Marine transportation safety investigation M21A0065

The occurrence

On 01 April 2021, Fisheries and Oceans Canada (DFO) assessed the weather conditions and notified fish harvesters that the snow crab fishery in area 12 of the Gulf of St. Lawrence would open at 0001 on 03 April 2021. At the time of the notification, there was ice in Richibucto Harbour, New Brunswick, and an excavator was needed to break ice at the wharf to put the Tyhawk in the water.

On 02 April at 0435, the master and 4 crew members sailed the 13.61 m open fishing vessel Tyhawk from Richibucto, New Brunswick, to Chéticamp, Nova Scotia, for the season. They were joined in Chéticamp by 4 additional crew members, who had driven from Richibucto.

On 03 April, starting at approximately 0240, the Tyhawk made 2 voyages from Chéticamp to the fishing grounds. On the first voyage, with the master and all 8 crew members on board, they set about 75 crab traps. During this voyage, ice was accumulating on the vessel. On the second voyage, the master and 4 crew members departed to set about 50 more crab traps.

On the trip to the fishing grounds, the master and 3 crew members napped in the accommodation space while another crew member stood watch. The winds had increased to 20 to 25 knots with 1 to 2 m seas. Waves were hitting the starboard side, and rain and freezing rain were falling. A second crew member came to the wheelhouse where he noticed an accumulation of water in the bilge. He called the master and the other crew members, and the bilge pumps were started. Shortly afterwards, a crew member went under the removable deck to get some of the gear and found water on the main deck. He alerted the other crew members, and the wash-down pump configuration was changed to dewater the bilge. At this time, the weather seemed to increase in severity and the vessel’s movements became more severe. Following a significant heel to starboard, the vessel’s main deck submerged, allowing water in addition to that already on deck to enter the Tyhawk.

Crew members could not reach the lifejackets and immersion suits stowed in the accommodation space or launch the life raft, which had slid under the removable deck. Shortly afterward, the Tyhawk capsized and the master and crew members climbed on to the overturned hull. One crew member called 911. The automatic emergency position-indicating radio beacon (EPIRB) floated free and at 1750, the Joint Rescue Coordination Centre Halifax received notice of an EPIRB signal from the Tyhawk.

As the overturned Tyhawk sank lower in the water, wave action repeatedly swept the master and 1 crew member clear of the hull and into the water. Eventually, the master and this crew member remained in the water. The fishing vessel Northumberland Spray arrived on scene and rescued the 4 Tyhawk crew members, but the master could not be located. The Northumberland Spray returned to Chéticamp and the 4 crew members received medical assistance. One crew member was pronounced dead. The search for the master continued through the night and all the next day. At 1955 on 04 April 2021, the case was turned over to the RCMP as a missing persons case.

Modifications without stability assessment

The Tyhawk had been modified by the addition of a removable deck. The investigation determined that the Tyhawk's stability was compromised in part by the addition of the removable deck, which had not been evaluated for its impact on the vessel’s stability. In 2013, Transport Canada (TC) inspected the vessel, issued a deficiency because of the removable deck, and required a stability assessment. The master completed a stability questionnaire in May 2015 and identified the existence of a removable deck, but he did not recognize the deck as a modification that would require a stability assessment. The stability assessment required by TC was not completed, and TC’s subsequent inspection documentation did not reference the removable deck.

For small fishing vessels and other small commercial vessels (15 gross tonnage and under) that are not passenger vessels, the definitions of “major modification” (something that “substantially changes” the capacity or size of a fishing vessel) and the requirements for a stability assessment (something that is likely to adversely affect stability) are qualitative and open to interpretation. It is the responsibility of the authorized representative (AR) to identify whether a modification is major.

While TC does provide some guidance to help ARs and masters identify major modifications, compliance with this guidance is voluntary. As well, the guidance is qualitative and requires knowledge of stability to correctly interpret.

Without an objective definition of a major modification, the impact on vessel stability of a major modification may not be identified by ARs, masters, and TC. As a result, there is a risk that vessels will operate without adequate stability for their intended operations. Therefore, the Board recommends that the Department of Transport introduce objective criteria to define major modifications to small fishing vessels and other small commercial vessels (TSB Recommendation M23-06).

Furthermore, TC does not require ARs to seek pre-approval or assessment of planned modifications, which could also assist in identifying whether a modification is likely to negatively affect stability. A systematic assessment by a competent person of all planned modifications, as is done in other countries, can assist in identifying which are major modifications and when stability assessments are required. Regulatory surveillance gives TC an opportunity to evaluate records of modifications. As many small fishing vessels and other small commercial vessels change hands, having an established record of modifications can help ensure that ARs, masters, and TC have complete and current information when evaluating vessel stability. Therefore, the Board recommends that the Department of Transport require that planned modifications to small fishing vessels and other small commercial vessels be assessed by a competent person, that all records of modifications to these vessels be maintained, and that the records be made available to the Department (TSB Recommendation M23-07).

Hazard identification in fisheries resource management

The master’s perception of risk in the planned fishing operation was influenced by several pressures, including economic and community incentives, approvals and certificates, and previous successful experiences. As a result, the master departed for the fishing grounds likely believing the vessel was stable and well adapted for the snow crab fishery.

In this occurrence, DFO moved the opening date for the snow crab fishery almost 3 weeks earlier than previous years’ opening dates. This decision was based on the advice of a sub-committee made up of representatives from industry and government. DFO and the sub-committee members considered the selection of the opening date and time for the 2021 snow crab fishery as routine. Consequently, hazards posed by changing the date, such as increased likelihood of colder water, ice, and freezing rain, or by opening the fishery at midnight, increasing the risk of fatigue, were not identified and assessed for safety implications.

Complex decisions, such as those about fisheries resource management, need to consider all relevant areas and interactions and must be supported by a comprehensive, methodical risk assessment. The quality of a risk assessment depends on the robustness of hazard identification. To identify as many hazards as possible, all relevant information must be considered by experts in their fields, including independent safety experts who are not impacted by the decisions.

When fisheries resource management measures and decisions do not consider the interactions between economic, conservation, and safety factors, including their cumulative effects, then decisions may be made for new and complex situations without adequate identification of safety hazards, increasing safety risks for fish harvesters. Therefore, the Board recommends that the Department of Fisheries and Oceans ensure that policies, procedures, and practices include comprehensive identification of hazards and assessment of associated risks to fish harvesters when fisheries resource management decisions are being made and integrate independent safety expertise into these processes (TSB Recommendation M23-08).

Media materials

News releases

Media advisory

Backgrounders

Speeches and presentations