HMCS CHICOUTIMI FIRES AND CASUALTIES BOARD OF INQUIRY

Executive Summary

1. In its report to the Convening Authority submitted on 17 December 2004, the Board of Inquiry stated that although several people unwittingly contributed to the chain of events that occurred in HMCS Chicoutimi on the morning of 5 October 2004, no one aboard the submarine or ashore could have known of the sequence of events about to unfold and no one can be held personally responsible for the outcome: serious fires, nine casualties, and the tragic death of Lieutenant (Navy) Chris Saunders.

2. The CO of HMCS Chicoutimi had fourteen years experience in Oberon class submarines.  He had been onboard HMS Ursula during sea trials and work-ups and had been in command of that same submarine, once renamed HMCS Corner Brook, during her transit to Canada.  He is a seasoned submarine commanding officer, and is amongst the most experienced Canadian officers in this class of submarines. He possessed the knowledge required to carry out his duties.

3. The upper lid vent is a simple hand operated spring-loaded valve subjected to the elements, which can become fouled by debris, and requires regular attention for smooth operation.  The lookout coming off watch discovered a loose brass nut on the upper lid vent and handed it to onboard technicians who determined that they would have to investigate and potentially make repairs.  That process would entail giving control of the upper lid to the repair team, a lid that is normally shut and under the control of the Officer of the Watch.

4. To affect repairs the CO made a risk assessment of his tower control options.  The seas were estimated at four-meters with the winds at 25 knots.  The Commanding Officer weighed the risks, developed a risk mitigation plan and opted to run opened up in order to expedite the repair of the upper lid vent as poor weather approached.  He would not dive the submarine until the repairs were complete.  The CO did not consider it necessary to run shutdown for the repairs, a reasonable assessment in that, for the thirty some minutes, both lids were open for the repair before the water ingress occurred.  Although the Board could not confirm that the CO had communicated his plan, the Officer of the Watch testified  that he was happy with the environmental conditions while running opened up.

5. Two men were working in the tower keeping an eye on the sea, ready to shut lids as required.  Despite their efforts, a higher than usual wave up-welled inside the fin causing an estimated 2000 litres of seawater to pour into HMCS Chicoutimi.

6. Based on the testimony of other experienced Victoria class commanding officers, the Board finds that the risk assessment, risk mitigation, and the conning tower option selected by the CO and implemented by the Officers of the Watch were reasonable under the conditions.  

Table of Contents

• Executive Summary
• Table of Contents
• List of Figures
• List of Abbreviations
• Part I – Conduct of the Investigation
• Chronology of Investigative Activities
• Part II – Findings
• Comparison of Oberon and Victoria Classes
• Victoria Class Knowledge
• Submarine Operating on the Surface
• Upper Lid Vent Defect
• Conning Tower Operation
• Command Appreciation of Risk
• Risk Mitigation
• Assess Environmental Conditions
• Select Suitable Course
• Select Suitable Speed
• Consider State of Buoyancy
• Consider Sentries
• Running Opened Up
• Monitor Repair
• Conclusion
• Part III – Recommendations
• Annexes
• Annex A – Reconvening Order

List of Figures

• Figure 1 - Beaufort Force 6 - wind speed 22 to 27 knots, wave height 3 to 4 meters
• Figure 2 - Beaufort Force 7, wind speed 28 to 33 knots, wave height 4 to 5.5 meters
• Figure 3 - Conning Tower Upper Lid (From Above)
• Figure 4 - Upper Lid Vent
• Figure 5 - Table of Pros and Cons of Conning Tower Operation
• Figure 6 - Victoria class Roll - 4 Meter Seas
• Figure 7 - Victoria class Pitch - 4 Meter Seas
• Figure 8 - Table of Conning Tower Freeboard

List of Abbreviations

BAE    BAE Systems Marine Limited
BOI    Board of Inquiry
CO    Commanding Officer
HMCS    Her Majesty’s Canadian Ship
HMS    Her Majesty’s Ship
MARS    Maritime Surface and Sub-Surface
SMP    Submarine Publication
VICES    Internal Communication System fitted in Victoria class submarines

Part I – Conduct of the Investigation

Chronology of Investigative Activities

1. The report on the Chicoutimi Board of Inquiry was delivered to the Convening Authority, the Chief of the Maritime Staff, on 17 December 2004.  After reviewing the report, the Convening Authority concluded that the Board had addressed each of the areas specified in the original terms of reference.  However, he also determined that the need existed to obtain additional information relating to decisions made and actions taken in respect of making repairs to the upper lid vent.  While the Board had sought and received some evidence on the issue in question, the Chief of the Maritime Staff required greater clarity and context before concluding his review of the Board of Inquiry.  As a result, the Board was ordered reconvened on 1 February 2005 and directed to prepare a supplementary report no later than 8 March 2005.

