February 21, 2023
Operations Manager
Canship Ugland Ltd.
St. John’s NL A1B 3M7
Chief Operating Officer
Atlantic Pilotage Authority
Halifax NS B3J 3K9
Subject :
Marine Transportation Safety Advisory Letter 01/23 (occurrence M22A0332)
Failure of personal flotation device to inflate
At approximately 2357 Newfoundland Daylight Time on 26 September 2022, shortly after completing a pilot transfer operation, a deckhand on the pilot vessel APA No. 18 fell overboard while the vessel was approximately 2 nautical miles east-southeast of the entrance to St. John’s harbour. After approximately 20 minutes in the water, the deckhand was recovered by a vessel of opportunity. The vessel of opportunity returned to port where the deckhand was pronounced dead. The Transportation Safety Board of Canada investigation into this occurrence (M22A0332) is ongoing.
During the course of an investigation, the TSB may communicate safety issues before an investigation is complete. This communication is undertaken to ensure that those best able to take remedial action and effect change are made aware of the identified safety issues in a timely manner. As the TSB is not a regulator, the identified issues are related to safety and not necessarily to regulatory compliance.
In this occurrence, when the crew member was retrieved from the water, the auto-inflating personal flotation device (PFD) he was wearing was not inflated. The occurrence PFD was brought to the TSB Engineering Laboratory for visual inspection and examination. The PFD had a 2-part inflator system with user serviceable components inside and outside of the bladder. Visual inspection noted that the PFD had no signs of damage or deterioration, such as broken hardware, detached webbing, or degraded structural components, that could have diminished its performance. During the examination, it was found that the inflator cap and inflator body were not mated. When these components are separated, the PFD bladder is not sealed and will not inflate. It is not known at what point the inflator cap and body became separated on the occurrence PFD.
In 2019 Transport Canada issued Ship Safety Bulletin 12/2019 Footnote 1 which highlighted the need to inspect and service inflatable lifejackets and PFDs regularly and according to manufacturers’ instructions. Leak testing should also be conducted if it is suspected that a PFD has been treated roughly or stored improperly.
PFD usage has been demonstrated and proven to save lives in the marine transportation industry.
The foregoing is provided for whatever follow-up action is deemed appropriate. The TSB would appreciate being advised of any action that is taken in this regard. An investigator may follow up with you at a later date. Upon completion of investigation M22A0332 the Board will release its report into the occurrence.
Yours sincerely,
Original letter signed by:
Clifford Harvey
Director, Investigations - Marine
CC.
- Director General, Marine Safety and Security, Transport Canada