DARTMOUTH. NS, July 4, 2013 /CNW/ - Today, the Transportation Safety
Board of Canada (TSB) released its investigation report (M12N0003) into
the accidental death on board the large fishing vessel Katsheshuk II. The accident occurred off Cape Freels, Newfoundland and Labrador.
On 10 February 2012, as 2 crew members were circulating in cleaned
holding tanks for inspection purposes, one of them inadvertently
activated the hydraulic lever for a shutter door. The door instantly
closed onto the other crew member, causing fatal injuries.
The investigation found that the company's safety management system
(SMS) did not identify the hazard with these hydraulic levers and
provided no procedures for the safe use of the shutter doors as a means
of access for cleaning the holding tanks. Also, the spring in the
hydraulic lever was compromised and would not automatically return the
lever to the neutral position as designed.
An effective SMS requires organizations to recognize the risks involved
in their operations and to competently manage those risks. The TSB has
repeatedly emphasized the advantages of SMS in the marine industry,
citing the absence of SMS in many occurrences over the last 14 years.
Following the occurrence, Katsheshuk Fisheries, Ltd. replaced the
defective hydraulic lever and addressed various safety issues related
to the incident. The company also developed safe working procedures for
safer operations in the vessel factory.
Marine safety management systems is a TSB Watchlist issue. Watch the TSB video!
The TSB is an independent agency that investigates marine, pipeline,
railway and aviation transportation occurrences. Its sole aim is the
advancement of transportation safety. It is not the function of the
Board to assign fault or determine civil or criminal liability.
SOURCE: Transportation Safety Board of Canada
For further information:
Transportation Safety Board of Canada
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