2. In the course of initial consultation with Board members, it was determined that one member, Lieutenant-Colonel Krause, would be unavailable to participate in the process for personal reasons.                                                                                                                                                                  .    The Convening Authority decided to proceed with the President and three remaining members.

3. The Board members independently reacquainted themselves with the testimony and evidence used for the original report.  This involved reading several thousand pages of transcript as well as reviewing over one hundred documents taken into evidence with special attention to the evidence that was deemed relevant to the limited scope of the reconvened inquiry.  Discussions on the general approach to be taken and on the required administrative preparations took place in order to re-assemble the Board in Halifax on 14 February.

4. The family of Lieutenant (N) Chris Saunders was contacted and informed that the Board had been reconvened.  They were invited to send a representative to be present when the Board received testimony, an invitation that they accepted.

5. As the Board initially met on 14 February and began the detailed planning of the inquiry, it became clear that in order to fully address the issues identified in the 1 February letter from the Convening Authority, the Board would have to scrutinize the actions and decisions of some key members of the crew.  The Board considered that it could receive evidence that might adversely affect the reputation of the Commanding Officer, the Officer of the Watch when the decision was made to run opened up to effect repairs to the upper lid vent and the Officer of the Watch who had charge of the submarine when the water ingress actually occurred.  In order to ensure maximum procedural fairness for those members should adverse evidence be received, the Board decided to serve Notices of Potential Adverse Evidence to the Commanding Officer and the two other officers on 15 and 16 February respectively. 

6. This process ensured that these individuals could benefit from a number of entitlements provided for in Regulations, including the opportunity to review all relevant evidence received by the Board, to be present for the remainder of the inquiry and to request additional questions be put to witnesses.  More importantly for the conduct of the investigation, members in receipt of a Notice could hire counsel to act on their behalf in exercising these entitlements. After they were served with their Notice, the three officers expressed the desire to be represented by counsel and to request that the Crown pay for their representation.  One of the legal advisors to the Board ensured that the officers served with Notice receive disclosure of the relevant information related to the inquiry.  He also assisted these officers with their requests for representation at public expense in order to expedite matters and limit the impact on the conduct of the BOI.  Nevertheless, the Board had to pause for five days to allow the three officers to secure counsel.

7. By 23 February, counsels for the three officers were secured and some procedural issues arose immediately.  The process the Board was engaged in was not well understood by counsel.  In order to clarify a number of issues, the President informed counsel in writing on 25 February of his intent for the conduct of the Inquiry, based on the applicable Canadian Forces regulations and orders. The President also invited all counsel to a meeting held on 28 February.  During that meeting, it became apparent that the Board would have to make some modifications to its schedule in order to ensure that counsel for the three officers in receipt of Notices could be present while evidence was being received.  The Board developed its schedule in consideration of counsel availability to ensure procedural fairness.  Testimony was scheduled to start at 0900hrs the next morning.

8. A few minutes before testimony was schedule to begin, one of the counsel served the Board with a motion for a Stay of Proceedings filed in the Federal Court in Halifax.  The motion alleged that counsel did not have enough time to adequately prepare for the receipt of the evidence.  It was accompanied by an Application for Judicial Review of the 25 February decision of the President regarding the conduct of the inquiry. Counsel who filed the motion attended the premises where the Board was conducting its meetings in anticipation of the planned testimony of that day.  Negotiations with the Board’s legal advisors resulted in an agreement to delay the presentation of his motion and to proceed with the witnesses planned for the week.  The motion was withdrawn a week later.   

9. With the development of the schedule it became apparent that the Board would not be able to submit a supplementary report on 8 March.  As a result, the President submitted to the Convening Authority a request for an extension to 31 March. The extension was approved, although the Board was encouraged to submit a report as soon as possible.

10. The planned testimony began at 1310, after a few hours delay, on 1 March.  The first person called was a Naval Architect with theoretical knowledge of Victoria class seakeeping.  The Marine Systems Engineer of HMCS Chicoutimi then followed and testified on his actions regarding the defect to the upper-lid vent.  The next day, the members of the repair party who worked on the submarine’s upper lid vent were recalled.

