Part III - Recommendations

Measures to prevent a recurrence of such fires and casualties (10a).

1. Notwithstanding the replacement of the red elastomer insulation on the main power cable joints, 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 toxicity of the materials that burnt during the fire in the CO’s Cabin and the Electrical Space. (6e)

2. The result of the smoke propagation index and toxicity of materials testing must be recorded and a copy placed on the medical records of each member of the crew onboard HMCS Chicoutimi on 5 October. (8f)

3. It is recommended that Emergency Breathing System equipment, design and procedures be updated as follows: (6n)

1. That the design of the mask assembly be reviewed to incorporate positive pressure regulators and a more robust regulator-to-mask connection;
2. That EBS masks be pre-rigged at watch-keeping positions;
3. That the number of couplings in each compartment be audited and increased as required to ensure that there are sufficient couplings for all situation and that couplings are easily found and accessible in a smoke filled compartment;
4. That sufficient masks stored in “rider bags” be held in the Weapon Stowage Compartment to support all riders in that compartment;
5. That standards be developed for Y couplings, the number and length of hoses, and the number and location of masks;
6. 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;
7. That state-of-the-art photo-luminescent tape be applied on all EBS couplings, rails and lockers;
8. That usage tables be developed that indicate time remaining based on system pressure and personnel onboard; and
9. That options for alternate supplies of air to the EBS be developed.

Any corrective action to improve the survivability in an HMC submarine disabled under similar circumstances (10b).

4. It is recommended that the following changes to the onboard electrical systems be considered: (6q)

1. That a 24 Volt casualty power system be developed that can draw from the main batteries; and
2. That VP equipment be fitted with an override switch to by-pass the 24 Volt control circuits.

5.The following changes to smoke clearance equipment and procedures are recommended: (6m)

1. That smoke clearance procedures be developed and documented that do not require electrical power; and
2. The addition of non-electrically powered smoke clearance equipment appropriate for use in a submarine damage control environment.

The training and qualifications of personnel involved in the response to the fires and post-incident medical treatment (10c).

6. It is recommended that the following training be implemented: (6o)

1. Develop more realistic firefighting training for submarine crews;
2. Train in a mock-up to include donning and clearing EBS in a smoke-filled environment;
3. The use of EBS with firefighting equipment;
4. Institute a class-wide standard 48 hours joining package;
5. Institute onboard blackout training; and
6. Conduct a review of Damage Control markings and update as required.

7. It is recommended that standard operating procedures for immediate response personnel (Attack BA) be defined and documented. (6m)

8. It is recommended that more emphasis be placed on implications and treatment of smoke inhalation during damage control and medical training. (8n)

9. The Board recommends that every submarine receive helicopter hoist training as part of the standard operating licence. (8q)

Any corrective measures to improve response to fires, including the response time, procedures or equipment for firefighting aboard this class of submarine (10d).

10. It is recommended that the following changes to the firefighting equipment in the submarine be considered: (6n)

1. That the Victoria Class fire risk assessment prepared by the Canadian Forces Fire Marshal be reviewed and updated as required;
2. That higher capacity and/or more CO₂ portable extinguishers be carried onboard due to the fact they can not be refilled at sea;
3. That an additional fitted fire-fighting unit that operates without pumps or power be added (e.g. a twin agent unit);
4. That dedicated boundary cooling hoses be located throughout the submarine; and
5. That the SFU-90 hose be installed using more robust fittings.

The improvement of existing fire prevention measures (10e).

11. It is recommended that the following actions be completed with respect to oxygen generators: (6e)

1. That all oxygen generators be fully inspected and all planned maintenance completed prior to their use;
2. That all personnel be reminded not to operate an oxygen generator if the status of the maintenance of the unit is unknown;
3. 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
4. That the oxygen generator involved in the incident onboard HMCS Chicoutimi be repaired and tested ashore prior to being used again.

Any corrective measures to improve CF reactivation procedures that would prevent fire (10f).

No specific recommendations as CF reactivation procedures did not play a role in the fires onboard HMCS Chicoutimi.

Any corrective measures with respect to doctrine, equipment, and training relating to operational capability restoration (10g).

12. It is recommended that the restoration procedures used by HMCS Chicoutimi be captured for use by Naval Training Establishments and Submarine Sea Training to train other crews. (6m and 6q)

13. It is recommended that an alternate Damage Control Headquarters be provided for in the Weapon Stowage Compartment. (6m)

Any other issues of relevance to this investigation (10h.)

14. It is recommended that Submarine Operating Authorities endeavour to route Victoria Class submarines surfaced/submerged. (6b)

15. It is recommended that an independently powered voice and data recording system be installed in the submarines and that standard operating procedures for its use be promulgated. (6j) 

16. It is recommended that the following water control measures be considered: (6e)

1. 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;
2. Develop operating procedures to govern actions in the event of large water ingress through open hatches while surfaced; and
3. 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.

17. It is recommended that standard operating procedures for conning tower operations be developed and enforced.  The procedures should incorporate responsibilities of key personnel and safety numbers; communications between on-watch personnel, and precautions to be taken. (6e)

18. It is recommended that the following changes to onboard communications systems: (6s)

1. That emergency satellite phones be carried at all times; and
2. That battery operated handheld radios be carried throughout the submarine for internal communications in the event of a power failure.

19. 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. (8q)

20. 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. (6n)

21. It is recommended that the casing party safety equipment be reviewed to ensure the adequacy of knives, harnesses and safety lines. (6p)

22. It is recommended that the following equipment be added to the medical equipment list for submarines: (8o)

1. Two oxygen bottles per watertight compartment;
2. An oxygen re-breather per watertight compartment;
3. A pulse oximeter per watertight compartment; and
4. Other equipment required to treat smoke inhalation casualties.

23. The Board recommends that Commanding Officers ensure that their standing orders are promulgated and understood by all personnel upon assumption of command.  These orders should include guidance with respect to: (6e)

1. the completion of, and responsibility for, complete and accurate records;
2. OOW turnover procedures; and
3. detailed duties and responsibilities of key personnel.

Annexes

Annex A - Terms of Reference

Annex B - HMCS Chicoutimi Events timeline

Annex C - All source navigational plot of HMCS Chicoutimi

Annex D - Fire Investigator's Report

Annex E - Fire Investigation Test Plan

Annex F - Location of Crew when Fire Erupts

Annex G - Sea State Table