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Marine transportation safety investigation M17C0232

This investigation has been completed. The report was released on 02 November 2018.

Table of contents

Person overboard and subsequent loss of life

General cargo vessel Amazoneborg
Trois-Rivières, Quebec

View final report

The occurrence

On , the general cargo vessel Amazoneborg was docked at Section 19 in the Port of Trois-Rivières, Quebec. The third officer was assigned to take the vessel’s draft measurements. Some time after 2210 Eastern Daylight Time, the third officer went to read the amidships draft marks on the vessel’s seaward side; he was later reported missing. Search and rescue authorities were notified of the situation and conducted a search of the area without success. The third officer’s body was recovered on 07 October 2017 near Champlain, Quebec.

Media materials

News release


Unsuitable equipment, inadequate work procedures led to 2017 person overboard and loss of life on the vessel Amazoneborg in Trois-Rivières, Quebec
Read the news release

Deployment notice


TSB deploys a team to the Port of Trois-Rivières, Québec, following an occurrence involving the cargo ship Amazoneborg
Québec, Quebec, 30 September 2017 — The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the Port of Trois-Rivières, Québec, following an accident involving the cargo ship Amazoneborg. The TSB will gather information and assess the occurrence.

Investigation information

Map showing the location of the occurrence


Photo of Mélissa St-Jean

Mélissa St-Jean has been a senior marine investigator at the Transportation Safety Board of Canada (TSB) since 2016.

Prior to joining the TSB, Mélissa has worked at the Canadian Coast Guard for 10 years in various positions and recently as acting Regional Supervisor in Search and Rescue. She also worked for 4 years as Marine Safety Coordinator for the Société des traversiers du Québec.

In addition to being a certified ship's navigation officer, Ms. St-Jean has a college degree in navigation from the Marine Institute of Quebec and a Bachelor of Maritime Studies from Memorial University of Newfoundland.

  Download high-resolution photos from the TSB Flickr page.

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.