CMS Review of BOI

337-11080-204011 (CMS)

11 April 2005

CDS

BOARD OF INQUIRY: HMCS CHICOUTIMI FIRES AND CASUALTIES

References:

1. HMCS CHICOUTIMI Fires and Casualties Board of Inquiry Final Report dated 17 December 2004 (enclosed)
2. 3371-1080-1 HMCS CHICOUTIMI Fires and Casualties Board of Inquiry Supplementary Report dated 18 March 2005 (enclosed)

General

1. Upon completion of handover and acceptance from United Kingdom authorities on October 2nd 2004, HMCS CHICOUTIMI commenced its transit to Halifax, Nova Scotia as the fourth and final Victoria Class submarine accepted by the Government of Canada from the United Kingdom.  During the late morning of October 5th 2004, CHICOUTIMI had an ingress of water through the conning tower, substantial enough to trigger a series of electrical events that culminated in an electrical arcing of the main power cables and fire in the Commanding Officer’s cabin that spread rapidly to the deck below, causing significant damage and casualties.  The crew contained, suppressed, and overcame the fires, stabilized the situation and sought help from the outside agencies.  Several hours later an unrelated fire occurred in an oxygen generator in the weapons storage compartment that was short-lived and caused no further injuries or damage.  In total, the crew sustained nine casualties, including one fatality, Lt(N) Chris Saunders.  Once outside assistance was rendered, restoration of on board systems commenced, medical care and evacuation were effected, the submarine was taken in tow October 7th and was returned to Faslane, Scotland, October 10th.  As a consequence to these events on the 5th and 6th, I convened a Board of Inquiry (BOI) October 8th, 2004.

2. My review of the CHICOUTIMI BOI at references A and B has been completed.  The BOI convened to investigate the circumstances surrounding the fires and casualties among the crew of CHICOUTIMI, which occurred on or after October 5th, 2004.  The BOI has determined that no blame, fault or culpability should be attributed to any person in respect of the fires and the death.  I concur with this determination and will elaborate in more detail in the following paragraphs.  That said, command decisions related to the repair of a faulty upper lid vent and the subsequent decision to run the submarine “opened up” required further scrutiny, particularly because the result of these actions started a chain of events that culminated in the fires and the death of Lt(N) Saunders.  As you are aware, I re-convened the BOI to gain a better understanding around this particular aspect.

3. The President of the BOI presented his final report December 17th and his supplementary report March 18th, meeting the requirements of my convening Terms of Reference.  The BOI focused on gaining a comprehensive understanding of what happened and how we can mitigate and if possible prevent such a reoccurrence.  I believe that the BOI proceeded in a manner that encouraged candour on the part of the witnesses.  This was very important to achieving timely and complete findings and conclusions in this very complex undertaking.  A matrix at annex A describes the directed requirements in the original Terms of Reference, the BOI findings and recommendations, as well as my own amplifying comments.  In the next paragraphs, I will comment and elaborate on what I consider to be the key matters raised by the BOI.

Comments on BOI Findings

The reactivation of systems in HMS UPHOLDER/HMCS CHICOUTIMI and readiness for sea

4. The findings of the BOI around reactivating the electrical and other systems in HMCS CHICOUTIMI in preparation for the surface and dived transit to Canada are supported.  The level of effort, visibility into issues and understanding of the submarines by the builder BAE, Ministry of Defence UK and our own Project Management Office showed an adequate degree of care and attention in the reactivation of the submarine for the Canadian Navy in these areas.  That some contractual issues and defects arose during the process is evident and not unusual.  This is the nature of preparing such a complex vehicle as a submarine for return to service.  A specific investigation into the state of the main power electrical system was undertaken by the BOI.  It was observed that this submarine had experienced two battery short circuit incidents in 1990 and 2003 during reactivation.  The BOI concluded after extensive review of documentation that no damage was done to the system, that the main power cables were adequately activated and that the main power system was seaworthy in accordance with the design of the system. Oversight processes inherent in the project, contract and transfer were judged to be sound by the BOI and on the basis of the evidence and testimony.  I agree. 

5. As noted above, an arcing in the main power cable connections located in the Commanding Officer’s cabin was the source of the fire that spread to the deck below.  The fact that Direct Current cables of opposite polarity were fitted within close proximity to one another within the Commanding Officer’s cabin and that these high energy connecters were located in an area which might potentially permit prolonged exposure to sea water was not appreciated by the UK or Canadian officials during reactivation of the Victoria Class submarine.  Equally, the consequences of water penetration or an electrical earth developing into a full short circuit of the main power cables were never anticipated.  This risk had never emerged in any previous risk or technical analysis such as the Frazer-Nash Upholder Class Safety Assessment that considered the consequence of significant water ingress through the conning tower of this class. The Safety Assessment did not foresee the development of an arcing/short circuit situation to the main electrical cables that could lead to a major fire.  Nor did the assessment connect this risk to any ingress of water through the conning tower and predict a deterioration of power cables on 1 Deck.  The Safety Assessment was completed by the Upholder Training Team (a group composed of senior Royal Navy (RN) personnel who had been with Upholder Class submarines throughout the build, operations and reactivation), the UK submarine design authority, Frazer-Nash consultants (professional risk analysis consultants) and Canadian technical authorities.  In short, some of the most highly qualified people available completed the risk assessment.  During the design, build, previous operational experience and reactivation process, the occurrence of a catastrophic fire of this type resulting from a seawater immersion had not been identified as a risk.  Furthermore, the BOI heard evidence of a similar volume of water which flooded through the conning tower in                                  while surfacing.  Not unexpectedly, this water ingress generated earths to some equipment, which was dealt with successfully by the on board electricians.  However, the water ingress did not result in any electrical event associated to the main power cables. 

