HMCS CHICOUTIMI BOARD OF INQUIRY – SUBJECT MATTER EXPERT (SME) REVIEW AND ACTION PLAN FOR IMPLEMENTATION OF RECOMMENDATIONS

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Annex A to
MS: 1080-2004011(CMS)
April 11 2005

Notes:

This action plan is based upon the Board of Inquiry Recommendations of the final report of the CHICOUTIMI Board of Inquiry (BOI).
The "Finding and/or Recommendation" column annotates the Finding required by the terms of reference in italics followed by the BOI Finding or recommendation in normal font.
The "Command Level Review" column confirms CMS support, non-support or qualified support with the Findings and Recommendations of the BOI. Supplementary Recommendations or corrective action already directed will be annotated in this column.
The "Timeframe" column directs the relative urgency of the required actions. The timeframe is annotated as "Immediate," "Short-term," and "Long-term". Immediate action items are those affecting ongoing operations or other matters of an urgent nature with due dates of generally less than 1-2 months. The Short-term actions are intended for completion within a 3-6 month timeframe, unless otherwise noted. Long-term action items are intended for finalization as soon as practicable.
OPIs are mandated to continuously review the progress of the Action Plan and must report status on a quarterly basis to CMS through MS COS Sec until such time as the plan is complete.
OCIs cooperate closely with the OPI toward implementation of Recommendations.
The "Status" column reflects the ongoing disposition of action contemplated, under way or finalized by the level in the chain of command that can execute on any particular recommendation. MS COS Sec maintains this column in response to reports provided by the OPIs for implementation of Recommendations.
CMS will report quarterly to the CDS on the status of the plan’s implementation.

Ser	Ref	Finding and/or Recommendation	Command Level Review	Timeframe	OPI	OCI	Status
1.	6(a)	Whether CHICOUTIMI was structurally, mechanically, technically sound and seaworthy to carry out the surfaced and dived transit to Canada.
		Finding
		The Board finds that the submarine was structurally, mechanically, technically sound and seaworthy to carry out the surfaced and dived transit to Canada.	Concur. The determination as stated in section 6a of the BOI is fully supported. The evidence included in the BOI through the various exhibits and testimony clearly demonstrates that CHICOUTIMI was seaworthy.
			The Main DC cable connectors in the CO’s cabin are located in an area that could potentially permit prolonged exposure to seawater. ECP 20030204 VPDC Distribution System – Main Power Cable connectors had been initiated prior to the incident to address a variable pressure earth of the Main DC cables at bulkhead 56.				ECP withdrawn to allow for expanded scope to cover all VPDC cables.
			It is recommended that with what has been learned during this investigation, the scope of this ECP be expanded to consider all Main DC cable connectors.	Immediate	DGMEPM/ DMSS3		Re-insulation for VICTORIA completed 14 Jan 05. Re-insulation for WINDSOR completed 21 Jan 05.
			All Main DC cable connectors are to be re-insulated	Immediate	MARLANT MARPAC		Re-insulation for CORNER BROOK to be completed during CWP. CHI to be completed during EDRWP Note: Connectors in #2 Battery Compartment Fwd of Bhd 56 Stbd side will not be done.
		Recommendations
		None	Concur
2.	6(b)	The chronology of CHICOUTIMI’s movements and the prevailing environmental conditions.
		Finding
		The Board developed an all source timeline attached as Annex B to the BOI detailing the chronology of the submarine’s movements. A detailed account of prevailing environmental conditions was provided at p. 21/126 to 23/126 of the BOI final report.	Concur. The Board’s determination of the chronology of CHICOUTIMI’s movements, and the prevailing environmental conditions, is supported.
		Recommendations
		It is recommended that an independently powered voice and data recording system be installed in the submarines and that SOPs be promulgated.	Concur. No automatic recording systems are fitted to VICTORIA class. Such a system, paralleling those used in the aircraft industry would provide invaluable data for future accident investigations. CMS Staff to raise an SOCD to specify the requirement.	Long-term	DGMFD/ MCP3	DGMEPM/ DMSS9 MSRMS 5	The Victoria Class vessels are fitted with an automatic voice logging system, which records 5 voice channels: VICES Command/TOOW Master Unit Tx & Rx; VICES Tower Group; ambient mike at Ship Control Position; and ambient mike at Command Position. The system is outdated, and is powered from 115vac. A replacement voice recording system, with an independent backup power source, is being investigated. Other than SONAR data, recorded on a separate recorder at the SC position, data is not recorded on the automatic logging system. No data sources have been identified as requiring logging.
		It is recommended that Submarine Operating Authorities endeavour to route Victoria Class submarines surfaced/submerged.	Concur. This is already standard Canadian doctrine that gives the CO maximum flexibility.	Immediate			Complete.
3.	6(c)	The date, time and location of the fires.
		Finding
		The Board finds that two unrelated fires occurred onboard CHICOUTIMI. On 5 October, at approximately 1315, sparks were seen and electrical popping noises were heard in the Control Room. Shortly after a fire ignited in the CO’s Cabin and spread to the Electrical Space on 2 Deck. The second fire occurred at 1910 on 5 October in a portable oxygen generator located in the Weapon Stowage Compartment.	Concur.
		Recommendations
		None	Concur.
4.	6(d)	The probable or known point(s) of origin of the fires.
		Finding
		Fire in CO’s Cabin and Electrical Space
		The Board finds that the point of origin of the CO’s Cabin fire was under the bunk aft of bulkhead 35, where main power electrical cables were found completely severed in close proximity to the deck. The rupture of the three cables occurred at approximately the same place on the cable run, namely at the junction between the cable and a bulkhead penetrator. The red insulating material covering all the junctions was mostly destroyed during the fire. The fire at the point of origin was extremely hot considering that two holes were perforated through the steel deck. The temperature was at least 1500 degrees Celsius and would have ignited all combustible materials and melted all metal with a lower melting temperature around the point of origin.	Concur.
