Language selection

Marine transportation safety investigation M21C0214

The TSB has completed this investigation. The report was published on 7 December 2023.

Table of contents

Person overboard and subsequent loss of life

Fishing vessel Suvak
Davis Strait, approximately 120 NM northeast of Qikiqtarjuaq, Nunavut

View final report

The occurrence

On at 0310 Newfoundland Daylight Time, a crew member on the fishing vessel Suvak went overboard while setting gillnets in Davis Strait, approximately 120 nautical miles northeast of Qikiqtarjuaq, Nunavut.

At the time, the Suvak was nearing the end of a 2-week fishing trip. Two crew members who were hauling and setting nets had been working long hours to complete all the fishing operation activities required before the vessel departed for port. They had set and hauled nets and completed other fishing operation activities throughout the day on 25 August and into the night, with 1 break of 1.75 hours. At the time of the occurrence, they had been awake for over 21 consecutive hours. The intention was for the crew members to have a rest period once the vessel departed. However, while setting nets in the early hours of the morning, one of the two crew members was pulled overboard after his arm became entangled in the buoy line. The crew member was recovered from the water and, despite significant lifesaving efforts, was later pronounced dead.

The investigation found that the 2 crew members who were setting the nets on the Suvak were experiencing sleep-related fatigue from a combination of acute and chronic sleep disruption, continuous wakefulness, and circadian rhythm disruptions, which reduced their cognitive abilities, including their ability to remain vigilant against risks. The crew member who went overboard had a smaller physical stature and had adapted the procedure for picking up the coils of buoy line to keep up the pace. In combination with mental and physical fatigue, this adaptation led to his arm becoming entangled in the buoy line.

The investigation identified risks related to the absence of fatigue management plans and risk assessments for operating procedures. It also identified a need for fishing allocation policies to take safety into account, and for emergency procedures, equipment, and drills for responding to entanglement situations to be implemented on board.

Oversight of occupational health and safety on fishing vessels registered in the Canadian territories

The investigation into this occurrence also found a gap in the oversight of occupational health and safety (OHS) on fishing vessels registered in the Canadian territories. Specifically, there had been no OHS inspections of the Suvak or of other fishing vessels registered in the territories. This was because the territories considered fishing vessels to be under Transport Canada’s jurisdiction, and Transport Canada considered OHS inspections of fishing vessels to be outside its jurisdiction. If there is no oversight of OHS on fishing vessels registered in the territories, there is a risk that crews of those vessels will be subject to OHS hazards in the workplace. Therefore, the Board recommends that

the Department of Transport, in collaboration with the Department of Employment and Social Development and the territorial governments, review the occupational health and safety oversight of fishing vessels registered in the territories to ensure effective workplace safety oversight.
TSB Recommendation M23-09

Media materials

News releases


TSB recommends a review of the gap in oversight of occupational health and safety on fishing vessels registered in Canada’s North
Read the news release

Media advisory


TSB to release one recommendation following its investigation into a 2021 marine accident near Davis Strait, NU
Read the media advisory

Investigation information

Map showing the location of the occurrence


Photo of Jason Melvin

Jason Melvin is a marine engineer with over 25 years of experience in the marine field. He joined the Transportation Safety Board of Canada in early 2021. During his career, Jason worked for the Canadian Coast Guard from 1995 to 2007 on vessels operating on the east coast of Canada from the Bay of Fundy to the Beaufort Sea. After a stint with Atlantic Towing from 2007 to 2008 as Chief Engineer and Offshore Supply Vessel Superintendent, Jason joined Suncor. Between 2008 and 2021, he held the positions of Marine Advisor, Marine Operations Supervisor and Marine and Air Team Leader. In addition, while still employed with Suncor, Jason was actively involved in internal incident investigations, progressing from SME to Senior Investigator. Jason was also Suncor’s representative in the joint operators’ response to the offshore helicopter safety investigation recommendations.

Class of investigation

This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.