TSB says modifications caused fatal sport fishing vessel incident near Tofino

Is there anywhere or does any one know what the real cause of the accident. Just interested in what those mods where that caused it. With so many of us rebuilding your boats it would be helpful to know so as not to make the same mistakes.
 
I haven’t read it, but any marine incident like this is an easy find. Google search “TSB reports”

Or hopefully this link will work (http://www.tsb.gc.ca/eng/rapports-reports/marine/2015/m15p0347/m15p0347.asp)


Modifications
After entering service in 1996, the Leviathan II underwent various structural and mechanical modifications and additions that included the following:

  • The heat exchangers for the engine cooling system were replaced with an aluminum-channel keel-cooling system.
  • A header tank for fresh water was installed on the starboard side of the main deck.
  • An RHIB on the top deck was replaced with a 12-foot aluminum boat.
  • A 25‑person inflatable life raft, which had been secured on the top deck, was removed from service.
  • The flying bridge on the top deck was enclosed by an aluminum structure with glass windows to provide protection from the elements.
  • A tank for fresh water was installed on the starboard side of the engine room, just below deck level, to service the marine head.
A declaration of modification history, submitted by the owners to TC in March 2011, did not mention any modifications.
 
Is there anywhere or does any one know what the real cause of the accident. Just interested in what those mods where that caused it. With so many of us rebuilding your boats it would be helpful to know so as not to make the same mistakes.

A Link from Vancouver Sun below. This was posted to my FB yesterday. It seems like water ingress from deck into pontoon bilge via holes that were drilled and that bildge water could not be removed due to dead battery ( that was also altered ) - boat I assume then listed with water weight and capsized in apparent rough seas

"the board says the bilge pumps, navigation and communications equipment stopped working when the operator was unable to start the engines before the vessel tipped"

"the safety board says significant parts of the vessel had been modified, including changes to the original design that allowed two batteries to operate separately. That was modified so both batteries, acting as the vessel’s only power source, charged and drained simultaneously"


"Modifications made to the vessel allowed the water shipped on deck to first enter the fish boxes and then drain into the pontoon bilges. Holes that had been made in the shipside and the bulkhead also allowed the water to enter the pontoons and into the stern buoyancy compartments and contributed to the stern’s sinking.”


http://vancouversun.com/pmn/news-pm...cial&utm_source=Facebook#link_time=1526424551
 
Thanks for the link Hambone, but I was more looking for the accident that Peahead was referring too.
Thanks Peahead. That what is was looking for.
I like to hear the reasons for these accidents so that we can check to see we don’t have the same issues on our boats or design the same issues when we are building ours.
 
Thanks for the link Hambone, but I was more looking for the accident that Peahead was referring too.
Thanks Peahead. That what is was looking for.
I like to hear the reasons for these accidents so that we can check to see we don’t have the same issues on our boats or design the same issues when we are building ours.
try:
http://bst-tsb.gc.ca/eng/enquetes-investigations/marine/2017/m17p0098/m17p0098.asp
http://bst-tsb.gc.ca/eng/rapports-reports/marine/2017/m17p0098/m17p0098.asp
 

^ that's the link for the report. Thanks for posting!

Below I've copied part of the report. It's interesting to note that elsewhere in the report it states that one of the people who eventually drowned couldn't fasten the lifejacket before entering the water. Another person helped fasten the lifejacket once the victim was in the water but the lifejacket wasn't worn properly.

3.0 Findings
3.1 Findings as to cause and contributing factors
  1. Three securing screws breached the watertight integrity of the vessel. When these screws went missing, the resulting holes allowed seawater ingress into the vessel's port pontoon.
  2. Water that had washed on deck due to shipping seas entered the port and starboard fish boxes through the pontoon hatch covers and eventually drained into both pontoons through the open fish box drain holes.
  3. Because neither engine was charging the battery unit, the power drained while running the vessel's electrical equipment and was insufficient to operate the bilge pumps. As a result, the water level steadily rose in the port pontoon.
  4. The water from the port pontoon progressed into the starboard pontoon through the hull's middle arc structure. Once the water level equalized, it rose simultaneously in both pontoons and caused the vessel's stern to sit low in the water.
  5. The water continued to rise and entered the vessel's 2 stern buoyancy compartments through the two 10 mm holes in the aft bulkhead, causing the stern to lower further.
  6. The additional weight of the operator and passengers at the stern of the vessel submerged the stern to the waterline, and shipping seas filled the deck with water.
  7. The vessel could not maintain its upright aspect, and all occupants abandoned the vessel into the water.
  8. Because the vessel's exact location could not be provided to SAR authorities, 1 hour and 40 minutes elapsed from the time the stern sank to the time everyone was recovered from the water.
  9. All 5 people in the water were subjected to cold water shock and immersion, resulting in 2 passengers becoming unconscious and drowning.
3.2 Findings as to risk
  1. If vessel modifications compromise the safety features of the original design, there is an increased risk that the vessel will not be adequate for its intended voyage.
  2. If operators of small commercial vessels do not comply with the Small Vessel Regulations, there is a risk that deficiencies in life-saving equipment and procedures will not be identified, compromising the safety of the vessel.
  3. If accurate position information is not provided in an emergency, there is a risk that valuable time will be lost while search and rescue resources try to locate the vessel.
3.3 Other findings
  1. The vessel's flares (expired) were in the accommodation area and were not easily accessible.
  2. The Mayday did not include the vessel's reported distance off Bartlett Island, which led some responding vessels to search closer to the shore.
 
