The TSB identified three direct causes: the absence of a required risk assessment before entering the lifeboat, inadequate securing cables that failed under shock load, and the engineer’s lack of equipment-specific familiarization.

Systemic failures and safety culture breakdown

However, the investigation uncovered deeper organizational deficiencies that health and safety professionals should recognize as warning signs. The TSB found that “the presence of formal safety management processes does not ensure that hazards are identified, and that an effective, mature safety culture is being developed.”

The company’s safety management system documentation exceeded 1,000 pages, yet critical information was not accessible to crew when needed. The updated lifeboat manual—which contained improved instructions designed specifically to prevent accidents—was not aboard the vessel.

Most critically, “crew members acquiring equipment-specific knowledge from familiarization, drills, and technical documentation” without such knowledge “may inadvertently activate safety-critical controls, thereby increasing the risks to themselves and other crew members.”

The investigation revealed that documented safety reporting mechanisms were not being used. A hydraulic leak on the lifeboat davit had been noted in monthly checks since June 2023 but never formally reported. The TSB noted a broader problem: “A mature safety culture, including a trusted process for communication, is necessary for 2-way communication between a vessel’s crew and shore-based management.”

Compliance-safety disconnect

The investigation emphasized a critical distinction for safety leaders: regulatory compliance does not equal genuine safety management. While the vessel had passed International Safety Management audits months before the incident with zero non-conformities noted, a subsequent audit identified approximately 47 maintenance deficiencies and determined the ship was “seriously lacking maintenance.”

The TSB found that operations had “drifted away from the 3 goals of an SMS and had become focused on regulatory compliance. A mature safety culture, complete with trusted, non-punitive, two-way communications to permit a full assessment of risk was not evident.”

This drift toward “paper safety”—where documentation demonstrates compliance but fails to address actual operational hazards—represents a systemic risk that extends beyond maritime operations.

The investigation underscores that safety leadership requires more than procedural frameworks. Effective safety culture demands open communication channels where crew members feel safe reporting hazards without fear of reprisal, equipment-specific training for all personnel performing maintenance tasks, and shore-based management actively seeking information about vessel conditions rather than accepting the absence of reported problems as evidence of safety.

The TSB has designated safety management as a priority issue for 2025, finding that “actions taken to date are inadequate, and that industry and regulators need to take additional concrete measures to eliminate the risks.”