Release of investigation report M21A0065 – Tyhawk

Speaking Notes - M21A0065 (Tyhawk)

Check against delivery.

Introduction - Kathy Fox

Good morning everyone, and thank you for joining us.

Today, we are here to talk about our investigation findings and recommendations regarding the 2021 capsizing of the fishing vessel Tyhawk, which resulted in the loss of two members from Mi’kmaq First Nation communities.

Our thoughts and condolences are with those who lost their loved ones and were impacted by this tragic accident.

Fish harvesting is the backbone of many coastal communities. But it is also one of the most dangerous occupations in the country; with an average of 11 fish harvesters dying per year – many from preventable accidents. 

The issues identified in this investigation are not new yet continue to cost the lives of fish harvesters every year.

I will now turn things over to Karie Allen.

Accident summary – Karie Allen

Thank you, Kathy.

On April 1, 2021, Fisheries and Oceans Canada notified fish harvesters that the snow crab fishery in area 12 of the Gulf of St. Lawrence would open at 12:01 AM on April 3^rd.

In the early hours of April 3, the Tyhawk departed from Chéticamp, Nova Scotia, to the fishing grounds to set crab traps. During this trip, ice was accumulating on the vessel due to freezing rain. The master and four crew members departed on a second voyage to set more traps later that day.

On this trip to the fishing grounds the wind and waves had increased. Waves were hitting the starboard side, and rain and freezing rain were falling, and water accumulated on board.

Nearing the fishing grounds, the vessel movements became more severe, there was a significant roll to starboard and the traps shifted. Shortly after, the deck submerged, more water entered and the vessel capsized.

Unable to don lifejackets or immersion suits or launch the life raft which had become trapped under the removable deck, the crew entered the water and climbed atop the overturned hull until help arrived from a neighbouring fishing vessel. During the wait, the master was swept into the water and subsequently declared missing. One of the recovered crew members was later pronounced dead.

Investigation findings – Karie Allen

The investigation identified several factors that contributed to this accident:

• Despite concerns raised by industry, the opening date set by Fisheries and Oceans Canada was moved earlier by almost three weeks compared to previous years, without completely assessing the safety risks.
• The master’s perception of risk was influenced by several factors, including his 20 years of experience fishing for snow crab, his familiarity with the area, and the vessel’s valid certificate of inspection from Transport Canada, which did not note any deficiencies. This likely led him to believe the vessel was safe and well adapted for snow crab fishing operations.
• Lastly, the vessel’s stability was compromised in part by the addition of a heavy removable deck used for snow crab fishing.

When we talk about stability, we are referring to a vessel’s ability to return to its upright position when disturbed by external forces such as wind and waves or fishing operations.

To better understand this, we have a simple animation that demonstrates how modifications to a vessel can affect its stability.

On the left we have an unmodified vessel and on the right, a vessel with modifications.

When additional weight is added higher up on a vessel, for example in the form of a removable deck and gear, it raises its centre of gravity. In other words, it becomes top heavy, resulting in the vessel’s roll becoming slower and deeper.

Add in the extra weight from the water and ice that accumulates on board, the vessel rests lower in the water and the roll slows even more, giving the impression that stability is better. But it’s the opposite.

Also, the freeboard, which is the height between the waterline and deck edge, decreases with the additional weight, increasing the likelihood of water entering the vessel, which increases the depth of the roll causing the deck edge to dip below the waterline.

Once the deck edge is immersed, a capsize or sinking happens very quickly.  

Over a 10-year period, the TSB investigated 19 occurrences similar to this one, resulting in 34 fatalities. These investigations identified factors that compromise vessel stability, including, raised centre of gravity and modifications.

It is important to note that when small fishing vessels capsize it is very quick and unexpected. Crews have very little if any time to find, don or launch lifesaving equipment, which is what happened in this occurrence. None of the crew on the Tyhawk were wearing personal flotation devices. Wearing a PFD on deck and installing life rafts to launch automatically can dramatically increase chances of survival in these situations.

Based on these findings, the Board has issued three recommendations that Kathy will talk about.

Recommendations – Kathy Fox

Thanks Karie.

Following Transport Canada’s inspection of the Tyhawk in 2013, the removable deck was identified as a deficiency requiring that a stability questionnaire be completed and that the vessel undergo a stability assessment.

Two years later, the master completed the questionnaire. Although he identified the removable deck, he did not recognize it as a modification that would require a stability assessment, and therefore it was never completed.

In 2017, Transport Canada inspected the vessel without the removable deck in place, cleared the deficiency, and issued an inspection certificate.

Current regulations state that stability assessments are required when a vessel has undergone a major modification, which is currently defined as “either a single modification or repair, or a series of modifications or repairs, that substantially changes the capacity or size of a fishing vessel or the nature of a system on board a fishing vessel and that affects its watertight integrity or its stability.”

However, both the definition of a major modification and the requirements for stability assessment are qualitative and open to interpretation.

Although Transport Canada provides guidance to determine if a modification requires a stability assessment, compliance with this guidance is voluntary, and without an understanding of vessel stability, this guidance is difficult to use.

Without a clear definition of what a major modification entails, vessel owners, masters, and even Transport Canada inspectors may not identify the impact of a major modification on vessel stability.

Therefore, the Board recommends that:

 

Fishing vessels are modified frequently and for various reasons, such as creating more storage or meeting different fishing licence requirements, or in the case of the Tyhawk, adding a removable deck.

However, Transport Canada does not require pre-approval or an assessment of planned vessel modifications on small commercial vessels.

In this occurrence, the master set out on a vessel that had been registered, inspected, and certified by Transport Canada, giving the impression that the vessel was safe, and did not require a stability assessment.

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.

As many small fishing vessels and other small commercial vessels change hands, having an established record of modifications can help ensure that all parties have complete and current information when evaluating vessel stability.

Therefore, the Board recommends that:

 

The last recommendation we are issuing is to Fisheries and Oceans Canada. In this occurrence, they moved up the opening date by almost three weeks from previous years, without considering the increased likelihood of colder water, ice, and freezing rain.

Additionally, opening the fishery at midnight increased the risk of fatigue. However, since the season-opening decision had been made routinely for the last several years, it was not seen as a new situation, and these new hazards were not identified as additional risks.

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 without adequate identification of safety hazards, increasing risks for ALL fish harvesters.

Therefore, the Board recommends that

Conclusion – Kathy Fox

As I mentioned when we started, the issues identified in this investigation are not new. This past March, we sat right in this very room to discuss our investigation into the 2020 fatal sinking of the Chief William Saulis, a scallop fishing vessel that didn’t have a formal stability assessment in place, which resulted in operating decisions made without sufficient knowledge of the safe operating limits.

The lives of six fish harvesters were lost that day.

AND in the eight months since we released that report, five more fish harvesters have died, one is missing at sea, and 11 more have suffered serious injuries. 

It’s important for operators to know their vessel limits and operate within them. Next week, thousands of fish harvesters and more than 1,500 small fishing vessels will be heading out for the opening of the lobster fishing season areas 33 and 34 in southwest Nova Scotia. 

As we know, the lobster fishery is competitive, and it is common practice for vessels to be modified and fish harvesters to load their vessels with as many traps as possible on opening day.

How many more fish harvesters have to die before changes are made?

Fish harvesters and operators don’t need to wait for the regulator to take action. Being proactive and going beyond regulatory minimums can save lives. I’ve said it before, but it bears repeating, safety is a shared responsibility. 

We don’t want to be sitting in this room again a year from now, two years from now, still talking about the same issues, and the deaths that could have been prevented.

Thank you.