HMCS CHICOUTIMI BOARD OF INQUIRY - LETTER OF DECISION

2 May 2005

Distribution List

References:

1. DAOD 7002-1
2. 1080-1 (CMS) dated 8 October 2004
3. 3371-1080-1 (CMS/RDIMS 37784) dated 1 February 2005
4. HMCS CHICOUTIMI Fires and Casualties Board of Inquiry, Final Report, dated 17 December 2004
5. HMCS CHICOUTIMI Fires and Casualties Board of Inquiry, Supplementary Report, dated 18 March 2005
6. 3371-1080-204011 (CMS) dated 11 April 2005

Introduction

1. On 5 October 2004, a series of events began on board HMCS CHICOUTIMI which led to fires, the crippling of the submarine, injuries to her crew, and the tragic death of Lieutenant (Navy) Christopher Saunders. It is my duty, through the reports of the Board of Inquiry (BOI), along with the Chief of the Maritime Staff’s (CMS) own assessment of the events, to identify the causes of this tragedy and take those measures necessary to prevent a recurrence.

2. As the approving authority, I must assess whether the BOI has been conducted in accordance with the Terms of Reference (TOR), whether the findings and recommendations are supported by the evidence, and whether the recommended actions suffice to ensure lessons are learned and the potential for recurrence of such events is reduced. I will address these assessments and my reasons for them in this letter of decision. In my view, five major areas warrant specific comment: smoke inhalation injuries; the medical evacuation decisions; communications; safety of the Victoria Class; and command accountability. I will address these five areas in this letter of decision.

BOI Conduct, Findings and Recommendations

3. Clearly the President and Board members have paid very close attention to the convening order and the order to reconvene the BOI. The reports at references D and E meet the requirements of the convening and reconvening orders. Each finding is supported by specific explanation and reference to testimony received or evidence gathered. I conclude that the BOI has been conducted in accordance with the TOR and that the findings are supported by the evidence.

4. The recommendations flow directly from, and speak to, the findings in the BOI. Moreover, each significant finding is accompanied by appropriate recommendations. I note CMS concurrence with all but one of the recommendations, and am confident that implementation of the actions recommended will address the causes of the fire. Other remedial actions recommended by the BOI will be implemented and will further reduce the overall risks associated with submarine operations. Finally, I believe the recommendations are complete. Therefore, I conclude that the actions recommended are sufficient in response to what we have learned about the events onboard HMCS CHICOUTIMI.

Smoke Inhalation

5. CMS concluded in his review of the BOI that a greater understanding of burn and inhalation injuries must be a key lesson as a result of the experiences gained from the HMCS CHICOUTIMI casualties. Clearly this lesson applies Canadian Forces wide. We must all take action to improve the understanding of burn and smoke inhalation injuries, now, and in the future. Therefore, I hereby direct ADM (HR-Mil) to build and execute a program to communicate and amend training to assure that understanding.

Medical Evacuation

6. It is clear from the BOI report and the amplifying information provided by CMS that the decisions regarding medical evacuation remain among the most difficult to assess for lessons learned. Based on the reports received from HMCS CHICOUTIMI, the testimony of the Commanding Officer, and the assessment by CMS, I conclude that the full extent of the injuries sustained by Lieutenant (Navy) Saunders were not evident until 6 October. This is not to fault the physician’s assistant, who provided extraordinary support and treatment given the difficult circumstances he faced, and given the limited medical equipment a submarine carries. Based on the information available to the commanding officer, and considering the risks presented by the state of the submarine and the environmental conditions, I conclude Commander Pelletier’s decisions to not evacuate the injured on 5 October but to evacuate them on 6 October were reasoned and prudent.

Communications

7. It is clear that communicating with HMCS CHICOUTIMI after the fire was challenging.  We must recognize that the first several reports of incidents are often based on an incomplete awareness of the event that has occurred, and sometimes contain information later determined to be inaccurate.  In receiving these reports, we must challenge and verify our understanding of the event and the status of those affected. That said, as a public institution we must strive to balance the public’s right to know against our operational experience that suggests the likely certainty that early reports often contain incomplete and sometimes inaccurate information. I support the BOI recommendations and accordingly, I have directed a review of our public communications to ensure that correct balance. I share CMS’ deep regret that false hope was provided to Mrs. Saunders.

Safety

8. There is inherent risk in the conduct of all military operations, and few that pose greater challenges than submarine operations. As a result of the events in October, it is essential that we address the safety of Victoria Class submarines. Safety in my view is the combination of equipment and the human element, and I will address each separately below.

