2024 RSHYR – Incident Review

Posted on June 30, 2025 by Alex Ockenden

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Reports & Bulletins

Issue: December 2024

Issue: September 2025

Issue: November 2025

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Lithium-ion battery fires: What we know so far

Fatal Silver Condor sinking reflects long-standing safety issues in commercial fishing

[caption id="attachment_40775" align="alignright" width="385"] Fatal Silver Condor sinking reflects long-standing safety issues in commercial fishing[/caption]

The Transportation Safety Board of Canada has published its final investigation report into the fatal Silver Condor sinking, which resulted in the deaths of three crew members near La Tabatière, Quebec.

What happened

On 24 September 2023, the fishing vessel Silver Condor, with 6 people on board, began its return trip to port after fishing for redfish. Around midnight on 25 September, the vessel started listing to port and sinking by the stern; as the vessel sank, all people on board entered the water.

At 0230, search and rescue authorities received a signal from the Silver Condor’s emergency position-indicating radio beacon. After trying to contact the vessel without success, a search was launched using several vessels and aircraft. All the people were eventually recovered from the water and brought to the hospital in Corner Brook, Newfoundland and Labrador. Three of the people were treated for hypothermia and other injuries, and the other 3 were declared dead. The vessel was not recovered.

Findings

These are the factors that were found to have caused or contributed to the occurrence:

The vessel was likely operated beyond its stability limits, reducing its freeboard and its reserve buoyancy, which contributed to its sinking when the sea state degraded.
Not all of the vessel’s immersion suits were accessible as the vessel sank; consequently, a crew member donned only a life jacket and, after being exposed to the cold water environment, he became hypothermic and died.
The way the life raft was stored likely prevented it from floating freely when the vessel sank by the stern. Consequently, the life raft was inaccessible to the complement as they abandoned ship, and they were then exposed to the elements.
Crew members had to don their immersion suits quickly because the vessel was rapidly sinking; consequently, 2 crew members did not don their suits properly and were exposed to cold water without adequate protection, which contributed to their deaths.
The master was acutely fatigued, which likely reduced his ability to recognize and respond to the unfolding emergency.

These are the factors in the occurrence that were found to pose a risk to the transportation system. These factors may or may not have been causal or contributing to the occurrence but could pose a risk in the future:

If the maximum weight of catch for safe loading of a fishing vessel is not readily available and shared among all crew members on board, there is a risk that the vessel will be overloaded and that its stability will be compromised.

If operational decisions are made according to a perception of vessel safety rather than validated limits, there is a risk that the vessel will be operated in a manner that may compromise its safety.
If personnel working on board a vessel do not regularly practise responding to emergencies with drills that include realistic scenarios, there is a risk that they will not respond effectively in an actual emergency.
If personnel on board a vessel have not been familiarized with activating the vessel’s distress alerting devices, the personnel might not be able to transmit an emergency signal, creating a risk that the emergency response will not be timely.
If there are gaps in actual radio coverage from coast stations in sea area A1, there is a risk that mariners will not be able to communicate with those stations, which could impede or delay response in an emergency.
If the regulatory oversight of radio equipment installation and maintenance is ineffective, equipment deficiencies can remain unidentified, creating a risk that emergency communications will be impacted.
If the complement of a fishing vessel works without sufficient periods of rest, there is a risk that they will not be able to respond effectively to an emergency.

These findings resolve an issue of controversy, identify a mitigating circumstance, or acknowledge a noteworthy element of the occurrence:

At the time of the occurrence, the vessel’s safety inspection certificate issued by Transport Canada was expired. The certificate was not valid when the Department of Fisheries and Oceans granted an experimental fishing licence to the vessel.
The master had been medically restricted from performing watchkeeping duties. However, during the occurrence voyage, he kept watch alone during the day and at night when the Marine Personnel Regulations required a certified watchkeeper and 1 other crew member to be on watch during periods of darkness.

