A lack of training, a broken piece of equipment, and overall unsafe work conditions led to the death of a crewmember on a fishing vessel last year, according to the Transportation Safety Board.
The Katsheshuk II was about 100 kilometres off Cape Freels when the accident happened in February 2012.
A 25-year-old St. Anthony man died when a small steel door in the hold of the ship slammed on his neck.
Transportation Safety Board investigator Chris Morrow said a lever that controlled the door had been broken for six months.
"Although the crew knew about it, as long as they were just working with shrimp they didn't see it as a problem, and it wasn't reported, so it was never fixed," Morrow told CBC News.
In a release Friday, Katsheshuk Fisheries said it has equipped its vessel with new equipment, as well as new training programs for employees.
It said it has conducted investigations and assessments aboard the vessel to ensure the safety of all crew members.
2 previous accidents led to less serious injuries
Two previous accidents aboard the 55-metre vessel led to less serious injuries.
The ship is owned by Katsheshuk Fisheries — a partnership between Ocean Choice International and the Innu Nation.
Morrow said safety plans are only effective when they're put into practice.
The safety board concluded that few, if any, safe work procedures existed for fish processing on the ship.
The report also noted senior officers were absent from nearly all safety meetings, and workplace inspections were limited to paper audits, with no visit to the ship itself.
While the Transportation Safety investigates the cause of transportation accidents, it's not responsible for determining who's at fault.