6. Any complex platform such as a submarine is necessarily subjected to a number of design and construction compromises.  In the case of the Victoria Class, given what we have learned, it is now clear that the main cable connections in the Commanding Officer’s cabin are located in an area that could potentially permit prolonged exposure to seawater in the event of an uncontrolled ingress of seawater through the conning tower or a burst seawater valve or internal sea water line.  In my view, this was an unintended and unforeseen but significant vulnerability.  To a great extent, this speaks to the nature of the trade-offs and compromises in warship design.  This is even more of a reality in a submarine where extremely limited space makes submarine design an enormous challenge.  It is also worth noting that you can never make a submarine (particularly a diesel-electric submarine) electrically risk free from water damage. This would be impractical for a multitude of reasons and there is an acceptance that some defects and equipment losses might occur.  Submarines are built using the principle of redundancy, allowing for sufficient spares and with a competent electrical team on board.  Obviously, avoiding taking water in the submarine is important, but the nature of the business and operation of a boat at significant depths with attendant water pressures cannot eliminate this risk.  What was very disturbing about this event was its magnitude, including the fire and casualties and the consequent loss of virtually every electrical system on board.  I would not have anticipated this in any ship or submarine.  This may have not been foreseen or anticipated but it resulted in an unacceptable situation.  With this in mind, and to ensure that this particular event cannot occur again, a complete re-insulation of the main cable connections at each bulkhead outside the battery compartments has been initiated in all Victoria Class submarines, and completed in VICTORIA and WINDSOR.  The water proofing of this repair specification has been successfully tested by actually immersing an energized and representative connection in salt water at the Defence Research Development Canada Atlantic facility for an extended period.   Notwithstanding that the probable cause of the arc and fire have been eliminated by these actions, the Canadian Naval Engineering Authority has, on the advice of the BOI and with my agreement, initiated a test program through the Naval Engineering Test Establishment, to understand to the greatest extent possible, the precise characteristics of the arcing and the combustion properties of the material involved in the fire.

7. The testimony of the heads of the technical departments in CHICOUTIMI and their senior subordinates indicates that all pre-sail checks had been completed without significant observation.  The defects that were listed during hand over and acceptance and those observed prior to getting underway were of a minor nature or addressed by a mitigation strategy that presented an appropriate factor of safety for the transit.  The Canadian Navy and the Royal Navy both follow a process for identifying and correcting defects on an ongoing basis.  Considering that ships and submarines are very complex platforms, it is the BOI view, corroborated by all the testimony reviewed from Canadian and Royal Navy witnesses that submarines do not sail defect-free.  In the opinion of the crew and technical authorities of both navies, CHICOUTIMI was in all respects ready for sea.  Indeed, much of the testimony suggests that the submarine, relative to the three Victoria Class submarines that had preceded her in reactivation, was assessed to be in the best condition upon leaving the U.K. 

8. I concur with the BOI assessment that there was due diligence in preparing the submarine and that CHICOUTIMI was safe and ready for sea.  The potential for a catastrophic failure of the main electrical power cables could not reasonably have been predicted during reactivation or in the preparation phase prior to sailing.

Training and crew readiness

9. The crew had received damage control and safety training through the Royal Navy as part of the Victoria Class submarine qualification and reactivation process. This training followed a logical progression that increased in complexity as the crew’s familiarity with the platform and Emergency Operating Procedures (EOPs) improved.  Training was initiated ashore with fire school training and progressed through specific Victoria Class occupations conversion training to alongside damage control training on board CHICOUTIMI.  This final alongside training of the entire crew, is commonly referred to as a “fast cruise.”  In the case of the reactivation, the “fast cruise” took place over a full week in which all emergency drills were performed. These drills were initiated as single evolutions and gradually developed until the crew responded satisfactorily to multiple emergencies by the end of the “fast cruise” period.  It was not until the “fast cruise” had been successfully completed that the submarine sailed for sea trials.  The crew then required a sea clearance by the Royal Navy (RN) Upholder Training Team on completion of the sea trials period as a precursor to acceptance by Canada and the subsequent surfaced and dived transit to Canada. 

10. When queried as to the preparation that this training provided, the crew, without exception, responded that considering the magnitude of this particular emergency at sea, the training they received had prepared them to deal with simultaneous fires on separate decks, arguably one of the worst possible damage control situations.  The crew was able to fight successfully both of these fires.  The BOI assessed that the training and preparation that the crew received were adequate.  I agree.  While training has been validated, we will take the opportunity to share this incident with other submarine navies and study very carefully how we can learn from this episode and further improve knowledge and procedures.

Adequacy of communications

11. The BOI finding “that the flow of information within and from CHICOUTIMI to other vessels and shore authorities during and following the fires was very challenging” needs to be emphasized to the greatest extent.  The arcing that started the main fire deprived the submarine of all main and auxiliary power, impacting internal communications and limiting the external communications capability to commercial portable systems.

12. The evidence shows that the CHICOUTIMI crew had a good understanding of the limitations on their internal communications and managed their meagre resources prudently.  The internal communication challenge was also compounded by the requirement to wear Emergency Breathing System facemasks throughout the first few hours and that any communications to the outside world needed to be first relayed to the bridge with an attendant loss in context, clarity, and follow-up. Externally, the loss of power left the submarine with a limited number of battery-powered handheld VHF radios and two battery-powered Iridium satellite telephones.  These radios and telephones were subject to high background noise from the wind and the sea when operated from the open bridge and had limited battery life.  This severely constrained the ability to communicate in as complete a manner as possible and for as long as required.  Satisfactory external two-way communications were not achieved, particularly in the vital first twenty-four hours of the incident.

13. Iridium satellite telephones are analogous to normal cell phones.  Because of the need to align the Iridium satellite telephone with the satellite, and to eliminate interference from inside the submarine hull, the Iridium telephone can be used only from the bridge.  The prevailing seas hitting the submarine on the beam, 25-35 knots of wind and a running diesel generator created a high level of background noise.  In addition, the erratic motion of the submarine’s bridge induced by the sea state resulted in the wallowing of the submarine to 30 degrees and sometimes more.  Considering the phone was used from the top of the fin, the location where the motion is the most pronounced, this continuous motion hindered the capability of the phone to maintain satellite lock.  It was understandable that communications by Iridium satellite telephone were challenging and prone to interruptions.  That said, the Iridium phone was vital and successful in raising the initial alarm.