9. The equipment component of safety includes the fundamental design of the submarine, its reactivation and the provision of emergency response equipment onboard.  At reference F, CMS concludes there was a vulnerability in the Victoria Class submarine in that a severe fire was caused by immersion of the main cable connections, and that this vulnerability was both unintended and unforeseen. I find the analysis to be comprehensive and compelling, and support CMS’ assessment. In that the bulkhead cables connections outside the sealed battery compartment have been re-insulated throughout the Victoria Class, the vulnerability has been mitigated. As for the reactivation of the submarines, there is nothing in the BOI report to indicate that the reactivation contributed to the tragedy or provides lessons for the Victoria Class submarines. I accept the BOI finding that there had been adequate care and attention to detail during the reactivation of HMCS CHICOUTIMI, and that CHICOUTIMI was safe and ready for sea. Finally, with respect to the emergency equipment carried onboard the Victoria Class submarine, the lesson to take from the tragedy onboard HMCS CHICOUTIMI is that the crew required every bit of emergency response equipment. I note and support CMS’ immediate and short-term efforts to increase the emergency response equipment onboard.

10. The second component of safety is the human element – the procedures we develop and the training we provide to our crews. I agree with the recommendations to emphasize more explicitly conning tower operating procedures and steps to understand better the performance of this platform while surfaced.

11. As for the training dimension of safety, I note that the training provided to CHICOUTIMI’s crew was instrumental in their being able to put the fires out and save the submarine. Notwithstanding that it may be possible to improve training, a fair conclusion based on the actions of the crew of HMCS CHICOUTIMI is that their training was sound and provided Victoria Class submariners the skills and knowledge they require to operate the submarines even in the most demanding of circumstances.

12. Having considered the equipment, the process to reactivate the submarines, and the procedures and training of the crew, I find the tragedy onboard HMCS CHICOUTIMI has made us aware of a safety concern of the Victoria Class submarines – that being the unintended vulnerability of the main cable connections at bulkhead 35 when immersed in sea water. Given the complete re-insulation of these connections to prevent arcing in the event of future immersions, I support CMS’ assessment that the Victoria Class submarines are safe for operations.

Command Accountability

13. In my view, the command decisions taken onboard HMCS CHICOUTIMI must be considered with the understanding that we are now in possession of significant information that was not known to Commander Pelletier at the time. We now know that an ingress of water could cause a catastrophic fire in the submarine. It is clear in the BOI report that Commander Pelletier could not have known this at the time. We now know that the injuries suffered by Lieutenant (Navy) Saunders were far more severe than was understood on October 5th and would ultimately be fatal. Commander Pelletier could not have known this at the time.

14. We demand a great deal of our commanders. We place in their hands the safety of their subordinates, and we demand they weigh information and take decisions in environments that can never be free of risk. We train and select them with these duties and responsibilities in mind, and we support them in their exercise of command. Finally, we hold them accountable for their decisions. In holding Commander Pelletier accountable – and with the certainty that he could not have known that his decision to run opened-up would lead to the tragic events – I support CMS’ conclusions that Commander Pelletier’s actions were prudent and reasonable given the knowledge and information he possessed at the time.

Conclusion

15. After careful review, I find the BOI has been completed in accordance with regulations and the convening orders, that the findings are supported by the evidence, and that the recommendations are sufficient and flow from the findings. Therefore, I approve the BOI and direct that those actions within CMS’ authority be implemented with priority on items that will have a direct bearing on improvements to the Victoria Class submarines. Moreover, I support the BOI recommendations that are beyond CMS’ authority alone to implement, and direct DCDS, CMS, CLS, CAS and ADM(HR-Mil) to take action to improve the understanding of, and training to deal with, burn and smoke inhalation injuries Canadian Forces wide, and to review and improve information assessment and release procedures.   Finally, I direct that the communications plan outlined in the BOI be executed with the addition that the CMS letter dated 11 April 2005 and this letter of decision also be included in the release of information.

16. The tragic accident onboard HMCS CHICOUTIMI brought to light a previously unknown risk to the safe operation of the Victoria Class submarine – the vulnerability of the main cable connections at bulkhead 35 when immersed in sea water.  A number of risk mitigation measures have been undertaken, including the re-insulation of these connections to prevent arcing in the event of future immersions that will reduce the risk to the safe operations of the submarines.  Given the progress made with theses remedial actions, I support the return of Victoria Class submarines to operations.

17. In closing I would like to add my personal and profound regret that the early reports of the events onboard HMCS CHICOUTIMI, while reassuring to the families of the crew in general, provided unwarranted hope to the Saunders family. It is my hope that the release of the BOI will help bring closure to the many people who have been deeply affected by this tragic event.

R.J. Hillier
General

Distribution List

Action

CMS
VCDS
DCDS
CLS
CAS
ADM (HR-Mil)
ADM (PA)

Information

ADM (Mat)
ADM (IE)
JAG