11. As counsel were not available for the next three days, the Board then prepared for the questioning of a Canadian Rear Admiral who had been a Fleet and a Formation Commander, as well as two experienced Canadian submarine Commanding Officers.  All three of these witnesses were heard on Sunday 6 March.  On 8 March the Board recalled the Officer of the Watch who had charge of the submarine when the conning tower was opened up, and the Officer of the Watch who had charge of the submarine when the water ingress occurred.

12. The Board was informed on 8 March of the decision by the Federal Court to dismiss the Application for Judicial Review of the decision of 5 November 2004 by the President of the Board to refuse access to Board’s meeting to a CBC journalist. 

13. On 9 March, the Commanding Officer was recalled before the Board to provide greater detail on his decisions and actions surrounding the upper lid vent repair.  He would be the last witness to testify.

14. Following the receipt of testimony from the Commanding Officer the Board began an intensive deliberation period aimed at determining whether or not adverse evidence was received during its re-convened phase and whether sufficient information had been gathered to be in a position to respond to the Convening Authority’s questions. This involved work on the supplemental report and its findings.

15. On 16 March the Board decided that the information obtained was sufficient and that no adverse evidence had been received.  Consequently, the Board decided to withdraw the Notices of Potential Adverse Evidence served on the three officers.  That removed the need for the three officers to call further evidence and submit final statements, effectively putting an end to the investigative phase of the Board’s work.  Following final deliberations, a supplementary report was delivered to the convening authority on 18 March 2005. 

Part II – Findings

Decisions made and actions taken in respect of making repairs of the upper lid vent.

16. In the report submitted to the Convening Authority on 17 December 2004, the Board provided some comments on the actions taken and decisions made with respect to the repair of the upper lid vent.  These comments are contained principally in paragraphs 110 to 120 of the 17 December report, which should be read in conjunction with this supplementary report.  Some of the information in the Board’s previous report is repeated in this portion of the supplementary report for clarity.

17. A recurring theme throughout the testimony received from the crew by the Board was that the Victoria class submarine was, in many respects, similar to the Oberon class.  This resulted in many procedures being carried over from one class to the other.  The Board interviewed several people to obtain a better understanding of the comparisons between the two classes.  After obtaining this background information, the Board then concentrated on the specific events surrounding the repair to the upper lid vent on 5 October. 

Comparison of Oberon and Victoria Classes

18. The core crewmembers of HMCS Chicoutimi were submarine qualified when they joined the boat.  Some were going to sea for the first time in a Victoria class submarine while others, including the Commanding Officer, had been crewmembers in other submarines of the class.  Most had extensive experience in Oberon class submarines. 

19. The Oberon design was developed shortly after World War II and evolved from submarines of that era.  The boats were designed to run on the surface to their area of operations and then dive to conduct their mission.  The hull form was therefore closer to that of a traditional ship hull with a “v” shaped bow for surface operations.

20. Given the need to remain undetected as much as possible, the Oberons were also designed to crash dive to avoid detection.  This involved rapidly bringing the bridge crew below as the ballast tanks were flooded to dive the submarine.  In order to dive as quickly as possible the submarines could be operated with the conning tower opened up to facilitate the rapid transfer of the bridge crew to the control room.  Running opened up on the surface was a reality of operating Oberon class submarines.

21. During the 1980s, the Royal Navy was developing a replacement for their diesel-electric fleet of Oberon class submarines.  By then, submarine hull forms had changed markedly.  The surface ship hull form historically used had been ideal for a surface raider that hunted on the surface and then dived to attack, but had its limitations.  With the advent of nuclear propulsion and the ability to remain submerged for weeks on end, the submarine hull form evolved from the typical surface ship design to the “tear-drop” design of the Victoria class that is commonly used today.  Although less efficient on the surface, this hull form is quieter and more efficient when dived than the shape used in the Oberon class. 

22. As the hull form design was evolving so was the efficiency of the propulsion systems.  Combined, these technological advances resulted in a diesel-electric design more akin to nuclear submarines than to its conventional predecessors.  The Victoria class submarine design was based on a concept of operations that saw the submarine diving upon leaving harbour and surfacing in the harbour approaches on returning from its mission.  This submarine was not intended for long transits on the surface, particularly in open ocean.

