News release

Unsafe procedures caused February 2012 death on Katsheshuk II

Dartmouth, Nova Scotia, 04 July 2013 — 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.


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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca