Date of incident: February 2021
Notice of incident number: 2021182060005
Employer: Marine transport company

Incident summary
Three crewmembers were on a tugboat towing a barge at night. The tugboat became exposed to rough seas and high winter winds. A large wave struck the port side, causing the tugboat to heel (incline) onto its starboard side, from which it could not recover. Water entered the engine room through the air vents behind the wheelhouse, and the tugboat capsized and sank, stern-first. Two crewmembers drowned. The third crewmember was able to get into the tugboat’s life raft, which then washed ashore; he sustained serious injuries before being rescued.

Investigation conclusions

Cause

• Tugboat sailed in inclement weather.
  • The weather forecast for the sailing route on the day of the incident included northerly outflow winds of 35 to 45 knots (65 to 83 km/h) and a temperature of –7°C, with a gale warning and freezing spray in effect. Vessels involved in rescue efforts recorded winds of 50 knots (93 km/h) with gusts up to 60 knots (111 km/h) and a temperature of –9°C. The weather effects overwhelmed the tugboat. It is also possible that the weather and wave conditions caused the barge to exert sufficient force to pull the tugboat back and down at the stern (referred to as girding).
  • After the crewmembers jumped into the water, one of them attempted to release the life raft, but the manual release buckle was frozen. Once the tugboat sank, the hydrostatic pressure engaged the release mechanism on the buckle, releasing the life raft.
  • After the tugboat sank, there was a delay of approximately 34 minutes before the transmission of the tugboat’s emergency position-indicating radio beacon (EPIRB) signal, which in turn delayed initiation of rescue efforts. This may have been due to the EPIRB (secured on the tugboat’s mast) being covered with ice when the tugboat sank, as well as VHF radio dead zones in the surrounding steep, mountainous terrain. Additionally, rescue efforts were hampered by the severe weather.

Contributing factors

• Instability of vessel. The tugboat had a low bow, and the freezing spray would have caused ice to accumulate on its wheelhouse, deck, mast, and winch release system. The wheelhouse was 0.6 m (2 ft.) higher than was originally designed. The higher wheelhouse combined with ice accumulation (additional weight) on the tugboat, especially on the upper portion of the vessel, may have affected the tugboat’s stability by raising the centre of gravity. A higher centre of gravity would have reduced the tugboat’s ability to recover from the significant heel to starboard caused by the large wave.
• Inadequate flotation and thermal protection. The immersion suits being not fully zipped up affected the suits’ ability to provide flotation and thermal protection. Fully zipped immersion suits might have decreased the severity of the incident.
• Poor risk assessment and decision making. The crewmembers’ employer planned the trip when the weather forecast indicated that the route would have high gale-force winds with freezing spray and sub-zero temperatures. The employer was aware of the effects of freezing spray and the conditions that could occur on the route, as on a previous occasion, another tugboat operated by the employer had become frozen due to cold weather and freezing spray on the sailing route. The employer reviewed the weather forecast on the day of the sailing, yet did not cancel it. In addition to not cancelling the sailing, the employer failed to provide appropriate instruction to the crewmembers to prevent exposure to the known hazards.
• Inadequate orientation and training. The employer did not fully orient and train all the crewmembers. In addition, its workers did not practise donning immersion suits and, more generally, the employer did not conduct marine emergency drills, including abandon ship.
• Lack of safe work procedures. The employer had no written procedures with respect to using immersion suits or working in winter conditions, including the hazard of sailing in freezing spray. Had the employer implemented a procedure indicating when immersion suits were to be worn during inclement weather, even when in the wheelhouse, the drownings might have been avoided, and the crewmembers might have had the flotation and thermal protection provided by an immersion suit.
• Failure to maintain safety management system.
  • The employer’s policies and procedures for operations were detailed in a document referred to as a safety management system (SMS). On numerous occasions, checklists that were part of the SMS were not completed, and the tugboat and immersion suits were not inspected and maintained as intended by the SMS.
  • Further, although the employer had a written procedure document for the sailing route, this document was not in the SMS provided to WorkSafeBC, and the employer’s senior managers were not aware of it at the time of the incident. The employer did not ensure that a qualified person was assigned to administer and oversee the SMS, despite “SMS Coordinator” being one of the job descriptions in the SMS.
  • The employer’s failure to ensure the management of and adherence to the SMS resulted in several critical failures in regard to planning to ensure a safe workplace, conducting and documenting inspections, assessing risk, providing supervision, and training workers.

Other health and safety issues

• Lack of certification. The employer failed to ensure that its workers were assigned work that they were certified to carry out.
• Outdated EPIRB contact information. Neither the employer nor the company that leased the tugboat and barge to the employer updated the tugboat’s EPIRB emergency contact information within a reasonable time after acquiring the tugboat. This failure could have led to a delay in notifying the employer when the EPIRB was activated. While it did not occur in regard to the incident, such a delay could have resulted in a delay in providing emergency responders with essential information about the tugboat and the crew.
• Inadequate tugboat maintenance.
  • Between October and December 2020, the tugboat sailed at least 11 times with the winch release system not working. The winch release system is a critical safety device to avoid girding — a severe marine emergency that can sink a vessel and cause harm to the crew.
  • Between October and November 2020, it was noted several times on pre-departure checklists that the radio system was weak, the starboard searchlight was dim, and the tugboat’s Global Positioning System (GPS) and Automatic Identification System (AIS) would spontaneously stop working. Also recorded were multiple instances of nautical charts and publications not being available.
• Lack of first aid attendant. At the time of the incident, there was no certified first aid attendant on the tugboat who had training recognized by WorkSafeBC.

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