Aide Memoire: HMCS CHICOUTIMI Crew Follow-up, March 2008

“Canadian sailors ask little in return for freely accepting the notion of unlimited liability which may cause them to suffer injury or lay down their lives for Canada. I believe that in return the Navy owes its injured sailors forthright leadership that addresses their personal welfare and ensures they have access to the medical care they require. This has been an obligation long recognized in the history of the Navy, and one that we will continue to meet in the future. We owe our sailors nothing less.”

Drew Robertson, Vice Admiral, Commander Maritime Command and Chief of the Maritime Staff, 14 March 2008

BACKGROUND

• 4 October, 2004: HMCS Chicoutimi, with a crew of 57 sailors, sailed from Faslane, Scotland.
• 5 October, 2004: Two technicians were sent to repair a faulty valve in the conning tower. During this time, a wave caused a large amount of water, estimated at 2,000 litres, to ingress into the submarine.
• Approximately two hours later, a fire occurred in the Commanding Officer’s (CO’s) Cabin and Electrical Space. The fire was caused by an arc in the main power cables in and around the CO’s cabin. The arcing was a result of water immersing the connectors joining the cables to the bulkhead penetrators after the ingress. Within seconds of ignition, the fire spread to the Electrical Space below.
• Crew response to the fire was rapid. The alarm was raised, power was isolated and the fire was attacked. By the time the fire was reported out, nine members of the crew displayed symptoms of smoke inhalation.
• A second fire in the oxygen generator occurred six hours after the first fire when two generators were operated to improve the quality of the air in the submarine. This fire was out within two minutes of being reported.
• 6 October: HMS Montrose, despite heavy seas, sent a doctor and a physician’s assistant to help with casualties. Three casualties were taken from Chicoutimi via helicopter to Sligo, Ireland. Lt(N) Saunders died shortly after arrival at the Sligo Hospital.
• 10 October: Chicoutimi, in tow, returns alongside Faslane.
• 12 October: CMS Vice-Admiral Bruce MacLean announced that a military Board of Inquiry (BOI) would be convened to investigate the fire and the death of Lieutenant (N) Chris Saunders.
• 17 December: The President of the BOI presented the final report, with a supplementary report presented March 18, 2005. The BOI found that the chain of events had, “outcomes that could not have been predicted, and tragic consequences for which no one can be held responsible.” However, there were 24 recommendations made by the BOI in order to improve safety practices onboard submarines.

INITIAL MEDICAL ACTIONS

• All crew underwent complete physical evaluations and spirometry (respiratory testing) after arriving in Faslane, Scotland. A complete pulmonary function testing protocol was performed in Halifax within 3 months after the fire (including methacholine challenge testing or MCT, which is the most sensitive diagnostic test for reactive airways diseases (i.e. asthma)). Where clinically indicated, a number of crewmembers underwent chest x-rays.
• In addition to individual medical work-ups, there were a series of occupational and environmental tests completed when HMCS Chicoutimi reached Faslane, by a team of DND occupational health specialists. These tests included a soot analysis and submarine air samples using specialized equipment transported from Canada.
• Approximately one year after the incident, all crewmembers underwent another complete history and physical evaluation. Those whose health examinations warranted it, or who had previously demonstrated abnormal respiratory test results, were recommended for additional respiratory testing.