14. Handheld VHF radios are omni-directional, short-range, line-of-sight systems that would only afford contact to a ship or aircraft in close proximity.  This communications avenue was not available to CHICOUTIMI until the first Royal Air Force (RAF) Nimrod Maritime Patrol Aircraft (MPA) arrived at 1744Z, some four hours after the fire.  While CHICOUTIMI’s VHF transmissions may have been clearer than those of the Iridium satellite telephone, the background noise problems would have been similar for the Iridium telephone.  A shortfall in using VHF is the requirement for one or more relay points in the chain (i.e., CHICOUTIMI to Nimrod to RAF Base Kinloss to UK Commander Task Force 311 (CTF 311) Northwood UK to Maritime Forces Atlantic Headquarters Halifax (MARLANTHQ)).  With the exception of the first Iridium satellite telephone call to the Submarine Operating Authority in MARLANT HQ and two Iridium satellite telephone calls to Commander MARLANT, reports that Canadian authorities received from CHICOUTIMI were filtered through several intermediate agencies.

15. The challenge which the principals on board faced in relaying the situation through intermediaries, including the factors behind their thought processes and decisions, is understandable given the pace, pressures, fatigue and incomplete situational awareness to which the participants were subjected.  It is evident that imprecise terminology or insufficient clarity or interrupted communications created a poor situational awareness outside the submarine.  The information flow to Canada, through NDHQ to the Government, was at times patently inadequate.  The communications arrangements involved in this series of events, illustrated at Diagram 1, were complex by necessity.  CHICOUTIMI interacted with two separate national chains of command, the RN Submarine Operating Authority (CTF 311) who was responsible for CHICOUTIMI during her transit, the Search and Rescue On Scene Commander (Her Majesty Ship’s MONTROSE) and the Rescue Coordination Centre in Scotland, the closest one to CHICOUTIMI’s position; all deeply engaged, each with valid and important interests and a need for access to information from the submarine.  Ambiguities, fatigue, a complex chain of communications, limited battery-powered communications in open bridge conditions confused the sense of understanding as to what was happening at the scene over the first twenty-four hours and particularly the status of the casualties.

Diagram 1  - Illustration of communication pathways

16. A key aspect of the challenges associated with the communications network and the inadequacy of the information flow was that initially, the number of casualties and their condition was not fully known by those on the bridge of the submarine who were in contact with authorities ashore or in the air.  In fact, in their conversations with Commander Task Force 311 at 1452Z and 1549Z, the submarine bridge indicated that the casualties were stable with non-threatening injuries and weather was unsuitable for personnel or equipment transfer.  As a consequence, the initial information provided by the CHICOUTIMI concerning the nature and extent of the casualties was viewed more optimistically in contrast to information provided the next morning after the full extent of the fire and injuries had been determined.  When the Commanding Officer also declined the helicopter transfer offered by the UK authorities because he deemed the transfer too risky, the impression ashore was that the casualties were in better condition than was actually the case.  A greater appreciation for the potential seriousness of inhalation injuries by authorities in Canada (see paragraphs 43 through 46) might have also tempered our sense of optimism that the casualties were in no immediate danger.  Nonetheless, the turn for the worse was clearly understood on board on the morning of October 6th, confirmed to authorities on scene, and subsequently corroborated by the RN Medical Officer after his transfer to CHICOUTIMI in the early afternoon of the 6th.  The saddest aspect of this inadequate chain of communications remains that initially all families were given a more optimistic prognosis than was actually warranted.  That Mrs. Saunders had a sense of hope, regarding her husband’s survival, which was ultimately dashed through what had to be shocking news, is a consequence that I deeply regret and for which I sincerely apologize.

17. Much has been learned on this score, including the fact that no one involved, either British or Canadian, knowingly or intentionally intended to downplay or minimize the seriousness of the situation on board through their efforts to inform or advise the leadership, the families or the public.  Notwithstanding, we in the Navy must use this tragic event as a sobering reminder to how critical it is to verify all information and improve our situational awareness as quickly as possible.  To the greatest extent we must balance this requirement with the need to apprise the public with the most accurate information as events unfold.  We must ensure all parties fully understand any communication limitations which might affect the accuracy of information particularly if preliminary or incomplete.

Command Decisions

18. I wanted to analyze certain aspects of the CHICOUTIMI incident specifically from a command perspective.  Command brings significant responsibility for the safety of the ship and crew at sea and command of a submarine is a most challenging subset in a very unforgiving domain.  In the context of this incident, and taking very much into account the BOI and its findings, I wanted to look very closely at how command was exercised at several key points.  This included the decisions to commence the voyage and get under way; to run opened-up; around fighting the fire in the control room; to decline the helicopter transfer on the evening of October 5th; and, to subsequently conduct it on October 6th. 

Determination to get under way

19. There is evidence that the Commanding Officer and crew understood that the submarine would experience a period of moderate weather.  Submarines and ships regularly sail in such conditions; it is a fact of naval life, and is indeed equally common in the larger world of maritime commerce.  The Commanding Officer tracked weather forecasts prior to sailing and assessed, even allowing a margin for prediction error, that the weather would not be bad enough to present any inordinate risk of damage to the submarine on the surface nor bad enough to preclude diving the submarine when he reached his allocated diving position.  I agree with this assessment.

Conditions and decisions which led to the determination to transit “opened up”

20. On leaving Faslane, CHICOUTIMI followed an expected sequence of running “opened up” (both upper and lower lids/hatches in the conning tower open) while transiting pilotage waters and busy traffic lanes and then shutting down (one of the two conning tower lids shut) on reaching more open water.  CHICOUTIMI operated in this latter condition until the morning of October 5th, when a defect was discovered on the upper lid vent during a watch change. 

21. There were two ingresses of water into the submarine on October 5th.  The first ingress of water in the early hours of October 5th was the result of not fully draining down the conning tower properly before opening the lower lid, the water in the conning tower having accumulated over some time due to spray coming down from the bridge during the changes of the watch.  The two events involving ingress of water were not linked by the BOI other than in the sense that they both involved the ingress of some amount of water down into the submarine. 