		Fire in Oxygen Generator
		The Board finds that the overheating of an oxygen generator was the point of origin of the fire.	Concur.
		Recommendations
		None	Concur.
5.	6(e)	The cause of the fires and all factors that contributed to the cause of the fires including, but not limited to, any operational, mechanical, construction, technical, procedural or human failures.
		Finding
		CO’s Cabin and Electrical Space Fire
		The Board finds that design, operational and human factors contributed to the cause of the fire. The Board also finds that an arc in the main power cables caused the fire in the CO’s Cabin, which then spread to the Electrical Space.	Concur.
		The Board finds that human factors played a role in the ingress of water in the submarine, and was one of the links in a chain of events that culminated in the more serious of the fires. Nevertheless there is neither evidence nor inference that anyone could have or should have predicted that a water-ingress would result in a serious fire.	Concur.
		Oxygen Generator Fire
		The Board finds that the fire in the oxygen generator resulted from overheating. The Board also found that the overheating was probably caused by a malfunction of the oxygen generator due to a brown piece of paper found in the location where a charcoal filter is normally located when the unit is in operation.	Concur.
		Recommendations
		It is recommended that the test plan attached at Annex E be executed to further isolate the specific cause of the arc and to determine the smoke propagation index and the toxicity of the materials that burned during the fire in the CO’s Cabin and the Electrical Space.	Concur. Recommend DGMEPM execute test plan at Annex E to BOI and findings forwarded to DMHS and the CF Fire Marshall.	Long-term	DGMEPM/DMCM Subs	DGMPR/DMHS CFFM	DGMEPM has initiated a task with NETE. Requirement to deliver to DMHS on completion is recognized.
			CF Fire Marshall to confirm findings of the Fire Report with reference to the results of the Test Plan		CFFM		Note: The Testing that is currently occurring within DGMEPM has been de-linked from the BOI. However, results will be forwarded to DMHS
			DMHS to ensure the results of the Test Plan are placed on CHICOUTIMI crew member files	Long-term	DGMPR/DMHS
		It is recommended that the following water control measures be considered:
		Make the hatch from 1 to 2 Deck watertight and reroute the scupper in the catch basin, at the base of the tower, to the Mastwell bilge;	Concur. Recommend DGMEPM investigate.	Long-term	DGMEPM/DMSS2	DGMFD/MCP3	Hatch – DMSS2 will investigate and raise EC if appropriate.
		Develop operating procedures to govern actions in the event of large water ingress through open hatches while surfaced; and	Concur.	Short-term	MARLANT/ SSTG	DGMEPM/DMSS2
		Improve the watertight integrity of the battery hatches to prevent any leakage into the battery compartments in the event of water ingress into the submarine.	Concur.	Immediate	DGMEPM/DMSS2	DMSS3	All battery hatch fasteners are inspected and replaced as necessary prior to sailing.
			The current design of the hatch and watertight integrity is sound, however, the design of fasteners and lugs is a class wide problem that if not checked regularly could affect the watertight integrity of the hatch. Recommend DGMEPM investigate possibility to change the fasteners.	Long-term	DGMEPM/DMSS2	DMSS3	Investigation has been initiated and is ongoing.
		It is recommended that SOPs for conning tower operations be developed and enforced. The SOPs should incorporate responsibilities of key personnel and hatch sentries, communications between on-watch personnel, and precautions to be taken.	Concur. It is clear that the procedures are extant and known within the community; however, they exist in a variety of locations. It is recommended that they be reviewed, refined and validated for consistency across the class and consolidated in documentation.	Immediate	MARLANT/ SSTG	MARLANT/ MOG 5
		It is recommended that the following actions be completed with respect to oxygen generators:	A project exists to replace the current oxygen generators within the next 2 years. In the interim, the recommendations are supported	Long-term	DGMEPM/DMSS4		NETE Task underway to test various commercially available options.
		That all oxygen generators be fully inspected and all planned maintenance completed prior to their use;	Concur.	Immediate	MARLANT MARPAC	DGMEPM/DMSS4
		That all personnel be reminded not to operate an oxygen generator if the status of the maintenance of the unit is unknown;	Concur.	Immediate	MARLANT MARPAC
		That the Mark V candles of lot 24Y D.O.M. 10/97 be inspected to ensure the lot meets the required specification prior to further use; and	Concur.	Immediate	DGMEPM/DMSS4		Complete. No candles from that lot are held by Canada.
		That the oxygen generator involved in the incident onboard CHICOUTIMI be repaired and tested ashore prior to being used again.	Concur.	Short-term	MARLANT	DGMEPM/DMSS4
		The Board recommends that COs ensure that their standing orders are promulgated and understood by all personnel upon assumption of command. These orders should include guidance with respect to:	Concur.	Immediate	DGMPR	MARLANT MARPAC
		The completion of, and responsibility for, complete and accurate records;	Concur.	Immediate	DGMPR	MARLANT MARPAC
		OOW turnover procedures; and	Concur.	Immediate	DGMPR	MARLANT MARPAC
		Detailed duties and responsibilities of key personnel.	Concur.	Immediate	DGMPR	MARLANT MARPAC
6.	6(f)	Whether the training of the crew, the doctrine applicable to reactivation and the reactivation procedures of CHICOUTIMI contributed to the cause of the fires.
		Finding
		The Board finds that the training of the crew, the doctrine applicable to reactivation and the reactivation procedures of CHICOUTIMI did not contribute to the cause of the fires.	Concur. The crew was properly trained to an identifiable standard commensurate with their mission. Technical preparations and readiness were sound and well documented. No preparatory elements, either technical or human, contributed to the cause of the fires.
		Recommendations
		None	Concur.
7.	6(g)	The property damage to CHICOUTIMI.