In a news release, TSB added commercial fishing continues to rank among the most dangerous occupations in Canada and remains on the TSB’s Watchlist due to persistent risks. This accident reflects long-standing safety issues in the industry and reinforces the need for improved day-to-day safety practices, such as operating within validated stability limits, ensuring ready access to lifesaving equipment, and conducting realistic drills to improve survivability when things go wrong at sea.

Download the full report: [download id="962"]

The post Fatal Silver Condor sinking reflects long-standing safety issues in commercial fishing appeared first on The International Institute of Marine Surveying (IIMS).

Lloyd’s Register alert on steam systems and steam hammer risks

[caption id="attachment_47532" align="alignright" width="385"] Lloyd’s Register alert on steam systems and steam hammer risks[/caption]

Lloyd’s Register (LR) have shared an investigation report into two fatalities which resulted from the catastrophic failure of a bellow type expansion fitting on a steam system pipeline on a LR class vessel. There have also been other steam systems and steam hammer risks this year which resulted in accidents.

Subsequent random inspection of vessels with similar expansion fittings as part of their steam piping system have highlighted the following issues:

Some expansion fittings have not remained in compliance with the makers’ limits for axial misalignment or were found compressed/ elongated beyond the makers’ recommendation. This has introduced unnecessary stress, without the steam system being under pressure.
Some fittings were inaccessible due to being enclosed in permanent lagging.
Pipework was no longer adequately supported, to prevent the unnecessary stresses on the fitting

Immediate action recommended

LR have recommended the following should be carried out as soon as possible:

Ensure expansion fittings are listed and clearly marked on the steam system plans and inspected regularly to confirm that they remain compliant with makers’ limits for misalignment and are not excessively compressed or elongated beyond permitted limits.
Check pipework at both ends of such fittings remains adequately supported to prevent undue stresses at time of installation and allow appropriate movement during service (considering the temperature variation of the pipe work which will cause the pipework to slide within the support clamps).
Where such expansion fittings are not accessible due to insulation or lagging, such inaccessible locations should be identified and the lagging arrangement changed to make it removable for periodic inspection.
Check that these fittings remain within their service limits and operational life.
The direction of flow should be confirmed in accordance with makers’ guidance.
Fitting should be compatible with the fluid (in this case steam) for the specific piping system.

Operating conditions and steam hammer

The investigation for this specific incident concluded that the primary reason for the catastrophic failure of the expansion fitting was due to steam hammer. This is a well-known phenomenon resulting from steam being introduced into a cold section of steam system pipeline or fitting (possibly with some condensation collected within), causing high-pressure shock waves.

It cannot be over-emphasised how essential it is that all persons on board responsible for operating any part of the steam system are suitably trained. They must be aware of the precautions to be taken before and while introducing steam into any part the steam system that has remained out of use and is colder than the steam temperature.

Read the class news: [download id="963"]

The post Lloyd’s Register alert on steam systems and steam hammer risks appeared first on The International Institute of Marine Surveying (IIMS).

Lithium-ion battery fires: What we know so far

[caption id="attachment_57755" align="alignright" width="385"] Lithium-ion battery fires: What we know so far[/caption]

Lithium-ion battery fires: What we know so far is a new publication published on behalf of the members of the Maritime Professional Council of the UK. That said, it is aimed at an international audience. The publication has been co-authored by Frances Birkett and Mike Schwarz of IIMS.

Deliberately designed not to be technically heavy, this 36-page overview aims to share some of the case studies and issues surrounding this emerging technology we have seen in recent years. It is designed to increase awareness of the challenges that lithium-ion batteries pose and offers guidance on how to handle and deal with them. Essential reading!

You can download the PDF here

The post Lithium-ion battery fires: What we know so far appeared first on The International Institute of Marine Surveying (IIMS).

CEO blog: November 2025

It seems to be report season! In recent weeks, I have been bombarded with a plethora of them reaching my inbox, more than seems normal for this time of the year, from recollection. Sadly, like you, I cannot make the...

The post CEO blog: November 2025 appeared first on The International Institute of Marine Surveying (IIMS).

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