Broken PFD, minimum staffing led to death of pilot boat deckhand in 2022: TSB report

An investigation by the Transportation Safety Board has determined the death of a pilot boat deckhand near St. John's was caused by a confluence of factors including a damaged flotation device, a flawed tether system and a minimum staffing level that left one person responsible for driving the boat and rescuing him from the water.

Terry Roberts, 61, died after falling overboard on Sept. 27, 2022. He was 3½ kilometres outside the narrows when the incident happened. 

The investigation report determined his personal flotation device did not automatically inflate when he hit the water, and he wouldn't have been able to inflate it manually since a critical piece of the device was broken.

"I would describe it as hazards known that could have been mitigated," said TSB senior investigator Karie Allen.

"A really, unfortunately preventable set of circumstances."

Roberts was on the final shift of a seven-day rotation. He and his wife, Christa, had a trailer packed and ferry tickets booked to move out of the province and start new.

The investigation pointed out that the manufacturer of the PFD had recommended they be serviced twice per year, while the company had done it only annually. It also found the company used a checklist that did not incorporate all of the manufacturer's advice.

"This is what led to it not being functional on the day," Allen said. "It's a known issue. Inflatable PFDs are actually really complex, and they don't actually provide any buoyancy whatsoever if they don't inflate."

The incident led to the TSB issuing a safety bulletin in 2023, calling on owners to maintain inflatable PFDs according to the manufacturer's instructions.

The pilot boat was owned by the Atlantic Pilotage Authority (APA), but operations were contracted to Canship Ugland. 

That evening started like many others, as they headed outside the narrows and into the open ocean to meet an incoming vessel. Roberts, the deckhand, was joined by the ship's master and a pilot.

The waves were between 1½ and 2½ metres, and the water was a chilly 14 C. 

The pilot made a seamless transfer onto the vessel, and they began to head back toward St. John's with two men left on board the pilot boat.

As the deckhand, Roberts was required to be tethered while outside the boat's wheelhouse. The investigation found that wasn't possible at all times, as deckhands would have to be untethered to go up and down the stairs to the wheelhouse, and when they were going from the side of the wheelhouse to the front.