		Finding
		The Board finds that there was extensive property damage to CHICOUTIMI. The extent of the property damage to the submarine is contained in the Repair and Damage Assessment Team report (Exhibit 45). It is important to note that some personal belongings of the crew were also damaged in the first fire.	Concur. The damage to the Captain’s Cabin and Electrical Space in CHICOUTIMI is significant, and will require significant effort to repair. Additional property damage occurred through the necessity to operate auxiliary systems for damage control, and/ or caused by the loss of power to main systems. The RDAT report (exhibit 45) estimates the scope of this potential damage. The effort to repair the property damage will demand considerable resources. A survey of the entire submarine followed by the repair of the defects discovered will be required.	Short-term	DGMEPM/ PMCHI	DMCM Subs	This will be encompassed in Phase 2 of the CHI EDRWP surveys.
		Recommendations
		None	Concur.
8.	6(h)	The nature and extent of the fires.
		Finding
		The Board finds that the fire in the CO’s Cabin and Electrical Space was electrical in nature and caused extensive damage. The fire in the oxygen generator resulted from the overheating of a candle and was contained in the oxygen generator. The Fire Investigator’s report at Annex D provides further detail.	Concur.
		Recommendations
		None	Concur.
9.	6(i)	Whether the actions of any person(s) contributed to the starting or spreading of the fires.
		Finding
		The actions of no one contributed to the starting or spreading of the first fire. Relative to the second fire, the actions of on-watch personnel who were ordered to burn two oxygen candles contributed to the starting of the fire only insofar as they acted to light the candle and followed the correct procedure to do it.	Concur. The lighting of the candles IAW operating procedures was correct, and in and of itself did not contribute to the fire.
		Recommendations
		None	Concur.
10.	6(j)	The chronology of response actions taken to fight the fires.
		Finding
		The Board developed a detailed chronology included at Annex B.	Concur.
		Recommendations
		It is recommended that an independently powered voice and data recording system be installed in the submarines and that SOPs be promulgated.	Concur. See Serial 2 Item 6(b).
11.	6(k)	Whether responses by the crew were conducted in accordance with applicable regulations and orders.
		Finding
		The Board finds that the crew responded in accordance with the relevant regulations and orders.	Concur.
		With respect to the Oxygen Generator fire, the Board finds that the crew reacted swiftly and in accordance with procedures in response to this fire.	Although there were some minor procedural deviations arising from the unique series of events, the overarching doctrine of firefighting in submarines was followed.
		Recommendations
		None	Concur.
12.	6(l)	The adequacy of relevant orders and procedures.
		Finding
		The Board finds that the relevant orders and procedures in place at the time of handover and acceptance were adequate. Furthermore, the response of the crew to the incident was adequate, which supports the suitability of the orders and procedures utilized.	Concur. The version of SMP 150 in use included Canadian input and had been validated in three previous submarines. It has served as the core of Canadian documents and, was indeed familiar to the crew. It was valid, current, and known.	Immediate	MARLANT MARPAC		VICTORIA Class SOPs and EOPs have been completed. SSOs are nearing completion. These documents replace SMP 150.
		Recommendations
		None	Concur.
13.	6(m)	The adequacy of response actions taken to fight the fires.
		Finding
		The Board finds that the responses to the fire in the CO’s Cabin and the Electrical Space were adequate.	Concur. The term "adequate", while technically accurate, does not do justice to the actions taken by the crew during this event. Their action was heroic. That they saved their boat is testimony to their courage, tenacity and skill.
		With respect to the Oxygen Generator fire, the Board finds that the response action taken to deal with this fire was in accordance with the EOP and therefore adequate.	Concur.
		Recommendations
		The Board recommends the following changes to smoke clearance equipment and procedures:
		a. That smoke clearance procedures be developed and documented that do not require electrical power; and	Concur.	Short-term	MARLANT/ SSTG	DGMEPM/DMSS4
		b. The addition of non-electrically powered smoke clearance equipment appropriate for use in a submarine damage control environment.	Concur. DGMEPM to investigate.	Short-term	DGMEPM/DMSS4	MARLANT/ SSTG
		The Board recommends the following with respect to Damage Control procedures:
		a. SOPs for attack response (Attack BA) personnel be defined and documented;	Concur. The conduct of submarine attack BAs is described generally within the EOPs. A more detailed description will be included in the Victoria Class Ship Standing Orders (SSOs).	Short-term	MARLANT/ SSTG	CFNES/ DC DIV DGMEPM/ DMSS4
		b. An alternate Damage Control Headquarters be provided for in the Weapons Stowage Compartment; and	Concur. This issue clearly bears scrutiny and the BOI finding WRT the WSC is valid. Furthermore, other options, including that of two alternate DCHQs, one in each watertight compartment, bear consideration. CMS staff to raise an SOCD outlining the deficiency.	Long-term	DGMPR	DGMEPM/DMSS4 DMSS2 DMSS 8 MARPAC/ MOG 4 MARLANT/ MOG 5
		c. The restoration procedures used by CHICOUTIMI be captured for use, where applicable, by Naval Training Establishments and the Submarine Sea Training Group.	Concur.	Short-term	MARLANT/ SSTG	DGMPR CFNOS (H) CFNOS (E)
14.	6(n)	The adequacy of fire detection, fixed and portable suppression equipment.
		Finding
		The Board finds that CHICOUTIMI was equipped with all required fixed and portable fire suppression equipment and fire detection systems. The systems and equipment were all serviceable, save for one dry chemical extinguisher.	Concur. The facts bear out that a combination of portable fire fighting extinguishers and the SFU 90, the first and second lines of defence, were sufficient to extinguish the fires aboard CHICOUTIMI. However, the facts also describe a potential vulnerability with other fitted systems designed to be the third level of attack, which depend on electrical power. It is agreed that the efforts to fit an independently powered/pressured high capacity fire fighting system must be pursued.