FOLLOW-UP MEDICAL ACTIONS

• Following the screening conducted one year after the event, follow-up occurred as per the clinical judgment of every crewmembers’ individual physician. Those who had demonstrated effects due to the fire were followed more closely than those without clinical symptoms or signs of a medical problem. In the CF, all members are scheduled for regular periodic health assessments with healthcare professionals, at which time they may bring forward any medical concerns.
• The chain of command has an obligation to ensure that former HMCS Chicoutimi members are aware of the many mechanisms in place to ensure they get the care that they need. Some of the means at their disposal include consulting their doctor at any time they wish, asking for a second opinion, taking any problems or issues they may have with treatment up their chain of command, submitting grievances, or speaking with the office of the ombudsman. This information will be briefed at the upcoming town hall.
• A DND occupational and environmental health specialist was asked to make evidence-based recommendations regarding the required medical follow-up for HMCS Chicoutimi crewmembers. This specialist did not recommend any long-term screening of crewmembers for specific chronic effects or for cancer, as the elevated risk due to chemical contaminant exposures from fire is very low. Key determinants of long-term risk are dose and duration of exposure to a toxin; a comparison can made to smoking – smoking one pack of cigarettes is not likely to cause cancer. However, smoking one pack daily over 20 years does significantly increase cancer risk.
• Generally, long-term respiratory effects from smoke inhalation injury are only observed in individuals suffering from significant acute symptoms. Reactive Airways Dysfunction Syndrome (irritant-induced asthma) is the most common manifestation of short-term high-dose smoke inhalation. Patients usually develop symptoms or signs of this illness within one year of exposure.
• In order to complete a thorough Health Risk Assessment, the BOI recommended that a toxicity of smoke test be conducted, whereby the fire is re-created, and the elements created by the fire are analyzed. This complex test requires specialized facilities. While the National Research Council was able to conduct the test, DND had to join a queue and wait its’ turn. It was only late in the fall of 2007 that DND received the results of the test, which are currently being analyzed by DND Occupational Health specialists, including toxicologists and industrial hygiene experts. This is expected to be completed by June 2008.
• While this process has taken longer than desired, it is imperative that the necessary time is spent to correctly complete this task, as it will enable the Navy to provide sailors with the best, most detailed risk assessment information possible.
• As always intended, once it can be determined what specific and comprehensive risks that the smoke posed to the sailors using all available evidence, a letter regarding the occupational health risk assessment will be placed on the medical records of HMCS Chicoutimi crewmembers and a copy will be made available to VAC as well as crewmembers themselves.
• A Director Casualty Support and Administration (DCSA) centre has been stood up in Halifax, which is mandated to ensure the provision of support services to ill and injured members, veterans, and their families. While this is currently operating in a limited capacity, this centre will soon be augmented by a CF-wide initiative that will create enhanced casualty support centres. These enhanced centres will allow improved administration, management and tracking by support staff. They will be closely aligned with the chain of command in order to be able to quickly correct deficiencies in support, and with the CF healthcare system.
• These enhanced centres will focus on returning the injured sailor to the navy workforce or transitioning members and their families into the civilian world in a seamless manner, with the best care possible. They will consolidate all the support services available to members by providing a single point of contact, thereby simplifying access for CF members, improving service delivery, and providing comprehensive 'whole person' oversight. It is expected that implementation across Canada will commence prior to Jun 08.

MEDICAL INFORMATION

• There is clear documentation on the personnel and medical records of those involved in the HMCS Chicoutimi fire. This includes annotations on their permanent personnel files with either accident reports or memorandums to indicate the members were involved in the fire.
• In addition, the medical records of these personnel were annotated - both in the members’ medical records (initial screening records, diagnostic tests, specialists reports, enhanced post-deployment screening questionnaires, etc as appropriate), in their mental health files (if required) and in a file known as a 'shadow file' - a backup copy of information which is kept by the CF Surgeon General.
• Only the complete medical records of serving members are accessible to the military; the medical records of retirees are archived by the Government of Canada. The shadow files of the surviving 56 crewmembers were personally reviewed by the Surgeon General to ensure the proper documentation is present. In all cases, medical notes were present to indicate that the sailor was involved in the incident, and all but one of the files had a subsequent enhanced post-deployment screening (which is particularly focused on identifying latent psychosocial issues) as well.
• There will also shortly be improvements to the monitoring of CF members’ health. The CF Health Information System is an enhanced electronic health record that will improve the ability to track CF personnel exposed to incidents involving workplace health hazards (such as those arising from this incident), wherever they work. In this way, tracking of individual members by the CF healthcare system will be much easier across the CF and surveillance for latent healthcare problems for events not immediately obvious (for instance exposure to an unknown radiation source) will be possible even if identified years later. This will provide the link between workplace and risk and will lead to enhanced monitoring of CF members potentially at risk. The final operating concept of this project is expected to be reached by 2011.

VETERANS AFFAIRS CANADA

• The CF/DND has a close relationship with VAC. There is a liaison officer embedded within each department, which allows the departments to share information. An institution called ‘The Centre’ has been established as a joint effort of both the Department of National Defence (DND) and VAC. The Centre is committed to providing information and services to injured and retired military members and their families.
• With respect to the Chicoutimi incident, the Navy continues to collaborate with VAC to give them all the information possible in order to assist sailors who are applying for a pension. VAC has received the names of the surviving 56 crewmembers and is reviewing each case to determine what can be done to assist with respect to the VAC programs and benefits that would apply.