22. The second ingress occurred at approximately 1115Z and involved an estimated 2000 litres of water that covered the deck of the control room, flowed into the Commanding Officer’s cabin and down to the lower deck.  The BOI found the following chain of events in relation to this ingress of water:

1. At approximately 1030Z, CHICOUTIMI was proceeding on the surface towards its allocated diving area.  Winds were blowing at approximately 30 knots from the northwest and the sea state was reported as sea state 5 or 6 (this generated seas in the order of three to four metres).  The submarine was running with the upper lid of the conning tower shut as is normally the practice when running on the surface in such conditions and location;
2. At this time, the lookout coming off watch discovered a loose brass nut from the upper lid vent as he went below and he reported this defect;
3. A discussion took place among the Commanding Officer, the Engineer Officer and the Outside Machinery Engine Room Artificer (OSERA), where the Commanding Officer directed that the defect with the lid vent be investigated and repaired if feasible;
4. The OSERA detailed a repair party to collect their tools and prepare to go up into the conning tower;
5. The Commanding Officer checked the prevailing environmental conditions through the periscope.  At 1052Z he ordered the officer of the watch to run “opened up” and the repair party commenced their work.   The upper lid was opened in order to allow the technicians to do the necessary repairs, and the lower lid remained open;
6. Approximately 23 minutes later, a wave welled up around and inside of the fin of the submarine to a height that surpassed the top of the conning tower upper lid, some four meters above the waterline.  The Board estimated some 2,000 litres of water entered the conning tower through the partially opened upper lid and flooded down through the open lower lid into the control room before both lids were fully shut and the wave had receded;
7. Clean-up of the water took about 45 minutes;
8. Shortly after the water ingress, a full electrical earth was reported.  The Commanding Officer directed that it be investigated and the source of the problem isolated; and
9. At approximately 1315Z, while the investigation into the electrical earth was ongoing, fire broke out in the Commanding Officer’s cabin, rapidly spreading down into the electrical space on 2 Deck.

23. The BOI found that as a result of the second water ingress, the main power cable connections were most probably immersed in seawater in a space below the Commanding Officer’s bunk, where there is an insulated joint between each cable and each penetrator passing through the bulkhead at frame 35.  The presence of water under the bunk was unknown at the time and clean-up efforts by the crew were concentrated on ensuring no water damage resulted to equipment in the control room or the battery compartment.  The insulating system at the bulkhead cable joint, upon technical analysis, was considered to be the probable cause of water entry.  It was determined by the BOI on evidence from UK authorities and supported by analysis by Canadian experts, that the joint insulation was designed to be fire retardant and splash proof.  There appeared to be no design intent for the joint insulation to withstand water penetration if immersed fully in water.  The water ingress into the control room most likely permitted the entry of seawater into the joint, thereby most probably starting low intensity electrical arc tracking which weakened and damaged the insulating material further and set the conditions for the resulting significant electrical arc that was the origin of the fire. 

24. Consequently, the decision to run “opened up” started a sequence of events that culminated in the fire and casualties on board CHICOUTIMI.  Noting this, I needed very much to re-convene this BOI, as I did at reference B, to provide a more comprehensive and in-depth account of the decisions and actions taken in respect of the repair of the upper lid vent, and the context in which these decisions were taken.  I needed to understand particularly the decisions of the Commanding Officer in ordering the repair and his decision to run “opened up.” 

25. Commanding officers of our ships and submarines are in significant positions of trust and authority.  I hold them accountable to a very high standard for their actions. They can expect particular scrutiny where their actions affect the safety of our sailors and ships.  Equally importantly, our officers understand and accept this accountability as a fundamental of command at sea in our navy.  This standard is not based on perfection; rather their actions are very much assessed against the norms of acceptable performance.  Where they do not measure up, our commanders can expect punitive action or censure which could include being relieved from command.  As Commander of the Canadian Navy, I also place to the greatest extent, my trust and confidence in our commanding officers for the decisions they take under the often challenging, unique and risky conditions of our profession. If they have acted responsibly and reasonably, they can expect my support.  In other words, I hold our commanding officers answerable for their actions, but, as a former commanding officer at sea in Canadian and Australian warships including submarines, I also understand that I must be very careful when evaluating decisions made by our commanders at sea, particularly with the certitude of hindsight.   Commanding Officers understand that their decisions and actions may be subject to critical scrutiny, but they deserve the latitude to exercise within the bounds of reasonableness the skills and judgement for which they were recognized when selected to command.

26. The Commanding Officer’s intent, according to his testimony, was to run “opened up” to investigate and repair the defect as he assessed the conditions to be suitable to do so.  He also expected that, if practical, either the upper or lower lid would be shut during the repair to reduce the overall exposure to seawater, although neither the BOI nor I were able to discern if this intention was either passed to or understood by the repair team.  However, it is clear from the evidence that the opening and shutting of hatches was controlled by the repair team so as to minimize any impediment to the repair process, which was the Commanding Officer’s priority.  The upper lid was shut briefly several times by the repair team as part of the repair process, while the lower lid was, as indicated above, open throughout the time that the investigation and repair to the defect were underway, some 23 minutes.  Logbook entries show that the submarine was running “opened up” throughout the repair procedure. The Commanding Officer expected the two-person repair team to act also as hatch sentries.  Both sailors showed good awareness of the prevailing sea conditions as the repair was made and understood well their responsibilities to shut one or both lids should a wave threaten. The bridge watch were well aware of their watchkeeping duties and kept the repair team advised of the sea conditions.  Until the significant wave flowed into the conning tower, sea height did not cause any particular concern to the bridge watch or the repair team.  Furthermore, according to the BOI during the three hours following the fire, the submarine was “opened up” in worsening sea conditions and no water entered the submarine.  This ingress came as a total and unexpected surprise to CHICOUTIMI despite the repair team being ready to shut the upper lid rapidly if required. The repair team reacted very professionally to mitigate the event further by shutting the upper and lower lids as quickly as possible and actually had shut the upper lid before the wave exceeded the upper lid height.  Unfortunately, the upwelling of water in the fin around the upper lid lifted the sentry and impeded the closing of the upper lid.