23. The Board heard that in the case of the Oberon the shape of the hull form would provide a better capability of righting itself than a Victoria class submarine.  This would result in the Victoria class having a tendency to ride through the waves rather than pitching up and down with them.  The Board heard testimony that commanding officers are generally aware of this seakeeping trait.  Of note, all of the information presented to the Board was based on the experience of Commanding Officers or on qualitative engineering data.  Limited hard data is available on the surface seakeeping performance of the Victoria class submarines.

The Board finds that more quantitative data is required on the surface seakeeping characteristics of the Victoria class submarines.

Victoria Class Knowledge

24. The crew onboard HMCS Chicoutimi that took the submarine through the reactivation process received extensive training on the Victoria class.  That training was designed to build upon their existing submarine knowledge.  The training provided to the crew was principally focussed on the operation and maintenance of various onboard systems, and on emergency operating procedures.  Each qualified submariner was provided with the training required for his function onboard the submarine.

25. The Royal Navy operated the Upholder class of submarines for approximately five years before withdrawing them from service.  The submarines were then tied up and out of service for several years before being transferred to Canada.  During that time, the Royal Navy ceased all diesel submarine operations and their experienced diesel submariners, including command qualified officers, moved on to other duties or left the Royal Navy.  As a result, there were few experienced officers involved in the transfer of the submarines to Canada who could pass along their knowledge and experience.  In the spring of 2000 a meeting was organized for designated Canadian COs, including the current CO of HMCS Chicoutimi, to meet with past commanding officers of Upholder class vessels. The focus of that particular seminar was on the operational capabilities of the class. 

26. The issue of running opened up on the surface was not discussed between Canadian COs and former Upholder class Commanding Officers.  Although the Board heard evidence that the Royal Navy and Canadian Navy had had incidents of water ingress through open conning towers in their submarines, none had resulted in the events that unfolded onboard HMCS Chicoutimi.  The risks of running opened up were stated in the Upholder Class Standing Orders that were in use in the submarines as they transited to Canada.  Canadian Commanding Officers testified that they were aware that there were risks in running opened up, mainly from water ingress, and would take necessary precautions.

27. The CO of Chicoutimi described his own knowledge of the Victoria class as medium to advanced.  He further indicated that he possessed the requisite ship handling knowledge to make the transit to Canada.  The CO had fourteen years experience in Oberon class submarines and he had been onboard HMS Ursula during sea trials and work-ups and had been in command of the same submarine, once renamed HMCS Corner Brook, during her transit to Canada.  He is a seasoned submarine commanding officer and is amongst the most experienced Canadian officers in this class of submarines.

The Board finds that the crew of HMCS Chicoutimi possessed the knowledge they required to carry out their duties.

Submarine Operating on the Surface

28. In the deeper waters, through which HMCS Chicoutimi was routed during the transit to Canada, a Victoria class submarine would normally be dived. However, HMCS Chicoutimi did not have permission to dive on 4 October as originally planned.  A late change in the submarine’s routing was ordered by the submarine operating authority on the day before sailing and required the boat to remain on the surface until the afternoon of 5 October.

29. The weather observation logged at 0600 on 5 October was northwest winds at 15 knots and four-meter seas.  The noon entry in the Submarine Ships Log indicates that the wind speed was 35 knots in four-meter seas that would have been broad on the starboard bow.  These entries were entered by the Petty Officer of the Watch who would have received the assessment of weather conditions from the Officer of the Watch on the Bridge.  That the seas were estimated at four meters is not in question.  However, the submarine did not carry an anemometer on the Bridge, making a precise assessment of the wind speed difficult.

30. As they did their hand-over at 1100, neither the off-going nor on-coming Officer of the Watch were concerned about the risks in running opened up in that environment.  When recalled before the Board for further testimony, the off-going Officer of the Watch stated that winds were approximately 25 knots at 1100 and that he was happy with the situation in a moderate sea state.  Using pictures from the Meteorological Services of Canada he stated that the conditions were between Force 6 and Force 7 on the Beaufort scale.  The photos he used to provide the Board with an understanding of the conditions were received in evidence and are included as figures 1 and 2 below. 

Figure 1 - Beaufort Force 6 - wind speed 22 to 27 knots, wave height 3 to 4 meters.

Figure 2 - Beaufort Force 7, wind speed 28 to 33 knots, wave height 4 to 5.5 meters.

