The error chain
Based on Transportation Safety Board of Canada reporting.
The circumstances surrounding the sinking of a Canadian fishing vessel off the northeast coast of Newfoundland in September 2005 and the loss of four of the eight crew constitute an error chain. That is a series of decisions or circumstances that separately may not be a threat to the vessel and crew. Combined, however, they can result in the loss of lives and the boat. As in this case, error chains may occur over the course of a few years, making them sometimes difficult to detect.
The steel boat was 65 feet long and about 130 gross tons with a draft of 10 feet. It was built in 1988 as a longliner and, over the years, underwent a series of modifications to do stern trawling and gillnetting in addition to longlining.
Because seas frequently shipped the work deck, it was fully enclosed to be weathertight in 2000. The freeing ports were welded shut and four submersible pumps were installed for dewatering. Other modifications included installation of an A-frame on the stern and winches on the shelter deck, fitting stabilizers on the port and starboard quarters, reconfiguring the accommodations to house 12 crew, enlarging the wheelhouse, and fitting a steel railing around the top of the wheelhouse.
The vessel was fishing for shrimp and turbot for about a week, and the holds were about 95 percent full with roughly 10,000 pounds of turbot, 1,600 pounds of bycatch, and 60,000 pounds of shrimp. Around midday, the crew began hauling the last set of the trip. The winds had subsided from the day before to 15 knots, and the waves were about 6 feet.
While retrieving the nets, the vessel had a starboard list, and waves were splashing in through the open hauling door on the starboard side.
In a moderate roll to starboard, the boat took several inches of water on deck. Another roll to starboard and the pumps were unable to keep up.
As the vessel listed heavily with a foot of water on the starboard side, the crew stopped the net hauler and took the vessel out of gear. The captain left the deck, where he was helping haul nets, for the wheelhouse to check for alarms. The boat took another heavy roll, and water poured through the hauling door.
The captain began retrieving immersion suits, and the crew tried to manually release the life raft on the wheelhouse, but it was blocked by the rails because of the list. By now, the boat was on its beam ends, and it continued to roll over until it was upside down. Only the skipper was able to don his immersion suit. The crew climbed over the side of the boat as it rolled, until they were standing on the bottom. They spotted the EPIRB floating nearby with its light flashing. The life raft did not float free.
When the crew was rescued, only the captain was wearing an immersion suit. Three other survivors without any type of PFD were hanging onto pieces of wood, Styrofoam, or the overturned and damaged aluminum hull. One deceased member of the crew was recovered. Three crew members were presumed drowned.
The vessel's EPIRB deployed and sent an emergency signal. In four hours a vessel and aircraft arrived to rescue the four surviving crew members. One reason for the delay were some problems with the procedures of the Canadian search and rescue resources. Also, the boat's EPIRB registration had incomplete information. On the Canadian EPIRB registration form, the owner of the vessel could enter two contact telephone numbers. On the back of the form was space for a 24-hour/emergency contact. (U.S. EPIRB registration forms provide spaces for primary and alternate 24-hour contact numbers.) Only the owner's home and cell phone numbers were listed. Unfortunately, there was no answer at the home number, and the skipper had the cell phone on the boat.
Because a high percentage of distress signals are false activations, this contact information is critical in the SAR process. Be sure your EPIRB registration provides a list of 24-hour contacts who know where your vessel docks and the area you are fishing. EPIRBs send out an immediate distress signal to the rescue coordination centers via satellite. However, it may take 60 to 90 minutes for the satellites that receive the signal to transmit an exact position.
No other distress alerting equipment was activated or used when the vessel sank or prior to its sinking. The boat had a digital selective calling-enabled VHF radio and a Global Maritime Distress and Safety System-compliant Sat-C system. With all that was happening on the vessel, and the speed at which the boat listed and capsized, there may not have been time to push the emergency button, or it simply could have been overlooked. A distress alert from either of these devices would have helped verify the location and emergency.
Another factor was the modifications made over years of service. The weight of the stern trawling and gillnetting equipment raised the vessel's center of gravity. The enclosed the work deck, dewatering pumps and welded-shut freeing ports proved to be critical when the vessel was hauling nets through a side door near the waterline. The pumps were unable to keep up with the water, which, along with the weight that had been added topside and the rolls the vessel was subjected to, apparently led to the capsizing.
Modifications to a fishing vessel are often necessary for operations. But it's best to have a naval architect review your plans. Track all equipment and gear added or removed from your vessel that cause weight changes. Also, owners and operators should take a basic stability course.
As the boat capsized the crew could not access the survival equipment. Many fishing vessels store their survival equipment in the wheelhouse, but it may not always be the most accessible location. PFDs must be accessible from the individual's normal work station and berthing area. There is no regulation preventing fishing boats from carrying additional safety equipment, available at different locations on the vessel.
Another problem with the survival equipment was the steel railings around the top of the wheelhouse. The life raft was inside the railing. It is unknown whether a hydrostatic release malfunctioned or the life raft was trapped by the railing. An inflatable life raft must be stowed so it can float free and inflate automatically. It also should be deployable by one person.
The investigation of this incident indicated that the crew did not practice emergency drills regularly, and some of them did not know where the immersion suits were. Ensure your crew is familiar with the location, care, and use of safety and survival equipment. Practice emergency drills for abandoning ship, fighting a fire, flooding, a man overboard, launching survival craft, donning immersion suits, making distress calls, and activating alarms.
A safety conscious fisherman will constantly analyze his situation. Know your vessel — its capabilities and limitations. Know the location and how to use your emergency, safety, and survival equipment. Train and drill for emergencies. Be responsible. Be safe. Be around to fish tomorrow.
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