		The Board finds equipment and systems were adequate to control and extinguish the fires that occurred onboard CHICOUTIMI.	Concur.
		The Board finds the Emergency Breathing System provided air for the crew during the fire, and worked as designed.	Concur.
		Recommendations
		It is recommended that the following changes to firefighting equipment in the submarine be considered:
		a. That the Victoria Class fire risk assessment prepared by the Canadian Forces Fire Marshal be reviewed and updated as required;	Concur. An update to the Command Fire Marshal risk assessment is required, as it does not consider the risk associated with the ingress of a substantial amount of water through the conning tower.	Short-term	CFFM
		b. That higher capacity and/or more CO2 portable extinguishers be carried onboard due to the fact they can not be refilled at sea;	Concur. Although the HIRA for the CHI fire determined that the current number of CO2 extinguishers is sufficient, it is considered prudent to increase the number of CO2 extinguishers as an interim measure until DGMEPM assesses the design of the fitted fire fighting systems.	Short-term	DGMEPM/DMSS4	DGMPR	EC developed to replace 12x2kg CO2 extinguishers with 20x5kg CO2 extinguishers
		c. That an additional fitted fire-fighting unit that operates without pumps or power be added (e.g. a twin agent unit);	Concur. Recommend DGMEPM investigate.	Long-term	DGMEPM/ DMSS4	DGMPR	PD being raised to conduct options analysis
		d. That dedicated boundary cooling hoses be located throughout the submarine; and	Concur. Recommend DGMEPM investigate.	Long-term	DGMEPM/ DMSS4	DGMPR	PD being raised to conduct options analysis
		e. That the SFU-90 hose be installed using more robust fittings.	Concur.	Immediate	DGMEPM/ DMSS4		Complete.
		It is recommended that Emergency Breathing System equipment, design and procedures be updated as follows:
		a. That the design of the mask assembly be reviewed to incorporate positive pressure regulators and a more robust regulator-to-mask connection;	Concur.	Long-term	DGMEPM/DMSS4	MARLANT/ SSTG DGMPR/ DMHS	DGMEPM is addressing this issue. All EBSs will be replaced with positive pressure masks as part of "Replacement SUBRON" NP project.
		b. That EBS masks be pre-rigged at watch-keeping positions;	Concur. DGMEPM to advise Submarine Sea Training Group (SSTG) of rationale/time required to purge EBS masks in order to develop an SOP.	Immediate	MARLANT/ SSTG	MARLANT/ Sea Trg Subs MARPAC/Sea Trg Subs	Masks for most watch-keepers have been pre-fitted. Action initiated.
		c. That the number of couplings in each compartment be audited and increased as required to ensure that there are sufficient couplings for all situations and that couplings are easily found and accessible in a smoke filled compartment;	Concur.	Short-term	DGMEPM/ DMSS4	MARLANT MARPAC	Complete. ECs 20040204(VIC), 20040208(CBR) and 20040209(WSR) The number of EBS outlets Fwd and Aft of WTB 56 have been increased by 40. In addition twenty short and six long hose EBS FFMs have been stored on board. To allow better access to recessed PCL couplings in Ward Rm and Messes, the proposal to add extension pieces to make the mouth of the PCL coupling sit proud of the ceiling per EC 20040246 is under review.
		d. That sufficient masks stored in "rider bags" be held in the Weapon Stowage Compartment to support all riders in that compartment;	Concur.	Immediate	DGMEPM/DMSS4	MARPAC MARLANT	Complete. Entitlement increased from 86 to 104 with provision of proper storage bags.
		e. That standards be developed for Y couplings, the number and length of hoses, and the number and location of masks;	Concur.	Short-term	DGMEPM/ DMSS4		Adopting Y couplings will dictate new reducer resetting. Empirical test have dictated that the EBS air reducer taking HP air from the AV & B system be reset upwards to give the 5.9 Bar outlet pressure required at each Y-fitting. DA guidance being issued.
		f. That extension hoses be manufactured and placed in appropriate locations throughout the submarine. These extensions could be used for personnel to climb to the bridge, to move casualties or to perform other activities that require more freedom;	Concur. SSTG to investigate and define requirements.	Short-term	MARLANT/ SSTG	DGMEPM/ DMSS4 MARPAC
		g. That state-of-the-art photo-luminescent tape be applied on all EBS couplings, rails and lockers;	Concur.	Immediate	DGMEPM/ DMSS4	MARLANT/ SSTG MARPAC	Complete. In addition, DGMEPM is investigating the use of LED rings as a long term solution
		h. That usage tables be developed that indicate time remaining based on system pressure and personnel onboard; and	Concur. Recommend DGMEPM advise on the completion of EBS modelling.	Long-term	DGMEPM/ DMSS4	NETE DGMPR/DMHS	In progress. NETE will be tasked to provide an estimate of the endurance inherent in the AV & B system, for various combinations of loads drawing off the A V & B system. The redesign of the EBS is likely not warranted at this stage; all that is needed is to know what the system can support as presently designed.
		i. That options for alternate supplies of air to the EBS be developed.	Concur. Recommend DGMEPM investigate means of cross-connecting ATP reservoirs and/or after planes and air emergency storage bottles to supply EBS.	Long-term	DGMEPM/ DMSS4		PD will be raised to conduct an options analysis.
		It is recommended that state of the art atmosphere monitoring system be installed for use during routine, damage control, and escape atmospheric monitoring situations. The system must have battery back up.	Concur. There is ongoing review of this evolving technology. Acquisition of solid state gas analyzing equipment is being investigated by the relevant technical authorities	Long-term	DGMPR/ DMHS	DGMEPM/ DMSS4 DRDC	Being developed as part of the Submarine Life-support System project (SLS).
