Safety communications related to TSB investigation M21A0065: April 2021 capsizing and loss of life of the fishing vessel Tyhawk
The occurrence
In the early hours of April 3, 2021, opening day for snow crab fishing in area 12 of the Gulf of St. Lawrence, the Tyhawk (M21A0065) departed from Chéticamp 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. As the Tyhawk neared the fishing grounds, the weather became more severe, as did the vessel’s rolling movements, which allowed water to accumulate on board. Shortly after, following a significant roll to starboard, the main deck submerged allowing for more water to enter, eventually leading to the capsizing of the vessel.
Safety communications
Definition of major modification
The investigation determined that the Tyhawk's stability was compromised in part by the addition of a 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 notice because of the removable deck, and required a stability assessment. The master completed a stability questionnaire in May 2015 and identified the 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 refer to the removable deck.
In accordance with the Fishing Vessel Safety Regulations, stability assessments are required for all new fishing vessels over nine metres and those that have undergone a major modification or a change in activity that is likely to adversely affect their stability. TC’s definition of major modification is
[…] a 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, that affects its watertight integrity or its stability.
For other small commercial vessels (15 gross tonnage and under) that are not passenger vessels, the definition of a major modification in the Small Vessel Regulations is similar. It is the responsibility of the authorized representative (AR) to identify whether a modification is major.
Both the Fishing Vessel Safety Regulations definition of major modification (that “substantially changes”) and the requirements for stability assessment (likely to adversely affect stability) are qualitative and open to interpretation. While TC does provide some guidance to help ARs and masters identify major modifications, the guidance is qualitative and requires knowledge of stability to interpret it correctly. Compliance with the guidance is voluntary. In contrast, TC’s guidance for maintaining a record of modifications is quantitative, noting that changes in weight of more than 100 kg should be tracked.
In this occurrence, the Board found that, without an objective definition of a major modification, ARs, masters, and TC may not identify the impact on vessel stability of a major modification. As a result, there is a risk that vessels will operate without adequate stability for their intended operations.
Regulators have a role to play in supporting the consistent identification of major modifications by providing specific, measurable, and understandable criteria. 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
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. In contrast, the United Kingdom requires that owners of fishing vessels seek approval from the Maritime and Coastguard Agency before carrying out modifications. There is no consistent understanding of what constitutes a major modification for small commercial vessels in Canada, and the true scope of this issue is difficult to quantify. In its 2016 regulatory impact analysis statement, TC estimated that 25% of fishing vessels would make major modifications, whereas Fish Safe NS estimated that most fishing vessels in Nova Scotia have made unreported modifications. In addition, TSB investigations have routinely identified vessels to which major modifications were made and not identified.
While ARs are responsible for vessel safety, TC is responsible for regulatory surveillance. 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.
To help ARs, masters, and TC inspectors verify that vessels are operating with adequate stability, 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 decisions
In this occurrence, Fisheries and Oceans Canada (DFO) moved the opening date for the snow crab fishery forward by almost three weeks from previous years. This decision was based on the advice of a subcommittee composed of representatives from industry and government. DFO and the subcommittee 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, which would increase the likelihood of colder water, ice, and freezing rain, or by opening the fishery at midnight, which would increase the risk of fatigue, were not identified and assessed for safety implications.
Fisheries resource management (FRM) decisions are complex, balancing economic, conservation, and safety concerns and their interactions and cumulative effects. In 2021, the season-opening decision was influenced by many FRM measures and policies. All commercial fishing vessels in Canada, the number of which is estimated at 18 000 to 29 000 vessels, are subject to FRM measures that influence the actions and behaviours of fish harvesters.
The TSB has previously investigated occurrences in which FRM measures were implemented and fish harvester safety was affected. For example, in September 2018, two people died when the fishing vessel Kyla Ann (M18A0303) capsized near North Cape, Prince Edward Island, while following a DFO-defined corridor instead of the established navigational route. In 2016, two people died and two others were presumed drowned after the crew of the Pop’s Pride (M16A0327) sailed in adverse sea conditions in order to ensure the FRM measures were met. The TSB’s Safety Issues Investigation into Fishing Safety in Canada (M09Z0001), published in 2012, identified FRM as one of the ten significant safety issues associated with fishing accidents. The report indicated that “meeting resource management measures can contribute to risk-taking” and expressed “concern that the safety risks associated with fisheries management measures are not adequately identified and addressed.”
FRM measures can have positive consequences for safety, whether they were implemented for that reason or not. For example, in the British Columbia and Quebec regions, some fisheries are restricted to daylight hours.
Complex decisions, such as those concerning FRM, 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 affected by the decisions.
