News release

Associated links (M18C0018)

Fitness for duty cited as key factor following fatal 2018 cardiac event aboard bulk carrier

Québec, Quebec, 6 August 20 – In its investigation report (M18C0018) released today, the Transportation Safety Board of Canada (TSB) cited that fitness for duty was a key factor in the fatal cardiac event that occurred aboard the bulk carrier Sage Amazon near Port-Daniel-Gascons, Quebec, in 2018. The report also cites issues with access to medical records for vessel crew members as a risk factor.

On 17 March 2018, the master of the bulk carrier Sage Amazon experienced a cardiac event while standing on a cargo hold access ladder. He fell from the ladder onto the main deck, receiving serious head injuries. At the time, the vessel was anchored three nautical miles off Port-Daniel-Gascons, Quebec. Medical aid, including cardiopulmonary resuscitation, was provided on the vessel, but was unsuccessful in reviving the master.

The investigation found that, after the master fell off the ladder, first aid initially focused on his head injuries. When the possibility of a cardiac event was raised, with no automated external defibrillator (AED) on board the vessel, it was not possible to confirm the master’s cardiac condition. Although various search-and-rescue resources had been dispatched, it took approximately 3 hours for first responders to reach the vessel—at which point it was too late for medical assistance.

Although the master had been declared fit for duty without restrictions, an independent examination of the master’s medical records, conducted for the purpose of this investigation, identified a number of medical conditions, including a previous cardiac event, that should have restricted his capacity for duty at sea. However, these were not disclosed during the master’s last marine medical examination in 2017. Previous TSB investigations have identified that seafarers may not disclose medical conditions out of concern that they will lose their employment. Therefore, if medical practitioners do not have access to full medical information and records, fitness for duty may not be assessed accurately, increasing the risks of seafarers endangering themselves, the vessel, the crew and the environment in a medical emergency.

In addition, current international standards do not include AEDs as part of standard medical equipment. Modern AEDs are compact, reliable, easy to use, and relatively inexpensive. Vessels carrying AEDs are better equipped to respond to some medical emergencies, which may improve their outcomes. If vessel crews do not have access to medical equipment such as an AED, which could assist following a cardiac event, there is a risk that shipboard personnel will not receive adequate medical treatment.

See the investigation page for further information.


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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca

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