			The following additional recommendations are made:
			a. The inclusion of Automatic Emergency Lights (AELs) is fully supported (as described in the recommendations made in exhibit 14); SSTG to raise SOCD to determine numbers and locations.	Long-term	MARLANT/ SSTG	DGMEPM/ DMSS3
			b. The recommendation with respect to the modification of SUBRON MSA lockers is also fully supported. Essentially this would discontinue the modification made by the Damage Control Engineering Change implemented as part of the "Canadianization Work Period" which modifies BASSCA/ EDBA Lockers to accommodate SUBRON MSAs. Recommend DGMEPM incorporate as part of SUBRON MSA replacement EC.	Short-term	DGMEPM/ DMSS4	MARLANT/ SSTG MARPAC	EC 1999 0233 was modified to include walk away brackets CORNERBROOK fitted
			c. The center fed hose reels should also be fitted with more robust fittings additional to the SFU 90.	Short-term	DGMEPM/ DMSS4	MARPAC MARLANT	Complete.
15.	6(o)	The adequacy of the training and qualifications of CF members involved in the response to the fires.
		Finding
		The Board finds that the training and qualifications of CF members involved in the response to the fires was adequate.	Concur. Although many witnesses allude to the 48-hour safety package, it appears that this was not systematically applied to every rider. The 48- hour safety package must be a standardized framework that allows each submarine to customize only those portions necessary (i.e. portable appliance locations). Standardized orders governing the conduct of this activity must be developed.	Short-term	DGMPR		The 48-hour safety package will be incorporated in Chapter 12 of Victoria Class SSOs currently being developed.
		Recommendations
		To enhance awareness and confidence in layout and equipment the Board recommends the following:
		a. Develop more realistic firefighting training for submarine crews;	Concur.	Long-term	DGMPR/ DMTE	CFNOS (H) CFNOS (E) MARLANT MARPAC
		b. Train in a mock-up to include donning and clearing EBS in a smoke-filled environment;	Concur.	Long-term	DGMPR/ DMTE	CFNOS (H) CFNOS (E) MARLANT MARPAC
		c. Use of EBS with submarine firefighting equipment;	Concur.	Long-term	DGMPR/ DMTE	CFNOS (H) CFNOS (E) MARLANT MARPAC
		d. Institute a class-wide standard 48 hours joining package;	Concur.	Short-term	MARLANT/SSTG	MARPAC
		e. Institute onboard blackout training; and	Concur.	Immediate	MARLANT/SSTG
		f. Conduct a review of Damage Control markings and update as required.	Concur.	Short-term	MARLANT/SSTG	DGMEPM/ DMSS4
16.	6(p)	The adequacy of the restoration of operational capability of CHICOUTIMI.
		Finding
		The Board finds that the restoration of operational capability of CHICOUTIMI was adequate.	Concur.
		Recommendations
		It is recommended that the casing party safety equipment be reviewed to ensure the adequacy of knives, harnesses and safety lines.	Concur. Agree that casing safety devices should be investigated. Acquisition of a quick-release harness should not automatically be assumed, since a quick-release device might invalidate the original purpose of the harness – to prevent falls. There might be a necessity for two types of harness – one for man aloft and one for the casing.	Short-term	MARLANT	MARPAC DGMEPM DMSS2 CFNOS	Casing Party Equipment – DMSS2 will act as OCI for this task
			Additionally, difficulties encountered when deploying the towing pennant must be investigated and rectified.	Long-term	MARLANT	DGMEPM/ DMSS2	Complete for VICTORIA and WINDSOR Towing Pennant – VIC Class Towing Pennant will be trialed and proven in VIC’s upcoming EDWP. EC action may result from this trial.WRT towing – The design of the ice rail will be investigated by DMSS2 both in terms of its strength and also in terms of the equipment that may be safely accessed from it, particularly on the forward casing (ie Bullring). EC action may result.Also WRT Towing – DMSS2 will collaborate with RN to obtain towing data for submarines and RN reports on CHI’s salvage. Adequacy of VIC Class Towing arrangements will be reassessed and EC action may result.
17.	6(q)	The adequacy of the doctrine, equipment, and training in respect of the restoration of operational capability of CHICOUTIMI.
		Finding
		The Board finds that the doctrine, equipment, and training in respect of the restoration of operational capability of CHICOUTIMI was adequate.	Concur.
		Recommendations
		It is recommended that the restoration procedures used by CHICOUTIMI be captured for use by Naval Training Establishments and Submarine Sea Training to train other crews.	Concur. As a matter of priority, Damage Control schools and Sea Training organizations must compile lessons identified/learned and adjust or enhance training protocols as necessary. The incident validated the methodology for training our sailors. The instruction of theory op operation and detailed systems knowledge, allowed ships staff to analyze this unprecedented situation and devise new procedures on the fly to restore operational capability.	Short-term	DGMPR/DMTE	CFNOS (H) CFNOS (E) MARLANT MARPAC
		It is recommended that the following changes to the onboard electrical systems be considered:
		a. That a 24 Volt casualty power system be developed that can draw from the main batteries and	Concur.	Long-term	DGMEPM/ DMSS3		DMSS 3 comment: The subs already have three sources of power for 24V control. The 24V module can be powered by either MG. Failing the availability of a MG, there is a 24V battery. In the event that loss of both MGs surpasses the life of the 24V battery, only then will 24V be lost. In the CHI incident, it was a command decision not to use main power for fear of further short circuits resulting in further fires with minimal FF equipment left to fight the fires. If it is considered that the risk of such an event occurring again in the future warrants a further 24V back-up ability, then there are two possibilities. Either possibility would require major engineering design, procurement etc and would not be ready or feasible to install until the next series of EDWPs.
		b. That VP equipment be fitted with an override switch to by-pass the 24 Volt control circuits.	Disagree. While I agree that this may be an eventual solution, I cannot concur with this fully at this stage. First, in the interim, the over-ride procedures developed by CHI must be captured as SOPs and instructed to other sub crews. Upon assessment of the utility of these new SOPs and in consideration of a possible solution to the 24 Volt casualty power issue above, a determination must be made if further EC action is warranted.	Short-term	MARLANT Recommend MARLANT to be OPI to assess new SOPs. DMSS 3 will become OPI if EC is raised.	DGMEPM/ DMSS3
18.	6(r)	Whether CHICOUTIMI was crewed in accordance with the Automated Establishment Report (AER) requirement.