27. As noted by the BOI, the Commanding Officer, Commander Pelletier, had the authority to run “opened up” under the extant orders (Royal Navy publication SMP 150).  He exercised this authority after judging personally through observation from the search periscope that conditions were suitable enough to have open concurrently both upper and lower lids.  He was solely responsible for taking this decision and is clearly accountable for the direct consequences of ordering this action – the ingress of sea water.  Events surrounding the defect and subsequent repair of the upper lid vent did not seem so significant at the time that it crystallized in the memories of all involved.  Unlike the recall of events following the fire, there is more variation in testimony about what was said, and to whom, about the planning and execution of the vent repair.  However, there is no doubt that the Commanding Officer ordered the submarine “opened up.”

28. Although running “shut down” on the surface in the open ocean would be the expected line-up for the conning tower, there is discretion for the Commanding Officer to run the submarine “opened up” or to invoke any variation on the line-up of the lids that he may view as required for a number of circumstances.  As noted in the testimony of one former and another current Victoria Class submarine commanding officer and reinforced from my own experience in submarine command, running “opened up” is not so unusual when operating while surfaced.  It is ordered for a variety of situations including preparations for diving, establishing a bridge watch upon surfacing, casing (deck) evolutions such as a transfer of personnel or materiel by boat, entering or leaving harbour, in high density shipping areas where there is potentially a greater risk of collision or for other circumstances where unrestricted access between the bridge and the control room is deemed appropriate by the Commanding Officer. A decision to run “shut down” or “opened up,” indeed opening or shutting any hull valve or hatch aboard a submarine, is made by the Commanding Officer based on a variety of considerations including ambient conditions (temperature, humidity, sea, swell and weather), geographic location, emerging or emergency requirements and the watchkeeping routine in force.  Running “opened up” in a submarine is not exceptional or unusual, but doing so must make sense for the conditions and be monitored closely by all personnel who have a duty to maintain the safety and integrity of the submarine. 

29. In this case, the Commanding Officer had a compelling reason to repair the upper lid vent as it affected his capability to dive.  This caused him to deviate from the expected operating routine and run the submarine in the “opened up” condition.  According to the Commanding Officer, he chose to emphasize completing the repair as his priority in view of the expected worsening weather and sea conditions.   According to the BOI, the Commanding Officer, his bridge team and the repair team were cognizant and alert to the “opened up” state of the boat.

30. The BOI examined the Commanding Officer’s command appreciation of risks and options associated with the repair of the upper lid vent, hearing testimony from the Commanding Officer, the Officers of the Watch and the members of the repair team.  The re-convened BOI heard testimony from two of our most experienced submarine commanders, currently serving, on the matter of running “opened up.”  The observations and comments of these two officers allowed the BOI to conclude that the Commanding Officer’s decision to run “opened up” was taken with a due and reasonable appreciation of the known risks attendant with the prevailing circumstances.  Although the BOI concluded that the Commanding Officer’s decision to run “opened up” was not essential from a purely technical perspective to complete the investigation and repair, they also concluded that the risk assessment, risk mitigation, and the conning tower option selected by the Commanding Officer and implemented by the Officers of the Watch were reasonable. I agree.  

31. Consequently, while I adjudge Commander Pelletier responsible and accountable for the ingress of water into the submarine, his decision to run “opened up” was reasonable for the circumstances.  He and his crew took the appropriate precautions to effect this decision and I agree with the BOI thatCommander Pelletier met the standard of informed and reasoned decision making that I expect in our submarine commanding officers around this issue.

32. I agree with the BOI recommendation that standard operating procedures around conning tower lid/hatch control need to be emphasized more explicitly to minimize any such reoccurrence. Also, I agree with the BOI that we need more quantitative modelling to understand better the handling characteristics of this class of submarine while on the surface.  The Navy will undertake this analysis to better assist our commanding officers.  This event has prompted me to reinforce to our submarine commanding officers, as a consequence of this event, to be exceptionally prudent when running “opened up” in all sea conditions.

33.  Notwithstanding, there cannot be hard and fast rules associated with submarine hatch and boundary control.  This must continue to be the prerogative of the Commanding Officer who must weigh potentially conflicting or ambiguous factors and advice when taking decisions at sea.  Finally, running “opened up” is not an extraordinary event, but a normal consideration for submarine operations for a number of circumstances while surfaced. 

Responsibility and accountability for the fire in the control room and electrical space

34. Furthermore, while I hold the Commanding Officer fully responsible and accountable for his decisions around the resulting water ingress, I cannot hold Commander Pelletier or anyone else in the submarine responsible and accountable for the fires and consequently the casualties that occurred on board CHICOUTIMI.  Based on the findings of the BOI, the ramifications and consequences that followed from the water ingress were well beyond what could have been reasonably foreseen by any member of the CHICOUTIMI crew including the Commanding Officer.  It had not been anticipated in the design or the reactivation of the submarine or through any risk assessment by some of the most experienced technical experts in the UK and Canada. The actions taken by the Commanding Officer and ship’s company when they discovered the initial earth were in accordance with standard operating procedures and their actions fighting the fire were outstanding and in some cases heroic.  This was a devastating and tragic event for the Navy and for many families and sailors for which closure will be long and difficult.  The BOI has highlighted that no individual ashore or afloat can be held responsible and accountable for the fire.  But we had a fire and we suffered a death and serious injuries on board CHICOUTIMI and the Navy has suffered a critical delay to the introduction of the Victoria Class to full operations.  In order to better understand the issue surrounding the fire, I directed the submarines alongside.  As a result, as mentioned earlier, a complete re-insulation of the main cable connections at each bulkhead outside the battery compartments has been initiated in all Victoria Class submarines and completed in WINDSOR and VICTORIA.  Material issues associated to the fire in CHICOUTIMI have now been resolved. 