MENTAL HEALTH

• With respect to mental health, a team of specialists (psychiatrist, mental health nurse, social worker and chaplain) flew to Scotland immediately following the fire. Each crewmember was interviewed by one of these specialists for basic screening and education regarding potential mental health reactions following significant incidents of this nature. Furthermore, all crewmembers were contacted by telephone by the Canadian Forces Health Services Centre (Atlantic) Mental Health Unit one month following the incident, and they underwent mandatory follow-on psychosocial screening three-months post-event. This was repeated during the one-year follow-up. Additional follow-up care was provided to any members who still required it.
• Sailors have a number of options at their disposal, which they will be reminded of in the upcoming town hall. They can seek mental health care services from their doctor, can be referred to the CF's comprehensive range of mental health services, have access to CF chaplains or social workers directly, and can access the CF Member Assistance Program (CFMAP), which is a voluntary, anonymous and confidential service initiated by the Canadian Forces (CF) and offered by the Employee Assistance Services of Health Canada to help members and family members who have personal concerns.
• Initially, approximately half of the HMCS Chicoutimi crewmembers required treatment by mental health professionals. Most sailors experienced mild problems, and most have since returned to full duty.
• For sailors who released and had ongoing mental health issues, continuity of care was ensured. Those remaining in the Halifax area were able to access the CF Operational Stress Injury Support Centre (OTSSC), and the Operational Stress Injury Social Support (OSISS) Program, a peer support network. If they retired to another city across Canada, care at another CF OTSSC or at a Veterans Affairs Canada’s (VAC’s) Operational Stress Injury (OSI) clinics would be available. Where this was not geographically feasible, Case Managers and military physicians handed over medical care directly to mental health specialists within the civilian health care system

PEREDITE/PITKOTE

• There have been many questions pertaining to peridite and pitkote and their potential effect within the smoke mix. While there is a thin layer of Peridite primer found on the inner steel hull of the submarines, a much thicker layer of Pitkote adhesive is used to adhere thick board insulation to the hull and the underside of the main deck.
• There was a minimal amount of Pitkote and Peridite involved in the fire - estimated as approximately one square foot of material. The combustion products of Peridite and Pitkote are toxic- but no more so than any other product or compound (i.e. paper, mattress etc.) burned in the fire. The Navy is concerned with the totality of the chemical substances found in the smoke; the greatest risks were likely posed by irritant gases. It is known there was a toxic environment created by the HMCS Chicoutimi fire, as would be expected in any fire.
• There are no plans to remove Peredite/Pitkote from the submarines, as it would entail an extensive and costly stripping of the pressure hull, as well as reconstruction. As Peredite/Pitkote pose a negligible risk in submarine operations, there is no requirement to remove these materials from HMC submarines.
• However, the safety of sailors and dockyard workers is paramount, and the Navy has stringent workplace safety regulations and procedures in place for working with substances such as Peredite/Pitkote. This includes precautions to ensure that the materials are removed from areas where welding must take place. It was welding operations during submarine modifications that gave rise to the original concerns about Peredite/Pitkote in 2001.

INFORMATION FLOW

• Designated ‘Champions’ have been identified to support the former crew of HMCS Chicoutimi as well as family members for any concerns they may have. These personnel are also responsible to ensure that the Navy’s leadership has visibility/insight into developing issues. Former HMCS Chicoutimi crew members who require assistance in reaching a Champion are requested to contact Navy Public Affairs at 613 945-0875 for further information.
• In order to improve information flow with respect to the Chicoutimi incident, the Navy will be publishing updates as reports and findings are completed. A summary of measures implemented as a result of BOI recommendations will also be published. This will be available on two comprehensive websites dedicated to the HMCS Chicoutimi incident. Those websites are listed below:

CONCLUSION

• The Navy has taken great care to learn from this tragic event. Nearly all the recommendations in the BOI were adopted. For instance, the Emergency Breathing System equipment, design and procedures were updated and improved, the amount of firefighting gear onboard was increased, smoke clearance equipment and procedures were improved, and firefighting training has become more realistic and robust. More rigorous water ingress control measures were implemented, as well a host of other measures, such as improving the emergency communications methods, improving the survivability in a disabled HMC submarine, and creating standard operating procedures for conning tower operations. The intent was to prevent an incident like this from happening again, and to improve the safety of the crew if and when an emergency occurred.
• As of March 2008, approximately 25% of the crewmembers have taken their release from the military. Over four years, this represents an approximate annual attrition rate of 6%, which is slightly below the CF average of 7%. The majority of these releases were voluntary, with only a small number being medically attributed to the event onboard HMCS Chicoutimi.
• The Navy has a covenant with its sailors, and will do everything possible to ensure their health and wellbeing. As demonstrated by the rigorous and comprehensive follow-up to the HMCS Chicoutimi fire, this has been true in the past, and certainly will continue in the future. We owe our sailors nothing less.