TSB report into deaths of 3 fishermen in Tabusintac released
2 recommendations stemming from grounding, sinking of Marie J in May 2013 made after previous incidents
Weeks after a small lobster boat grounded on a sandbar in Tabusintac Bay last year and sank, killing all three people on board, five additional green buoys were added to the narrow channel "for increased navigational safety," a report by the Transportation Safety Board reveals.
A review by Canadian Coast Guard Aids to Navigation (CCG NavAids) on June 25, 2013, determined the buoys were required on both sides of the channel because it was less than 30.5 metres wide, the newly released report states.
Fishermen in the northeastern New Brunswick community had been complaining about the narrow channel in the area prior to the Marie J sinking on its return to McEachern's Point harbour on May 18, 2013, and had urged Fisheries and Oceans Canada to dredge the area.
The TSB report also found that a new channel had been marked with buoys on April 26, 2013, just weeks before the fatal accident, but CCG NavAids did not issue any notice to mariners about the buoys being moved to a different channel until June 25, "which indicated that the buoys were unreliable in the new dredged channel."
Search and rescue organizations were also unaware of the changes, the report found.
The Halifax-based Joint Rescue Co-ordination Centre believed the position of the sinking was in the Tabusintac gully, as it was depicted on the Canadian Hydrographic Services charts, which still showed the buoyed channel as being in the old gully.
As a result, crews began searching in an area that was 3.9 km south of the actual site.
"Although it is unlikely that the inaccuracy of the original reported position of the vessel affected the final outcome of this particular SAR operation, knowledge of the precise location of a vessel in an emergency is often critical to the outcome of a successful SAR operation," the report states.
The latest update of CHS charts, published in July 2014, still depict the previously buoyed channel in the old gully, TSB found.
In a letter to the TSB, dated July 2014, CCG said it is “working to modernize its risk-based methodology to design and review Aids to Navigation Systems."
Survival suits, beacons recommended
TSB also repeats two outstanding recommendations in its report.
It suggests that Transport Canada expedite new rules to require fishermen to carry survival suits, following the drowning deaths of Ian Benoit, Samuel-René Boutin, and Alfred Rousselle.
The Marie J was fitted with the required minimum of lifesaving appliances, but none of the fishermen were wearing a life jacket or personal flotation device (PFD), the investigation found. The vessel did not have any additional lifesaving appliances, such as survival suits, the report states.
"Within the fishing community of Tabusintac, it was not common practice for fishermen to wear PFDs or carry additional lifesaving equipment beyond that required to be carried by regulation."
The proposed change would require fishing vessels of 12 metres or more in length operating less than 25 nautical miles from shore to carry anti-exposure worksuits and immersion suits when the water temperature is less than 15 C.
I believe this report is important in helping to understand how industry and the government can learn from this and further enhance the safety of mariners in the future.- Minister of Fisheries and Oceans Gail Shea
Fishing vessels of less than 12 metres that opt to carry an Emergency Position-Indicating Radio Beacon or a means of two-way communication rather than a life raft or other survival craft would also be required to carry immersion or anti-exposure worksuits if the water temperature is less than 15 C.
TSB also says the department should require small fishing vessels to carry a beacon during coastal voyages to indicate their position in an emergency to ensure navigational safety.
Both recommendations were made after previous incidents, dating back to 1992, but remain outstanding, according to the 22-page report.
TSB also found some provinces are more "proactive" and "comprehensive" in their approach to fishing safety than others.
In Nova Scotia, for example, the provincial Department of Labour regulates certain aspects of fishing, including those related to labour relations and workplace safety.
But New Brunswick's WorksafeNB Occupational Health and Safety Act excludes fishing vessels as places of employment, and is not involved in matters related to fishing safety.
Fisheries and Oceans Canada is reviewing the TSB's findings carefully, Minister Gail Shea said in a statement issued on Thursday afternoon.
"I believe this report is important in helping to understand how industry and the government can learn from this and further enhance the safety of mariners in the future," Shea said.
"I believe this is an opportunity to engage in a dialogue and to work closely with the provinces and the fishing industry to promote greater industry safety and would like to reiterate our government’s commitment to working with all concerned in this regard."
Fishing pressures may encourage risk-taking
Tabusintac Bay, located at the mouth of Tabusintac River, is fronted by a 14-km stretch of sandbars that contain numerous tidal gullies, according to the TSB.
A route within a gully that allows vessels to pass through to the open sea is "in a constant state of flux" as a result of predominant wind and wave action, the report states.
"These winds, waves and tidal action, as well as winter ice thickness, also affect the structure of the stretch of sandbars, causing existing gullies to gradually or suddenly silt in and new gullies to open up in different locations."
On May 18, 2013, the Marie J, a Northumberland-style fishing vessel, headed out at about 4:40 a.m. in poor weather conditions, including winds of 25 knots and wave height of three to four metres.
"Fishermen compete for their share of the resource, which may encourage risk-taking activities such as overloading vessels, working while fatigued, and operating in poor weather," the TSB report states.
The Marie J did turn back, however, and attempted to enter the only available channel, which "posed a number of challenges," TSB found. The channel was narrow, shallow, perpendicular to the direction of the wind and waves, and subject to strong tides.
In addition, the accuracy of the buoy locations was unknown; the channel was prone to silting and bottom shifting, the buoys themselves could shift in position, and it was near low tide, with breaking waves from the northeast, the report states.
Marie J grounded on a sandbar at about 5:30 a.m. and remained awash on the sandbar for about 20 minutes before it was pushed over into deeper water by breaking waves, the investigation found.
The vessel was never recovered, with the exception of the wheelhouse, which was later located on the beach.
The master, who had 18 years of fishing experience in the Tabusintac Bay area and had served as a master for the last eight years, had only operated the Marie J for about 10 fishing days prior to the fatal accident. He had leased it after his previous vessel had been destroyed by fire.
The Marie J differed from his previous vessel, mainly in the increased weight of the hull and decreased visibility from the wheelhouse, TSB found.
The body of one of the fishermen was recovered in the afternoon, and the other two bodies were recovered the following day.
TSB investigated the sinking of the Marie J to advance transportation safety. It is not the board's function to assign fault or determine civil or criminal liability.