When FRM 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. The Board therefore 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
Safety communications related to TSB investigation M21A0065: April 2021 capsizing and loss of life of the fishing vessel Tyhawk
The occurrence
In the early hours of April 3, 2021, opening day for snow crab fishing in area 12 of the Gulf of St. Lawrence, the Tyhawk (M21A0065) departed from Chéticamp 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. As the Tyhawk neared the fishing grounds, the weather became more severe, as did the vessel’s rolling movements, which allowed water to accumulate on board. Shortly after, following a significant roll to starboard, the main deck submerged allowing for more water to enter, eventually leading to the capsizing of the vessel.
Safety communications
Definition of major modification
The investigation determined that the Tyhawk's stability was compromised in part by the addition of a 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 notice because of the removable deck, and required a stability assessment. The master completed a stability questionnaire in May 2015 and identified the 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 refer to the removable deck.
In accordance with the Fishing Vessel Safety Regulations, stability assessments are required for all new fishing vessels over nine metres and those that have undergone a major modification or a change in activity that is likely to adversely affect their stability. TC’s definition of major modification is
[…] a 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, that affects its watertight integrity or its stability.
For other small commercial vessels (15 gross tonnage and under) that are not passenger vessels, the definition of a major modification in the Small Vessel Regulations is similar. It is the responsibility of the authorized representative (AR) to identify whether a modification is major.
Both the Fishing Vessel Safety Regulations definition of major modification (that “substantially changes”) and the requirements for stability assessment (likely to adversely affect stability) are qualitative and open to interpretation. While TC does provide some guidance to help ARs and masters identify major modifications, the guidance is qualitative and requires knowledge of stability to interpret it correctly. Compliance with the guidance is voluntary. In contrast, TC’s guidance for maintaining a record of modifications is quantitative, noting that changes in weight of more than 100 kg should be tracked.
In this occurrence, the Board found that, without an objective definition of a major modification, ARs, masters, and TC may not identify the impact on vessel stability of a major modification. As a result, there is a risk that vessels will operate without adequate stability for their intended operations.
Regulators have a role to play in supporting the consistent identification of major modifications by providing specific, measurable, and understandable criteria. 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
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. In contrast, the United Kingdom requires that owners of fishing vessels seek approval from the Maritime and Coastguard Agency before carrying out modifications. There is no consistent understanding of what constitutes a major modification for small commercial vessels in Canada, and the true scope of this issue is difficult to quantify. In its 2016 regulatory impact analysis statement, TC estimated that 25% of fishing vessels would make major modifications, whereas Fish Safe NS estimated that most fishing vessels in Nova Scotia have made unreported modifications. In addition, TSB investigations have routinely identified vessels to which major modifications were made and not identified.
While ARs are responsible for vessel safety, TC is responsible for regulatory surveillance. 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.
To help ARs, masters, and TC inspectors verify that vessels are operating with adequate stability, 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 decisions
In this occurrence, Fisheries and Oceans Canada (DFO) moved the opening date for the snow crab fishery forward by almost three weeks from previous years. This decision was based on the advice of a subcommittee composed of representatives from industry and government. DFO and the subcommittee 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, which would increase the likelihood of colder water, ice, and freezing rain, or by opening the fishery at midnight, which would increase the risk of fatigue, were not identified and assessed for safety implications.
Fisheries resource management (FRM) decisions are complex, balancing economic, conservation, and safety concerns and their interactions and cumulative effects. In 2021, the season-opening decision was influenced by many FRM measures and policies. All commercial fishing vessels in Canada, the number of which is estimated at 18 000 to 29 000 vessels, are subject to FRM measures that influence the actions and behaviours of fish harvesters.
The TSB has previously investigated occurrences in which FRM measures were implemented and fish harvester safety was affected. For example, in September 2018, two people died when the fishing vessel Kyla Ann (M18A0303) capsized near North Cape, Prince Edward Island, while following a DFO-defined corridor instead of the established navigational route. In 2016, two people died and two others were presumed drowned after the crew of the Pop’s Pride (M16A0327) sailed in adverse sea conditions in order to ensure the FRM measures were met. The TSB’s Safety Issues Investigation into Fishing Safety in Canada (M09Z0001), published in 2012, identified FRM as one of the ten significant safety issues associated with fishing accidents. The report indicated that “meeting resource management measures can contribute to risk-taking” and expressed “concern that the safety risks associated with fisheries management measures are not adequately identified and addressed.”
FRM measures can have positive consequences for safety, whether they were implemented for that reason or not. For example, in the British Columbia and Quebec regions, some fisheries are restricted to daylight hours.
Complex decisions, such as those concerning FRM, 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 affected by the decisions.
When FRM 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. The Board therefore 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