

      Download high-resolution photos from the TSB Flickr page.

    Class of investigation

    This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 days. For more information, see the Policy on Occurrence Classification.

    TSB investigation process

    There are 3 phases to a TSB investigation

    1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
    2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
    3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

    For more information, see our Investigation process page.

    The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.