On Friday, WorkSafeBC released a 22-page report regarding the incident at Tolko Industries Ltd. on Jan. 30, 2017, that claimed the life of Ivor Lundin, 57.

The report, which had some redacted sections, listed the main cause as an improperly-closed engine hatch, which caused the boat to become swamped and sink. There were also these contributing factors:

An improper and non-functional personal flotation device;

Failure to identify hazards when working alone or in isolation;

Failure to implement a drug and alcohol policy in a timely fashion.

The drowning occurred in Tolko's log storage pond on Okanagan Lake. A boom boat is a purpose-built tugboat that moves raw logs.

The boom boat was reportedly operating approximately 150 feet from shore. Lundin, who was unable to escape from the boat, drowned in approximately 10 feet of water. The report said the boat's engine hatch was not closed properly, and that an open hatch would allow large amounts of water into the engine compartment if the boat was swamped.

The report also noted that the sinking and drowning were not witnessed, and that the boat sank between 9:02 p.m. and 9:09 p.m.

"The exact circumstances surrounding the sinking of this boat are unknown because the incident was not witnessed," said WorkSafeBC.

"However, given the information that is available and the nature of this work, it is logical to conclude that the boat was swamped by water that rapidly filled the engine compartment, causing the boat to sink quickly."

The report added "given the nature of this work, swamping could occur if the front of the boat was driven underwater as a result of a collision with an object (such as a bundle of logs) or from pushing a bundle of logs."

Regarding the life jacket, WorkSafeBC said the personal flotation device (PFD) worn by Lundin "was not appropriate for the task at hand because it was neither inherently buoyant nor automatically inflatable."

The report also said "the PFD was inspected after the incident and was found to be non-functional. The pull cord that activates the inflation mechanism was improperly routed, rendering the PFD inoperative. This could have been due to improper repacking by users of the PFD or a design and manufacturing issue."

In the minutes after the boat's sinking, the report noted that one employee was wondering where it was.

At 9:15, one employee saw lights projecting up from under the water. A few minutes after that, another boat was launched to investigate. The roof of the sunken tugboat was about four inches underwater.

A mill shutdown was reportedly ordered and a search began. A search and rescue team arrived, and at approximately 2 a.m., the body was discovered in the wheelhouse of the sunken boat.

The boat was built in 1973, but received "a significant refit during the winter of 2012-13, which included replacing the wheelhouse, and rebuilding the engine."

WorkSafeBC also said "a partially full bottle of alcohol was found in a backpack recovered from inside the wheelhouse. The contents of the bottle were tested and found to be slightly lower than the 40 per cent alcohol content specified on the label of the bottle."

As part of its contributing factors, WorkSafeBC said "the employer had an alcohol-testing regimen but did not implement it."

The last contributing factor was Tolko's failure to identify hazards when employees are working alone or in isolation.

The report said while at least three workers were in position to observe Lundin, he was physically isolated from them or rescue personnel because he was alone in a boat, far from shore.

WorkSafeBC said it identified two violations of the Workers Compensation Act by Tolko: Failure to ensure the health and safety of workers; and failure to ensure a worker working alone and exposed to the risk of drowning wore a lifejacket meeting specified requirements.