Marine transportation safety investigation M22C0005

Table of contents

    Crew member fatality during berthing
    Ferry Madeleine II
    Coopérative de transport maritime et aérien
    Cap-aux-Meules, Quebec

    The occurrence

    On 09 January 2022, a crew member was fatally injured while berthing the ferry Madeleine II in Cap-aux-Meules, Quebec. No damage or pollution was reported.


    Safety Communications

    Safety advisory

    Investigation information

    Map showing the location of the occurrence

    M22C0005

    Crew member fatality during berthing
    Ferry Madeleine II
    Coopérative de transport maritime et aérien
    Cap-aux-Meules, Quebec

    Investigator-in-charge

    Image
    Photo of Yevgen Lezhankin

    Yevgen Lezhankin joined the TSB as an investigator with the Central region of the Marine branch in 2018. Yevgen holds a Master Mariner certificate and has worked at sea for 22 years, navigating internationally and in Eastern Canada. Before joining the TSB, Yevgen was working as a Transport Canada marine safety inspector in Port-Cartier and Quebec City. Yevgen graduated from Odessa State Maritime Academy and has a bachelor’s degree in navigation.


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    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.