Upper Lid Vent Defect

31. The upper lid vent is a hand operated spring-loaded valve that is used every time someone is cycled through the conning tower.  It is a simple device that due to its location is subject to the elements, which can lead to fouling by debris and salt deposits.  Items of this nature typically require regular attention for smooth operation.  The onboard technicians have some experience with the device.

32. On the morning of 5 October the lookout coming off watch on the bridge of HMCS Chicoutimi discovered a loose brass nut on the upper lid vent in the conning tower as he came below.  The nut was handed over to onboard technicians who determined that they would have to proceed to the top of the conning tower to investigate the state of the vent and potentially make repairs.  Given that the vent was an integral part of the upper lid, the Commanding Officer would not dive the submarine until repairs were completed.  The work needed to be completed prior to reaching the submarine’s intended dive position on the afternoon of 5 October. 

33. The defect was not a significant event for the crew; it was a precursor to the unpredictable events that would follow.  Although the crew had very detailed memories of the fire and surrounding events, their memories were limited on the events leading up to the vent repair, which rendered the Board’s work more difficult in this area of inquiry. 

Figure 3 - Conning Tower Upper Lid (From Above)

34. The Board heard that a similar defect on the vent had occurred previously while the submarine was undergoing sea trials prior to the handover of the submarine to Canada.  In that instance BAE technicians had repaired the vent to the satisfaction of the crew.  Various tests, including a vacuum test just prior to sailing for Canada, indicated that the vent was operating properly.

35. Once the defect was discovered on the morning of 5 October a search of onboard stores revealed that the submarine carried no spare parts.  On ascending the tower the two-man repair party determined that the vent needed to be disassembled and cleaned, and that no parts were required.  The technicians also determined that they could immediately affect repairs.  Once cleaned, the vent was reassembled and the lock nut originally discovered by the lookout reinstalled.  A hammer and screwdriver were used to tighten the nut, as the repair party did not have a tool that would fit over the lock nut.  After breaking a couple of screwdrivers, one member of the repair party proceeded below for additional tools.  However, he would not return to the upper lid.  He testified that as he was proceeding through the lower hatch he felt water falling on him.  He shut the lower lid from inside the Control Room in an attempt to limit the ingress of water.  The remaining technician attempted to shut the upper lid, which he did, but not before water entered the submarine.  The remaining technician was able to complete the repair unassisted.  He did so and then returned to the Control Room with the Officer of the Watch’s permission, shutting the upper lid behind him.

Figure 4 - Upper Lid Vent

Conning Tower Operation

36. On the surface, Victoria class submarines will generally run shut down in accordance with applicable standing orders.  While running shutdown the Officer of the Watch and a lookout are present on the Bridge in the fin above the conning tower.

37. In this mode of operation, the conning tower is used as an air lock to cycle personnel between the Bridge and the Control Room.  After obtaining permission from the Officer of the Watch to climb to the Bridge, a crewmember leaving the Control Room enters the tower and shuts the lower lid.  The pressure differential between the inside of the tower and the external environment is then equalized using the vent on the upper lid. A pressure differential results mainly from the main engines drawing a slight vacuum in the submarine.  Once the pressure is equalized the upper lid is opened and the person proceeds to the Bridge.  At this point the tower is “reversed” as the lower lid that is normally open is shut, and the upper lid that is normally shut is open.  When the crewmember returns to the Control Room the process is reversed.

38. There are occasions when the submarine is run “opened up”.  This involves opening both the upper and lower lids of the conning tower, de facto opening the Control Room to the external environment.  Normally when running opened up the tower is not manned and no sentries are posted on the hatches.  The submarine may only be run opened up with the permission of the Commanding Officer.  In pilotage waters or seaborne approaches a CO can be particularly busy in dealing with surface contacts, and may need to transit quickly between the Control Room and the Bridge.  Moreover, the submarine is routinely run opened up during diving and surfacing operations.  This is done to transfer personnel and equipment quickly to and from the Bridge.

