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Marine Investigation Report M94W0026

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Marine Investigation Report M94W0026 MARINE OCCURRENCE REPORT CAPSIZING AND SUBSEQUENT GROUNDING OF THE FISHING VESSEL "LADY DEVINE" FORWARD BAY, JOHNSTONE STRAIT, BRITISH COLUMBIA 14 APRIL 1994 REPORT NUMBER M94W0026 MANDATE OF THE TSB The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework governing the TSB's activities. Basically, the TSB has a mandate to advance safety in the marine, pipeline, rail, and aviation modes of transportation by: ! conducting independent investigations and, if necessary, public inquiries into transportation occurrences in order to make findings as to their causes and contributing factors; ! reporting publicly on its investigations and public inquiries and on the related findings; ! identifying safety deficiencies as evidenced by transportation occurrences; ! making recommendations designed to eliminate or reduce any such safety deficiencies; and ! conducting special studies and special investigations on transportation safety matters. It is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board must not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings. INDEPENDENCE To enable the public to have confidence in the transportation accident investigation process, it is essential that the investigating agency be, and be seen to be, independent and free from any conflicts of interest when it investigates accidents, identifies safety deficiencies, and makes safety recommendations. Independence is a key feature of the TSB. The Board reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be fully objective in arriving at its conclusions and recommendations. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Marine Occurrence Report Capsizing and Subsequent Grounding of the Fishing Vessel "LADY DEVINE" Forward Bay, Johnstone Strait, British Columbia 14 April 1994 Report Number M94W0026 Synopsis The "LADY DEVINE", heavily laden with prawn traps, was struck on the port quarter by a large swell and capsized. The two crew members climbed up on the hull and waited for rescue, but the vessel drifted in a westerly direction and grounded in Forward Bay, British Columbia. The two crew members suffered from hypothermia and the deck-hand later drowned. The owner/operator was stranded on West Cracroft Island, British Columbia, for two days before the "LADY DEVINE" was sighted by a passing vessel and he was rescued. The Board determined that the effective after freeboard and transverse stability of the "LADY DEVINE" were markedly reduced due to the number of prawn traps stowed on the afterdeck. The weather deteriorated later in the day and stabilizers were not deployed. The stacked prawn traps and a nylon tarpaulin presented a large surface area to the strong wind and acted like a large sail retarding the vessel's return to the upright. The vessel shipped and retained water on the weather deck, downflooded, and capsized to starboard. Seawater entered the forward under-deck compartments through the open door at the after end of the wheel-house and through the fish hold when the unsecured fish hold hinged hatch cover became displaced. Ce rapport est également disponible en français. TABLE OF CONTENTS Table of Contents Page 1.0 Factual Information ................................................................................................................................................................................... 1 1.1 Particulars of the Vessel ................................................................................................................................................................. 1 1.1.1 Description of the Vessel ............................................................................................................................................................... 1 1.1.2 Stabilizers .......................................................................................................................................................................................... 1 1.2 History of the Voyage ..................................................................................................................................................................... 2 1.3 Injuries to Persons ........................................................................................................................................................................... 4 1.4 Cold Water Survival ........................................................................................................................................................................ 4 1.5 Certification ...................................................................................................................................................................................... 4 1.5.1 Vessel ................................................................................................................................................................................................. 4 1.5.2 Personnel .......................................................................................................................................................................................... 4 1.6 Damage to the Vessel ..................................................................................................................................................................... 5 1.7 Environmental Damage ................................................................................................................................................................. 5 1.8 Weather and Tidal Information ................................................................................................................................................... 5 1.8.1 Weather as Recorded by the Vessel ............................................................................................................................................ 5 1.8.2 Environment Canada Recorded Weather .................................................................................................................................. 5 1.8.3 Nearest Recorded Weather ........................................................................................................................................................... 6 1.8.4 Tidal Information ............................................................................................................................................................................ 6 1.9 Capsizing and Subsequent Grounding Position ....................................................................................................................... 6 1.10 Life-saving Equipment ................................................................................................................................................................... 6 1.11 Search and Rescue Resources ...................................................................................................................................................... 6 1.12 Stability .............................................................................................................................................................................................. 7 1.12.1 Prawn Traps ...................................................................................................................................................................................... 7 1.12.2 Rolling Motion ................................................................................................................................................................................. 7 1.13 Situational Awareness and Information Processing ............................................................................................................... 8 1.14 Factors Affecting Decision Making ............................................................................................................................................. 8 2.0 Analysis ................................................................................................................................................................................................................. 9 2.1 Introduction ...................................................................................................................................................................................... 9 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 2.2 Stability .............................................................................................................................................................................................. 9 2.3 Sea State ............................................................................................................................................................................................ 10 2.4 Situational Awareness and Information Processing ............................................................................................................... 10 2.5 Crew Decision Making ..................................................................................................................................................................
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