Care of casualties and chronology of medical evacuation

35. Casualties were sustained on board CHICOUTIMI during the fire on October 5th at about 1315Z.  The submarine’s Physician’s Assistant (PA), who was initially restricted forward of bulkhead 35 during the fire, conducted a preliminary assessment of Lt(N) Saunders and LS MacMaster in the control room at about 1345Z while both casualties were breathing with the aid of the Emergency Breathing System (EBS).  Lt(N) Saunders told the PA at that time that he was                                                                             Following this, the PA was called away to the motor room to assess other casualties.  These initial assessments were all severely complicated by the conditions of thick smoke, the wearing of EBS facemasks, the challenge of communicating through the facemasks in a smoke-filled environment and the very great difficulty in manoeuvring through the completely dark, heavily rolling, cramped compartments of a submarine.  The stress to the crew as they fought to save their submarine during this initial 30 minutes would have been enormous.  For the PA and the casualty clearers to have accomplished what they did was remarkable.  Over the course of the afternoon, the PA continued to monitor the two most serious casualties, Lt(N) Saunders and LS MacMaster.  Lt(N) Saunders was moved from the control room to the Cox’n office at 1406Z, then to the wardroom. Again, the ability of the PA to assess and administer treatment to the casualties was restricted for the first few hours by the significant amount of smoke in the air and the need to remain on the EBS.  Once the atmosphere had been cleared of smoke and all the gas monitoring stations in the submarine reported that the atmosphere readings for all gases were safe, Lt(N) Saunders, who was in the wardroom and LS MacMaster were moved to the junior ranks mess on 2 deck at about 1620Z, where a more thorough assessment was completed.  During this period, other casualties were brought to the junior ranks mess for assessment, bringing the total to nine. 

36. The BOI reveals that early on the PA determined that at least Lt(N) Saunders and LS MacMaster were going to require expeditious evacuation - he later added PO2 Lafleur as a third requiring shore-based attention.  Because of the complexity of the situation (i.e., dealing with the fire, smoke, subsequent smoke-clearing, breathing on the Emergency Breathing System, and the number of casualties), the PA did not brief the Commanding Officer until between three and four hoursafter the fire,at some time after 1630Z of October 5thabout the same time as the submarine environment was declaredsafe to remove Emergency Breathing System masks.  After the first brief from the PA to the Commanding Officer, there was a shared awareness regarding the need for medical evacuation.  However, it was the Commanding Officer’s decision that the prevailing conditions (i.e., sea state, crew fatigue and limited time until sunset) and the disabled state of the submarine would make any attempt at a medical evacuation on the afternoon or evening of October 5th, either by fishing vessel or by helicopter, unsafe with unacceptable risk to those executing the evacuation, the casualties themselves and the submarine.  These same conditions would also preclude any attempt at transferring medical supplies such as oxygen cylinders from a helicopter.

37.  A potential option available to the Commanding Officer during October 5th was the fishing vessel WESTERN ENDEAVOUR whose Master made an offer of assistance including a proposal to come alongside the CHICOUTIMI to transfer personnel.  Transferring personnel, especially casualties, to the WESTERN ENDEAVOUR would have been risky, as was highlighted by the exceedingly difficult small boat transfer carried out in better conditions the following day.  Had the WESTERN ENDEAVOUR tried to come alongside close enough for a transfer, there would have been a significant risk of physical damage to the submarine as well as a high risk of injury for personnel doing the transfer - both casualties and handlers.  The possibility of a serious collision and further damage to the submarine cannot be discounted.  Even had there been a successful transfer, the level of care available to the injured was unknown. The Commanding Officer would have needed to consider sending his PA with the casualties, depriving the submarine of their only source of medical expertise. Notwithstanding, keeping WESTERN ENDEAVOUR available in the vicinity until HMS MONTROSE, the RN ship dispatched to the area by CTF 311, arrived was very sound decision in the event that the crew had been forced to abandon the submarine.

38. In the first few hours following inhalation injuries, the condition of even the most serious of the casualties appeared to have improved.  The Commanding Officer remarks in his testimony that, during his visits to the casualties on the evening of October 5th, he formed the impression that the situation appeared to be stabilizing and I consider that this was a reinforcing consideration to his decision to keep the casualties on board overnight.  During the morning of October 6th however, it is clear that the Commanding Officer was aware of the deteriorating condition of the more serious casualties and recognized the urgency of moving them to a medical facility.  With MONTROSE due to arrive on station by 1000Z, the Commanding Officer set sights on a boat transfer to accomplish their evacuation.  Concern for the condition of the casualties, combined with lingering doubts over the safety of a helicopter hoist in the prevailing conditions, led the Commanding Officer to decide to await the arrival of MONTROSE, now revealed to be late morning due to the pounding seas as the ship closed CHICOUTIMI.  The desire to evacuate casualties by boat, which the Commanding Officer had then concluded to be the safest method of transfer, seemed to him the most prudent course of action in the circumstances.  Even if MONTROSE was unable to deal with the casualties on board, they could have been transferred to a helicopter more safely from MONTROSE’s more stable flight deck than from the bridge of CHICOUTIMI.

39. Unfortunately, MONTROSE was delayed until approximately1230Z on October 6th.  Once on scene, a RN medical officer and medical assistant were dispatched by Rigid Hull Inflatable Boat (RHIB) to the CHICOUTIMI at 1319Z.  The extreme difficulties experienced with the boat transfer demonstrated to both commanding officers that it would be impossible to safely transfer the casualties back to MONTROSE by boat.  Over the next two hours, the RN medical officer assessed the casualties and administered treatment.  He then briefed the Commanding Officer of CHICOUTIMI that three casualties, earlier identified by the CHICOUTIMI PA, required immediate evacuation and he recommended that this be conducted by helicopter.  This was communicated to MONTROSE.  The On-Scene Commander, the Commanding Officer of MONTROSE, subsequently called for the ready Search and Rescue (SAR) helicopter to deploy to CHICOUTIMI to conduct the medical evacuation (MEDEVAC).