39. The defect on the upper lid vent on the morning of 5 October was such that the operation of the Conning Tower needed to be considered.  The repair team would likely have to work on both sides of the upper lid and would require a degree of freedom with the lid.  There were basically three options available for the operation of the conning tower during the repair of the upper lid vent:

1. Continue to run shutdown.  Under this option the technicians would reverse the tower and work on the upper lid.  Should anyone need to proceed to the Bridge then the repair team would have to cease work and one of them would have to enter the tower and cycle the lids back to their normal line up to allow the person to enter the conning tower and proceed to the Bridge.  Repairing the vent did not make the upper lid unusable.  However, given that the technicians would be disassembling the vent, the tower could only be cycled if the main engines were shutdown to eliminate any pressure differential;
2. Use only the lower lid as a single boundary.  This is not a normal mode of operation of the conning tower.  Under this option the submarine would be isolated from the external environment by the lower lid only.  The repair party would shut the lower lid behind them and then open the upper lid to work on the vent.  Personnel transiting to and from the Bridge would have to open the lower lid and proceed aloft, thus opening the conning tower entirely to proceed aloft.  This option would require that main engines be shut down; and
3. Run opened-up.  Under this option the technicians would open up the tower and proceed aloft for the repairs.  Both lids would be open throughout.

40. The Board heard that all of the above options were feasible and safe.  There were pros and cons to each, which are shown in the following table.

Figure 5 - Table of Pros and Cons of Conning Tower Operation

Command Appreciation of Risk

41. A decision is seldom, if ever, a selection between two simple black or white options.  It normally involves making a selection along a spectrum of options all of which involved varying degrees of risk and return.  In a military context risks will frequently increase or decrease as a function of the changing environment.

42. A warship is a very complex environment.  It must be all things to its crew.  It must contain all of the facilities of a small town; power generation, water and sewage treatment, hotel, restaurant, and transportation.  It must also contain the sensors and high explosives that make it a military vessel.  It is residential, commercial, industrial and military zones all within a few hundred feet.  No city or town would ever permit all of these elements to coexist in such close proximity, yet such is the environment of a warship.  The close proximity of all of these elements increases the risk at hand.  For decision makers these factors also increase the complexity of the command appreciation of any risk that may be present. Such appreciation is fundamentally about managing the risks.

43. A former Fleet and Formation Commander described risk management as command assessment.  A command assessment was described first and foremost as thinking in terms of understanding the consequence of error should a plan not unfold as intended.  It also involves having off-ramps as the plan unfolds to mitigate against the vulnerability of a single point of failure.  The command assessment must also consider the degree to which the plan deviates from the norm of standard operating procedures.  Finally, it considers whether or not the team involved is ready to deal with the situation at hand.

44. Faced with a defect to the upper conning tower vent on the morning of 5 October the Commanding Officer had to decide upon the best course of action in order to affect repair.  Because he would not dive the submarine with a defective upper lid vent, the CO had two choices.  The first was to affect the repair at sea.  The second was to go alongside to repair.  Given that defects with conning tower lid vents are not uncommon, it was believed that the work could be completed onboard.

45. With the prospect of deteriorating weather as the day progressed, the CO saw a window of opportunity to deal with the defect quickly and safely.  Having discussed the repair with senior staff in the Marine Systems Engineering Department the CO determined that it was prudent to proceed with investigation and repair of the defect at sea.

The Board finds that the onboard technicians could complete the repair safely at sea and that the Commanding Officer’s decision to do so was reasonable.

Risk Mitigation

46. Having decided to attempt the repair at sea, the CO had to decide how to operate the conning tower.  The Board heard testimony from the Commanding Officer that the main risk he then had to consider in deciding how to operate the conning tower was the potential for water ingress into the submarine.  He stated that there was also the possibility of personnel injury from falling if a person was working in the conning tower with both lids open.

47. The CO had to select the best option with regards to conning tower operation during the investigation and repair process.  As discussed previously there were essentially three options.  Firstly, continue to operate the tower running shutdown; secondly, use the lower conning tower lid as a single boundary or thirdly run the submarine opened up.  In the determination of the best course of action the CO weighed a number of factors in support of risk assessment and mitigation.  In order to examine the risk assessment made by the CO the Board called other experienced submarine Commanding Officers to determine how they would approach a similar situation.  The Board then considered whether or not the CO considered each of these factors. 

Assess Environmental Conditions

48. The Board heard testimony from other experienced Victoria class Commanding Officers that it is prudent to evaluate the environmental conditions before deciding on the conning tower configuration.  One stated that the CO could proceed to the bridge himself in order to gain a full appreciation of environmental conditions, however, it would normally be done from the Control Room. 

