News release

Associated links (M18C0240)

Injury on passenger vessel Amadea highlights risks posed by lack of training and procedures

Québec, Quebec, 16 July 2020 — In its investigation report (M18C0240) published today, the Transportation Safety Board of Canada (TSB) found that manually overriding a winch system’s built-in safety feature and not wearing protective equipment contributed to a serious head injury while a crew member assisted with stowing a lifeboat.

On 9 September 2018, a scheduled lifeboat drill was taking place on board the passenger vessel Amadea, which was docked in the port of Québec, Quebec. Following the drill, a crew member was seriously injured while stowing lifeboat No. 4 and transported to a local hospital by ambulance.

The accident occurred as several crew members were using the davit’s manual winch to complete the stowage of the lifeboat. To make this task easier, the bosun overrode the built-in safety feature which maintains a slight drag in the winch brake system by releasing the electromagnetic brake with a lever, further than what would normally be accomplished by hand alone. The investigation also determined that the two davit arms were misaligned, requiring extensive manual winching of the lifeboat. Two crew members continued manual winching and the excessive tension on the winch system caused them to let go of the crank handle. Because the electromagnetic brake was released, the crank handle suddenly kicked back and spun backwards, hitting a seaman on the head. The seaman was not wearing any protective headgear.

The investigation revealed that the injured crew member was not trained or familiarized with the task and was unaware of the risks and hazards associated with it. The investigation also found that the onboard safety management system did not include training or any formal operating procedures on lifeboat recovery and stowage, or on operating the davit winches. If crew members are not trained in the safe operation of critical shipboard equipment such as life saving appliances, there is a risk that they will not operate such equipment in a safe manner. In regards to the equipment design, it was determined that if the design allows operators to override or disable its built-in safety features, these features will not function as intended, increasing the risk that the crew will be injured while operating this equipment. Additionally when operating lifeboat winches and davits, and when using lashings, crew members need to wear proper personal protective equipment.

Following the occurrence, the vessel’s manager Bernhard Schulte Cruise Services had lifeboat No. 4’s davit and winch inspected. It updated the Amadea’s training manual so that it now includes a procedure for lifeboat recovery. This procedure specifies that crew members must wear protective headgear (helmet), gloves, and safety shoes while performing any activity involving lifeboat winches, davits and lashings.

See the investigation page for more 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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