		Finding
		The Board finds that CHICOUTIMI was crewed in accordance with the Automated Establishment Report.	Concur. Two deviations were noted by the Board of Inquiry, stemming from minor differences between RN and CF policies. These had no impact on the incident.
		Recommendations
		None	Concur.
19.	6(s)	What communication capabilities were available to CHICOUTIMI after the fires and when they became available.
		Finding
		The Board finds that CHICOUTIMI had VHF radios and Iridium satellite phones available from the time of the fires onboard until their return to Faslane, Scotland.	Concur.
		Recommendations
		It is recommended that the following changes to onboard communications systems:
		a. That emergency satellite phones be carried at all times; and	Concur.	Immediate	DGMEPM/ DMSS9		This is, and will continue to be, standard equipment.
		b. That battery operated handheld radios be carried throughout the submarine for internal communications in the event of a power failure.	Concur. Communications difficulties were exacerbated by the effect of background noise on the open bridge. Action must be taken to identify and acquire technologies, for example noise-excluding headphones or throat microphones, to minimize the effects of background noise when using fitted or portable communications devices from an open submarine bridge.	Long-term	DGMEPM/ DMSS9		To overcome the effect of background noise on the open bridge headsets designed to be used in a high noise environment, usable with internal and external communications should be used. This will require the installation of a headset jack on the bridge. Handheld radios are an effective short-term solution but these have problems of coverage, use in high noise environment and ergonomics. The ER/MR wireless communication system is being replaced with a two-way radio communication system with headsets designed to be used in a high noise environment. Recommend this system be examined for use through the submarine as a long –term solution. This will require a statement Of Capability and Deficiency and a project setup to implement this capability. Also trials and evaluations would need to be conducted to determine how best to implement the technology.
20.	6(t)	The flow of information (content, by what means and when) within and from CHICOUTIMI to other vessels and shore authorities during and following the fires.
		Finding
		The Board finds that the flow of information within and from CHICOUTIMI to other vessels and shore authorities during and following the fires was very challenging.	Concur. Given the poor communications out of CHICOUTIMI, the number of intermediate nodes in the information flow, and the variety of communications channels used, as well as the pressure of dealing with the thirst for information on the part of multiple agencies, it is not surprising that significant communications problems were experienced. This confusion did not affect responses to CHICOUTIMI’s emergency but did impact on external agencies’ understanding of the situation.
		Recommendations
		None	Concur.
21.	7(a)	Any autopsy report.
		Exhibit 51 (Forensic Pathology Consultation Report by	The autopsy report is pending and will be provided to Canada by the State Pathologist of Ireland, .
22.	7 (b)	A copy of the death certificate.
		Exhibit 52 (CF Medical Certificate of Death) Exhibit 53 (Coroner’s Certificate of Death)	Disease or condition directly leading to death – inhalation of hot fire gases following a fire on CHICOUTIMI – signed by Dr. Barry Alexander McLellan, Chief Coroner, Province of Ontario. See exhibit 52.
23.	7 (c)	Any medical examiner’s or coroner’s report.
		Exhibit 50 (Medical Examiner Report - Coroner Investigation Statement by the Chief Coroner for Ontario)	Forensic Pathology Consultation Report - contained in the BOI documentation.
24.	7(d)	All CF 98 "Report of Injuries or Exposure to Toxic Material".
		Exhibit 119 (55 total) Exhibit 134 (1 total)	CF98s are contained in the BOI for all crewmembers of CHICOUTIMI.
25.	8(a)	The cause of the death of Lieutenant (N) C. Saunders.
		Finding
		The Board finds that Lieutenant (N) Saunders’ death was caused by complications related to smoke and fire gas inhalation.	Concur. due to inhalation of combustion products – para 7 Forensic Pathology Consultation Report - Pending confirmation by Irish health authorities upon completion of coroner’s inquest.
		Recommendations
		None	Concur.
26.	8(b)	Whether Lieutenant (N) C. Saunders was on duty at the time of his death.
		Finding
		The Board finds that Lieutenant(N) Saunders was on duty at the time of his death.	Concur.
		Recommendations
		None	Concur.
27.	8 (c)	Whether any pre-enrolment or pre-existing medical conditions contributed to his death.
		Finding
		The Board finds that Lieutenant (N) Saunders	Concur. Submariner medical examination completed 20 December 2001 as per CFMO 27-12 and the new MSI CF 7000-200.
		Recommendations
		None	Concur.
28.	8(d)	Whether Lieutenant (N) C. Saunders or any other person(s) were responsible for the death of Lieutenant (N) C. Saunders.
		Finding
		The Board finds that neither Lieutenant(N) Saunders nor any other person was responsible for the death of Lieutenant(N) Saunders.	Concur.
		Recommendations
		None	Concur.
29.	8(e)	Whether his death was attributable to military service.
		Finding
		The Board finds that Lieutenant (N) Saunders’ death is entirely attributable to military service. He suffered the injuries that would ultimately lead to his death while conducting his assigned duties onboard CHICOUTIMI in accordance with CFAO 24-6, paragraph 30.	Concur. Lt(N) Saunders’ death was caused by inhalation of hot gases and smoke from fires onboard CHICOUTIMI.
		Recommendations
		None	Concur.
30.	8(f)	The injuries to other personnel aboard CHICOUTIMI.