I read through most of that second link - very interesting and thanks agentaqua for posting .....

Despite all the things done wrong ( and there were so many) when all had gone completely sideways it is too bad they didn't have a portable VHF/GPS handheld for back-up communication that didn't rely on the vessel's pwr to function. With a vessel's electrical systems down , a portable VHF likely would have brought help faster and more precisely and that might have made a difference in the outcome. Apparently their EPIRB was defective and PLB wasn't activated. A very affordable portable VHF especially one with GPS/DSC / MMSI is what I have. Not perfect but better than not having it !

"In addition, because the vessel's power supply was dead, the very high frequency (VHF) radiotelephones and global positioning system were not functional; the operator was therefore unable to relay the vessel's exact location to the Joint Rescue Coordination Centre (JRCC). The SAR team therefore had to search a wider area based on an approximate location that the operator reported via cellphone"

I noticed that the vessel was operating as commercial but was registered as a Pleasure Craft. That just makes tragic even worse.....

"* The vessel was registered as a pleasure craft but used as a commercial sport fishing vessel."
 
Jesus what a read eh. They go in the water at 1317hrs. Coast guard fast boat is underway at 1319hrs, arrives at 1445hrs. Basically an hour and a half in the water before help gets there, two drown in this time.

This is how screwed you are out there if something goes wrong. Nobody ever expects the boat to sink, but FFS have a plan and be prepared to self rescue until help gets there. The sea has no mercy for you.
 
"
  1. Three securing screws breached the watertight integrity of the vessel. When these screws went missing, the resulting holesallowed seawater ingress into thevessel's port pontoon."
Sunk by screws. That's yet another example why you should never use screws on a boat!
 
"
  1. Three securing screws breached the watertight integrity of the vessel. When these screws went missing, the resulting holesallowed seawater ingress into thevessel's port pontoon."
Sunk by screws. That's yet another example why you should never use screws on a boat!

Hold on there, screws are just fine for many applications on a boat, probably not best to breach flotation chambers and such, but just fine elsewhere.
 
very surprised anyone in a commercial application would run power the way they did.... from habit as whipped by the ol man, always switch batteries to one or the other when trolling or on anchor. sounds like they had all components running with both batteries in the on position while on anchor!!! this one mistake of a few mistakes cost a couple lives.. not at all professional and downright stupid.
 
Hold on there, screws are just fine for many applications on a boat, probably not best to breach flotation chambers and such, but just fine elsewhere.
Ok cup holders can be okay. I've replaced many screw fasteners that pulled on my boat on major items: deck, rod holders, trolling motor, trim tabs. Where do you think they are fine?

http://www.yachtsurvey.com/Screwit.htm

"One would think that after 40 years of fiberglass boat building, virtually all builders would know that you do not use screws to fasten parts of the hull together, or even attach hardware to the vessel."

http://www.yachtsurvey.com/hardware_attachments.htm
 
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Tragic. Several issues that led up to the event. Least of which was vessel was not properly registered nor compliant to Small Commercial Vessel Program rules. For starters if he had the mandatory high water alarm installed there would have been early warning of trouble. Secondly the electrical system did not have a proper house batter and separate start batteries. That way even if the house was drawn down due to high load created by electronic equip, you could always start the mains and power up the system. As always, most of these crashes or sinkings start from a series of small un-noticed errors and are compounded as time goes by.

A good reminder if hiring a guide to ask if the captain and vessel have all their TC safety training and inspections complete.
 
I blame DOT for not getting out of their office and enforcing the rules.

Also, there doesn't seem to be any way to create separation between the gypos and us who have done all the due diligence and enrolled in the Blue Decal program. The summer before this tragic incident Transport Canada was actually in Tofino for a week, checking boats. I asked them for an inspection to make sure i was fully compliant and passed. This operator and 3 or 4 others kept a real low profile. There are lots of places you can hide if you know the area.

Super sad. If this was my husband and father of my children i would not rest until i got my pound of flesh.

Also, i hear thru the grapevine this operator is talking about getting another boat and hanging his shingle out again....super ballsy!
 
Tragic. Several issues that led up to the event. Least of which was vessel was not properly registered nor compliant to Small Commercial Vessel Program rules. For starters if he had the mandatory high water alarm installed there would have been early warning of trouble. Secondly the electrical system did not have a proper house batter and separate start batteries. That way even if the house was drawn down due to high load created by electronic equip, you could always start the mains and power up the system. As always, most of these crashes or sinkings start from a series of small un-noticed errors and are compounded as time goes by.

A good reminder if hiring a guide to ask if the captain and vessel have all their TC safety training and inspections complete.

It was gross negligence! I see a civil suit coming
 
Tragic. Several issues that led up to the event. Least of which was vessel was not properly registered nor compliant to Small Commercial Vessel Program rules. For starters if he had the mandatory high water alarm installed there would have been early warning of trouble. Secondly the electrical system did not have a proper house batter and separate start batteries. That way even if the house was drawn down due to high load created by electronic equip, you could always start the mains and power up the system. As always, most of these crashes or sinkings start from a series of small un-noticed errors and are compounded as time goes by.

A good reminder if hiring a guide to ask if the captain and vessel have all their TC safety training and inspections complete.
TOTALLY, searun! What I can't understand is why didn't they notice and feel the extra water in the boat and investigate? Likely would have been some list - and you can feel the extra weight - sometimes even feeling the weight and sloshing (even hearing it b4 the engines are started-up) and feel the changes in stability - all w/o an electric alarm. There should have been a niggling feeling of "We better check that out" BEFORE they left the dock....
 
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