Deficient procedure responsible for the death of a CTMA officer

Deficient procedure responsible for the death of a CTMA officer
Deficient procedure responsible for the death of a CTMA officer

The TSB report attributes the accident that cost the life of the first officer of the Madeleine II on January 9, 2022, to failures in CTMA mooring procedures.

The report signed by investigator and former captain Yevgen Lezhankin highlights several shortcomings during the docking of the ship. These deviations from maritime rules led to the tragic event.

Jean-Nicolas Poirier, 34, of Havre-aux-Maisons was fatally struck in the head by the guard that suddenly broke free when a mooring bitt gave way as the ship was docking at wharf no. 2 in the port of Cap-aux-Meules. The officer was pronounced dead within minutes of the accident.

In the maritime world, this type of accident is called whiplash. This is one of the major hazards of docking operations. Whiplash occurs when a line under tension breaks or suddenly releases during mooring operations.

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The Madeleine II had no written procedures to guide the crew during docking procedures. (File photo)

Photo : CTMA

The BST notes that the CTMA had no written procedure for mooring the Madeleine II and that a third sailor would have been necessary to install the two rising guards provided for the docking maneuvers.

The investigation was unable to determine why a third sailor was not present during the mooring.

In the absence of this procedure, the report states that the crew was deprived of guidelines for decision making and the risks associated with using the two-guard mooring method in the absence of a third deckhand were not well understood.

The investigator notes that supervising mooring operations is a task in itself and should not be carried out by a crew member who takes an active role in the manoeuvres in progress, which was the case during the January 2022 accident.

In January 2022, while the Madeleine II was docking, the winch of the first mooring guard got stuck, triggering an alarm.

The winch operator was unable to warn Jean-Nicolas Poirier because he had lost visual contact with the victim, who was busy handling the 2nd rising guard in the whiplash zone. The captain was not notified in time to be able to stop the vessel urgently.

A quay under construction

In March 2022, Ottawa had condemned several berths on Wharf No. 2 and prohibited traffic on certain portions of the Port of Cap-aux-Meules due to the deterioration of the wharf. The load-bearing capacity of certain open portions of the wharf had been reduced by half since the wharf was built in 1971.

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During the accident, a mooring bitt on wharf no. 2 in Cap-aux-Meules suddenly came loose due to the tension.

Photo : Radio-Canada / Isabelle Larose

The report also notes that the facilities on quay no. 2, which were being renovated, were not entirely adapted to the needs of the Madeleine II, which increased the risk of accidents.

The BST note more than the CTMA had commissioned a mooring study on the use of quay no. 2.

Recommendations of the study on the replacement of the bollard [bitte d’amarrage] B80 as well as the use of a single rising guard on the B81 bollard were not followed. If risk analyses do not take into account the recommendations of relevant studies, such as maximum load limits on a bollard during mooring, there is a risk that the identified hazards will not be mitigated.the investigator wrote in his report.

Finally, the BST notes that none of the three men assigned to the aft mooring station, where the accident occurred, were wearing safety helmets.

Following the accident, Transport Canada required the implementation of mooring procedures for the Madeleine II at Cap-aux-Meules and Souris.

According to this procedure, the ferry no longer uses a second rear guard during maneuvers and uses a tug during docking at Cap-aux-Meules when the wind is greater than 25 knots.

Dangerous areas at the moorings have been demarcated and training on the use of the winch has been provided to those responsible. Two other federal investigations have been launched following this accident, one by Transport Canada and the other by Employment and Social Development.



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