		Finding
		The Board determined that any crewmember who had received medical attention and had a CF 2138 prepared on them would be termed a casualty.	Concur. Placement of documentation related to the CHICOUTIMI fire on the medical records of crewmembers will be guided by Medical Directive 1/01MEDICAL MANAGEMENT OF EXPOSURE OR SUSPECTED EXPOSURE TO AN ENVIRONMENTAL AND INDUSTRIAL HEALTH HAZARD OR PUBLIC HEALTH CONCERN and advice from Forces Health Protection (FHP).
		The Board finds that the following personnel were casualties as a result of the fires onboard CHICOUTIMI:
		a.	Concur.
		b.	Concur.
		c. Petty Officer 2nd Class Lafleur	Concur.
		d. Leading Seaman MacMaster	Concur.
		e.	Concur.
		f.	Concur.
		g.	Concur.
		h.	Concur.
		Recommendations
		The Board recommends that the smoke propagation index and material toxicity tests detailed in the Fire Investigator’s report (Annex D) be conducted and the results entered in the medical files of the entire crew.	Concur. Analysis of combustion materials from the CHICOUTIMI fire will be conducted in consultation with FHP.	Long-term	DGMEPM/ DMCM SUBS	DGMPR/DMHS FHP NETE DGMEPM/ DMSS2	Testing is occurring and should be completed in May 05. Material toxicity – DMSS2 will review the the smoke propagation index and material toxicity tests detailed in the Fire Investigator’s report (Annex D) once the BOI report is released and determine the way ahead.
31.	8 (g)	The cause of those injuries.
		Finding
		The Board finds that there was a common cause for all injuries aboard CHICOUTIMI. All casualties suffered smoke inhalation injuries as a result of the fires that occurred aboard CHICOUTIMI on 5 October.	Concur.
		Recommendations
		None	Concur.
32.	8(h)	Whether any pre-enrolment or pre-existing medical conditions contributed to the injuries.
		Finding
		The Board finds that there was no pre-enrolment or pre-existing conditions for any of the casualties that contributed to their injuries	Concur.
		Recommendations
		None	Concur.
33.	8(i)	Whether the injured were on duty at the time of the injuries.
		Finding
		The Board finds that all of the casualties were responding to the fires onboard CHICOUTIMI and were on duty at the time of their injuries.	Concur.
		Recommendations
		None	Concur.
34.	8(j)	Whether the injured or any other person(s) were responsible for the injuries.
		Finding
		The Board finds that no injured individual was responsible for their own injuries and that no other person is responsible for the smoke injuries suffered by the nine casualties who were identified in the aftermath of the fires.	Concur. Injuries to the CHICOUTIMI crew suffered during and immediately following the fire were the result of inhalation of hot fire gases and/or smoke. The extent of injury was proportional to the amount of time it took individual crewmembers to plug-in and don an EBS mask and proximity to the fire.
		Recommendations
		None	Concur.
35.	8 (k)	Whether the injuries were attributable to military service.
		Finding
		The Board finds that all injuries suffered by crewmembers as a result of the fires are entirely attributable to military service as any crewmember injured was conducting assigned duties onboard CHICOUTIMI in accordance with CFAO 24-6, paragraph 30.	Concur.
		Recommendations
		None	Concur.
36.	8(l)	The matters referred to in sub-paragraphs a to e in the event of any subsequent death(s) occurring among the injured.
		Finding
		There were no subsequent deaths.	Concur.
		Recommendations
		None	Concur.
37.	8 (m)	The post-incident medical response.
		Finding
		The Board finds that the post-incident medical response onboard CHICOUTIMI was not limited to the provision of medical treatment to the casualties.	Concur. See Appendix 1.
		Recommendations
		None	Concur.
38.	8 (n)	The adequacy of the training and qualifications of CF personnel involved in the post-incident medical response and treatment.
		Finding
		The Board finds the training and qualifications of CHICOUTIMI Physician’s Assistant and the two-member casualty clearing team were adequate.	Concur. WO Marshall, the boat’s PA, was, at the time of the incident, fully and properly qualified 6B and trained for independent duty. This includes training on the recognition and management of smoke inhalation injuries.
		Recommendations
		The Board recommends that more emphasis be placed on the implications, recognition and treatment of smoke inhalation during damage control and medical training.	Concur. In view of the fact that smoke inhalation injuries are, fortunately, uncommon events in the CF, it is appropriate to review training of CF health care providers in this specialized field of medicine and take advantage of lessons learned from this tragic incident to enhance our response to future events of this nature.	Short-term	DGHS
39.	8(o)	The adequacy of the medical equipment and doctrine.
		Finding
		The Board finds that all medical equipment listed in the Submarine Scale of Issue was present onboard CHICOUTIMI when the submarine sailed on 4 October.	Concur. With respect to doctrine, the PA is appropriately trained for independent duty.	Short-term	DGHS DGMPR/DMHS	MARLANT MARPAC
		Recommendations
		The Board recommends that the following equipment be added to the medical equipment list for submarines:	Concur. DMHS is to take the lead in reassessing submarine medical equipment. This review shall be conducted as a matter of priority.	Short-term	DGMPR/DMHS	DGMEPM/ DMSS4, DMSS2
		a. Two oxygen bottles per watertight compartment;	Concur.	Short-term	DGMPR/DMHS	DGMEPM/ DMSS4, DMSS2
		b. An oxygen re-breather per watertight compartment;	Concur.	Short-term	DGMPR/DMHS	DGMEPM/ DMSS4, DMSS2
		c. A pulse oximeter per watertight compartment; and	Concur.	Short-term	DGMPR/ DMHS	DGMEPM/ DMSS4, DMSS2
		d. Other equipment required to treat smoke inhalation casualties.	Concur.	Short-term	DGMPR/ DMHS	DGMEPM/ DMSS4, DMSS2
40.	8 (p)	The reporting of the casualties including coordination among Canadian, Irish and United Kingdom (U.K.) authorities.