40. The decision to proceed with the MEDEVAC was made by the Commanding Officer of CHICOUTIMI in consultation with the Commanding Officer of MONTROSE, the PA, and the RN medical officer.  It is evident that Commander Pelletier was extremely concerned about conducting a helicopter MEDEVAC, considering the environmental conditions, the state of the submarine, limited fire-fighting capacity and crew fatigue.  With the arrival of the helicopter, and despite his reservations with respect to the safety of the evolution, Commander Pelletier decided to conduct the MEDEVAC.  This decision emphasizes my earlier comments at paragraphs 18 and 25 with respect to command and commanding officers.

41. In assessing the validity of the command decisions for this series of events, I have taken into account that any transfer to and from a submarine at sea is always undertaken with some risk.  Even in the best conditions, a submarine transfer from the bridge presents a very poor visual reference for the helicopter pilot while in the hover.  The bridge area is small and demands close attention from all personnel involved in the transfer. Moreover, the bridge is at the highest point in the submarine where the motion is appreciably accentuated, particularly when the vessel is stopped in water, as was the case in CHICOUTIMI when the boat lost all propulsion as a result of the fire damage.  There are a number of standard procedures undertaken in the submarine to prepare for the transfer such as lowering all masts, preparing for a helicopter crash on deck, positioning the submarine on the best course and speed for a transfer and stopping the diesel generators—none of which was going to be possible. On the day of the fire, with approaching darkness, no electrical power, no propulsion, masts raised, with significant submarine rolling and a crew exhausted from fighting fires and dealing with casualties, an attempt at conducting a helicopter transfer from the bridge could have had potentially catastrophic consequences for the aircraft and/or the submarine.  In light of these extreme conditions, I agree with the BOI that Commander Pelletier ordered the medical evacuation of the most serious casualties to proceed in very demanding and marginal transfer conditions on the afternoon of October 6th but also at a point with the best chances of success.

Awareness of the complexity and seriousness of inhalation injury

42. I have given particular scrutiny to the topic of inhalation injuries and the degree to which its impact was fully understood by all those involved with decisions during the CHICOUTIMI incident.  The obvious dangers of fires are well known to everyone and we have all been sensitized to the disability and disfigurement caused by severe burns.  This being said, exposure to smoke, soot and hot gases carries an additional risk of inhalation injuries, particularly from fires in enclosed spaces.  Sadly, this tragedy has highlighted that inhalation injuries are not well understood in the general Canadian Forces population and because complications of inhalation injuries can be typically delayed for up to 12 to 48 hours, their significance can be underestimated.

43. It is also understood that recognizing the severity of inhalation injuries is difficult for even well-trained health care providers and it is not uncommon for these injuries to go unnoticed in the hours immediately following accidents involving exposure to smoke and fire.  Recognition of the full extent of inhalation injuries requires laboratory services for blood tests, x-ray examinations and sophisticated monitoring equipment to repeatedly assess the casualty for complications such as pulmonary edema or pneumonia.

44. The primary objectives of treatment for inhalation casualties are to maximize delivery of oxygen to the tissues and maintain an open airway. Victims of significant inhalation injuries require the services of a fully equipped intensive care unit and the expertise and skills of a highly specialized team of health care providers.  The existence of burn centres in many of our country’s finest medical facilities attests to the seriousness of these injuries and a recognition that care of casualties with burns and inhalation injuries is extremely complex and labour intensive. 

45. Considering that the resources available to the Physician’s Assistant (PA) in CHICOUTIMI were far more limited that those found at a fully equipped medical facility ashore, the treatment that the PA provided to the casualties was the best that could have been provided in the circumstances.  He recognized that at least three sailors required evacuation, made this clear to command and provided appropriate medical care leading to their evacuation.  Lt(N) Saunders was a remarkable officer; this was clear from the evidence and testimony. In my view,                                                                                                                                             gave individuals on board greater confidence than was warranted.   Of note, in his testimony, when asked if the final result of Lt(N) Saunders’ injuries would have been the same, had he been ashore and had immediate access to a hospital emergency room, the pathologist replied, “I believe that is true, yes.”  Therefore an earlier evacuation, even had one been possible, might well have ended just as tragically. The greater understanding by the general Canadian Forces community of burn and inhalation injuries and their support must be a key lesson disseminated as a result of the experiences gained with the CHICOUTIMI casualties.

CMS Conclusions and Recommendations

46. A number of training, technical and logistical issues are commented on in the BOI, with attendant findings and recommendations.  I concur with all but two of these, and where there is disagreement, it is minor and technical in nature.  I have commented on all recommendations in some detail in the review matrix at Annex A.  As will be noted, a number of these issues are already being addressed or are in fact completed.

47. The most pertinent naval technical initiative, one worthy of note again, relates to an unintended and unforeseen vulnerability which was not understood prior to this incident.  The main power cable connections in the Commanding Officer’s cabin are, it is now clear, located in an area that could potentially permit prolonged exposure to seawater with ingress of water from several potential sources.  To avoid a further such occurrence, the navy has applied a confirmedrepair specification and methodology to all main power junctions outside the sealed battery compartments that could conceivably be exposed to seawater.  This work was conducted in parallel to the BOI process, and includes the re-sealing of cable connectors in VICTORIA and WINDSOR.  Similar work will be part of the ongoing Canadian Work Period in CORNER BROOK and CHICOUTIMI.  I consider this the key technical factor from this BOI in ensuring the safety of the class to continue to conduct operations at sea.   

48. I am satisfied that our sailors have received the kind of emergency training that makes them competent to take these submarines to sea. In this case this training was instrumental and fundamental to the crew’s excellent response to the fire.  CHICOUTIMIs saved their submarine.  In my discussions with the submarine leadership and crews, there is strong confidence in their submarines.  At the same time, I know that this event has shaken the confidence of others while it captured the attention and concern of Canadians.  The Navy will need to re-establish the trust and confidence of Canadians in this program.  I, the navy leadership and submariners remain convinced that this is the right capability for Canada and that they are safe and superior submarine.

49. Although not part of the BOI review, it is important to note that we are going to experience two simultaneous and reinforcing challenges affecting our ability to maintain overall submarine currency at sea as we look ahead.  First, new submariners without previous time at sea in submarines are trained well enough to go to sea but are not seasoned.  Each day at sea increases their confidence and grows their experience level.  This is normally reinforced through the guidance provided by those in the submarines with greater submarine experience.  But at the same time, our more experienced submariners are less familiar with this class of submarines.  They, like the newly trained ones, have successfully converted to the Victoria Class and are trained well enough to take these submarines to sea, but they have spent months away from practicing their trade as a consequence to the delays with this program.  They have not been able to consolidate their overall experience in this new class.  Only sea time under a controlled and paced regime can resolve this situation. 

50. Consequently on a broader front, I have directed Formation Commanders and technical authorities to prioritize navy resources and planning to eliminate in every way possible any operational, personnel and materiel impediments which might impact the submarines’ sea-going program.

51. At the Canadian Forces and departmental level, the following are added for consideration:

1. Assistant Deputy Minister (Materiel) and my technical staff have completed the critical requirements necessary for the submarines to return to sea.  Other action items from the BOI are being progressed as per Annex A;
2. It is recommended that National Defence Command Centre (NDCC) be equipped with a crisis management centre, with physical space and communications equipment, to allow Environmental Commanders and their staff to man a watch cell, form a more cohesive element than afforded by the common National Defence Headquarters footprint and in turn deliver more coherent and timely updates and advice to the leadership of the Canadian Forces and the department; and,
3. Awareness regarding the serious consequences of inhalation injuries needs to be emphasised within the Canadian Forces community at all levels and in all environments.

Communications Plan

52. The release of BOI information will not occur until after you approve the BOI and the Minister has been informed.  If you agree to close the Board, it is my advice that an appropriate number of Board Reports (references A and B), severed for access and privacy, be provided to the following: Lt(N) Saunders’ Next of Kin, CHICOUTIMI, other fleet units, and MoD UK through Canadian Defence Liaison Staff London.  Mrs. Saunders’ copy will be hand delivered by a senior naval officer designated by myself.  The ship’s company of CHICOUTIMI, the submarine community and senior naval officers in the chain of command will be briefed by myself assisted by selected Board members.  These reports and briefings would be completed in advance of any public release of references A and B, again appropriately severed for access and privacy.

53. Recognizing Assistant Deputy Minister (Public Affairs) as the lead agency for executing the communications component of the plan, I have tasked navy public affairs as the point of contact to coordinate and work closely with the department for synchronization of this communication plan as well as any press conference activity that emerges. 

54. Assistant Deputy Minister (Public Affairs) is responsible for the public release of BOI information on the web.  Pursuant to NDHQ Secretariat’s recommendation, it is envisaged that the CHICOUTIMI BOI will be posted to the Vice Chief of the Defence Staff website with links to that site embedded in the home pages of other stakeholders.  This approach will emulate the department’s “common look/common feel” format already established for the Boards of Inquiry for Tarnak Farm, Jowz Valley Mine Strike and the Kabul Suicide Bombing. 

55. Notwithstanding, briefings to Mrs Saunders and others need to have taken place prior to commencement of any release to the general public.

56. At this point, a press conference to explain the results of the Board is anticipated.  I would plan to lead this event and be supported by the President of the Board and others as deemed appropriate.  The most logical location would be Halifax.   It is envisaged that preceding any press conference a “lock up” of the media in Halifax with the severed Board Report intended for public release should occur.  The documentation provided to the media would be a copy of the material that has been formatted for posting to the VCDS web site.  Officials, familiar with the BOI content; technical terminology; and submarine operations, safety and engineering aspects pertaining to the BOI, would be present during the media lock-up for the purpose of assisting the media with any questions they may have in preparation for the press conference.

57. On balance, the interests of all concerned would be best served by being as forthcoming as possible with as much information as legal, privacy and proprietary concerns permit to Lt(N) Saunders’ family, the serving submarine community and the public at large.

Recommendations for Exemplary Performance

58. In reviewing the Board’s evidence and testimony, it became apparent that there were individuals in CHICOUTIMI  and  elsewhere who conducted themselves in an exemplary fashion and deserve appropriate recognition for their deeds.  These observations will be followed up in an appropriate manner.

Appreciation to Governments and Agencies

59. There was overwhelming support from many countries and agencies in the rescue of CHICOUTIMI. The Royal Navy and Royal Air Force mounted an unparalleled and  courageous operation to assist CHICOUTIMI for which we in the Canadian Navy are forever grateful.  The Irish Navy, United States Navy, Sligo Hospital, other auxiliary and fishing vessels at sea reacted compassionately and selflessly to help our stricken submarine. Other Canadian government departments including Department of Foreign Affairs and Public Works Government Services Canada provided immeasurable help and advice to accomplishing the safe return of CHICOUTIMI.  I or another senior Canadian naval officer has responded personally or in writing to each of these outstanding agencies and units.

Approval Sought

60. On the whole, I am in agreement with the findings and recommendations tendered by Commodore Murphy and his BOI.  I consider his approach to the investigation to have been thorough and his report an excellent basis for lessons learned and improvements to both procedural and technical aspects of operating the Victoria Class submarine.  The BOI report offers not only the chronological and technical dissertations, but the human tale as well.  In offering a coherent and cogent account of the many and complex issues involved in the incident, the Board represents a key investigative and remedial product.

61. My comments herein, and as attached at Annex A, serve to further express my views surrounding this event. I stand ready to further elaborate or discuss these comments.  Your approval of this report is requested.

M.B. MacLean
Vice-Admiral
Chief of the Maritime Staff

Enclosures

Annex A: HMCS CHICOUTIMI Subject Matter Expert (SME) Review and
Action Plan for Implementation of Recommendations

Appendix 1: Post Incident Medical Response

Appendix 2: Chronology and Adequacy of the Medical Evacuation from HMCS CHICOUTIMI