		Finding
		The Board finds that CHICOUTIMI used satellite phones and VHF radios to provide shore authorities with the most up-to-date casualty information. This was the only means of communication available after the fire. The Board also finds that the coordination among Canadian, Irish and United Kingdom authorities with respect to the casualties was adequate.	Concur. Evidence supports that the medical understanding on-scene was complete and relayed to Command. Communications challenges (see 6(t)), imprecise terminology as to the condition of the casualties, and lack of clarity with respect to the level of urgency with which the evacuation was viewed, particularly as it pertains to agencies away from the scene of action, is equally evident. This imprecision appears to be the greatest contributor as regards UK and Canadian agencies’ misunderstanding of the seriousness of the casualties.	Immediate
		Recommendations
		None	Concur.
41.	8(q)	The chronology and adequacy of the medical evacuation from CHICOUTIMI.
		Finding
		The Board finds that the medical evacuation from CHICOUTIMI was adequately conducted and was executed at the appropriate time. The chronology of the medical evacuation is contained in Annex B to this report.	Concur. See Appendix 2
		Recommendations
		It is recommended that a lifting point be installed directly below the bridge and above the conning tower to assist in medical evacuations and for lifting other material out of the submarine. It is further recommended that a suitable stretcher and appropriate extraction training be provided for evacuation from a submarine.	Concur. SSTG to document requirements for DGMEPM action.	Long-term	DGMEPM/ DMSS2	MARLANT	Bridge Lifting Point – DMSS2 will investigate and raise EC action as appropriate.
		The Board recommends that every submarine receive helicopter hoist training as part of the standard operating licence.	Concur. Hoist training shall be incorporated into the Trials License specifically to take into account the vulnerabilities of the boats and crew at this stage of the Program.	Short-term	DGMPR	MARLANT MARPAC
42.	8(r)	Any other issues of relevance to this investigation. None.	Concur.
43.	9	If, after a thorough investigation and determination of the facts, the BOI finds that a member was killed or injured through the fault of some other person, it shall record whether the member, or his personal representative, has received, been offered, or claimed or intends to claim compensation from the person at fault. Not applicable.	Concur.
44.	10(a)	Measures to prevent a recurrence of such fires and casualties.
		Recommendations
		See Serial 5 Reference 6 (e) Serial 30 Reference 8 (f) Serial 14 Reference 6 (n)	Comments at 6(e), 6 (n) and 8(f) refer.
45.	10(b)	Any corrective action to improve survivability in an HMC submarine disabled under similar circumstances.
		Recommendations
		See Serial 17 Reference 6(q) Serial 13 Reference 6(m)	Comments at 6(m) and 6(q) refer.
46.	10(c)	The training and qualifications of personnel involved in the response to the fires and post incident medical treatment.
		Recommendations
		See Serial 15 Reference 6 (o) Serial 13 Reference 6 (m) Serial 38 Reference 8 (n) Serial 41 Reference 8 (q)	Comments at 6(m) and (o), and 8(n) and 8(q) refer.
47.	10(d)	Any corrective measures to improve response to fires, including the response time, procedures or equipment for firefighting aboard this class of submarine.
		Recommendations
		See Serial 14, Reference 6 (n)	Comments at 6(n) refer.
48.	10(e)	The improvement of existing fire prevention measures.
		Recommendations
		See Serial 5 Reference 6 (e)	Comments at 6(e) refer.
49.	10 (f)	Any corrective measures to improve CF reactivation procedures that would prevent fire.
		Recommendations
		None	Concur.
50.	10(g)	Any corrective measures with respect to doctrine, equipment, and training relating to operational capability restoration.
		See Serial 13 Reference 6 (m) Serial 17 Reference 6 (q)	Comments at 6(m) and 6(q) refer.
51.	10(h)	Any other corrective measures to be taken.
		Recommendations
		See Serial 2 Reference 6 (b) Serial 10 Reference 6 (j) Serial 5 Reference 6 (e) Serial 19 Reference 6 (s) Serial 41 Reference 8 (q) Serial 14 reference 6 (n) Serial 16 Reference 6 (p) Serial 39 Reference 8(o)	Comments at 6(b), 6 (e), 6 (j), 6(n), 6(p), 6(s), 8 (o) and 8(q) refer.
52.	New	Review of BOI Information with the Families of Casualties. It is necessary to review in detail the findings and recommendations of the BOI and this report with the families prior to public release and release to the submarine community. It is recommended that CMS ensure that the chain of command is made available to pursue this initiative.	Concur.		CMS
53.	New	Review of BOI Information with the Operational Submarine Community. It is necessary to review in detail the findings and recommendations of the BOI and this report with the submarine community prior to public release. It is recommended that CMS ensure that the chain of command is made available to pursue this initiative.	Concur.		CMS
54.	New	Public Affairs Approach - General. It is recommended that ADM (PA) provide the public affairs approach, questions and answers and talking points prior to the release of BOIs and coordinate the posting of the minutes of proceedings on the DND web site once severance has been granted.	Concur.		CMS	ADM (PA)
55.	New	The Supplementary Report of 18 Mar 05 recommended that the performance of the Victoria class submarines operating on the surface in various weather conditions and at various speeds be modelled. The results should then be shared with all Commanding Officers and watchkeeping officers to ensure that they fully understand the characteristics of the submarines.	Concur.	Long Term	DGMEPM/ DMSS2		Victoria Class Surfaces Seakeeping – DMSS2 will undertake an investigation of the surfaced manoeuvring characteristics of the VIC Class. Modeling results will be compared against full-scale trial data.

HMCS CHICOUTIMI BOARD OF INQUIRY – SUBJECT MATTER EXPERT (SME) REVIEW AND ACTION PLAN FOR IMPLEMENTATION OF RECOMMENDATIONS

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Review and Approval Documents

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Supplementary Report

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