49. The Board also heard that a CO can solicit the opinion of the Officer of the Watch with regards to the environmental conditions when considering conning tower operations.  According to testimony of the Officer on whose watch the submarine was opened up, and the testimony of the Officer of the Watch on whose watch the water ingress occurred, neither was sought out by the Commanding Officer for input or opinion on running opened up.  Both did testify however that they were comfortable with the CO’s decision and would have advised the Commanding Officer if they had had any concern about the environmental conditions for running opened up. Neither Officer of the Watch was concerned.

50. In his testimony the Commanding Officer of HMCS Chicoutimi indicated that he did not seek out Officer of the Watch input into his decision to run opened up.  He stated that he had assessed the weather from the vantage point of the periscope and that he was well aware of the weather observations recorded in the ship’s log that morning and of the weather forecast.  He also stated that he had a good appreciation of the outside conditions from his cabin located near the bottom of the conning tower.

The Board finds that the Commanding Officer assessed the environmental conditions present from the Control Room.  He did not cycle himself through the tower and proceed to the Bridge or speak to the Officer of the Watch about environmental conditions based on his personal assessment from the periscope.  Proceeding to the Bridge or speaking to the Officers of the Watch would not have made a difference as both Officers of the Watch agreed with the CO’s assessment.

Select Suitable Course

51. The Board heard that steering a course that keeps the seas broad off the starboard bow would provide a safe environment for the repair party and reduces the risk of taking water down the tower by limiting the motion of the submarine.  A course that keeps the seas forward of the beam will also prevent pooping.  Testimony from the Commanding Officer indicated that he assessed the submarine’s course relative to the prevailing sea conditions and determined that the seas broad on the starboard bow were suitable for the repair.  The Board received testimony from other Victoria class experienced Commanding Officers that selecting a course that would place the prevailing sea conditions broad on the starboard bow was reasonable. 

52. Testimony received by the Board from a Naval Architect who had modelled Victoria class performance indicated that the selected course was indeed suitable to limit the motion of the submarine.  This modelling is reflected in the following two tables.  Of note is that no detailed model exists for the Victoria class submarine operating on the surface.  The model used to assess the submarine movements was in fact a surface ship model.  This approach provided a suitable qualitative assessment of the submarine’s performance on the surface, but was not suitable for a quantitative assessment.  For that reason no y-axis scale is shown in figures 6 and 7.

Figure 6 - Victoria class Roll - 4 Meter Seas

Figure 7 - Victoria class Pitch - 4 Meter Seas

The Board finds that the CO considered the course of the submarine and made a reasonable assessment that the current course was appropriate for the repair.

Select Suitable Speed

53. The board heard testimony from both the Commanding Officer and other command experienced officers that, along with selecting the appropriate course, there is an optimum speed range that limits the motion and reduces the risk of water ingress if the conning tower is opened up. 

54. In his original testimony the Commanding Officer stated that he did consider speed as part of his risk mitigation.  He stated that he had reduced from 13 knots to below 4 knots as he had recalled deploying the foreplanes at the same time.  However, the navigational documents provided to the Board indicate that the speed was reduced to 10 knots when the engines were shut down prior to running opened up, and that the foreplanes were extended some two hours later.  A speed reduction when shutting down the engines is part of standard operating procedures.  When presented with these documents when he reappeared before the Board the CO did not dispute the fact that the speed reduction was less than he remembered.  In examining this evidence the Board then considered whether the actual speed reduction was sufficient to mitigate this aspect of the risk.

55. A qualitative assessment of the submarine’s motion was completed for various speeds under the environmental conditions present.  The assessment revealed that a further reduction in speed would have had little effect on the motion.  The results of the modelling are shown in figures 3 and 4 above.

56. The Officer on Watch on the Bridge was not concerned that there was any risk of water ingress.  The casing was not continuously awash and the submarine was not being hit by significant waves.   This was true at 13 knots and at 10 knots once the conning tower was opened.

The Board finds that the Commanding Officer reduced speed by 3 knots as part of the process of running opened up.  This reduction proved adequate under the prevailing conditions.

Consider State of Buoyancy

57. The Board heard that the practice of trimming down on 4 main ballast tank during a surface transit is both common and prudent in that it provides for better propeller efficiency.  As testified to by other experienced Victoria class Commanding Officers, the submarine should normally be restored to full buoyancy prior to slowing down or running opened up.  Notwithstanding this view, the Board received evidence from a Naval Architect that trimming down the submarine on 4 Main Ballast Tank reduces the freeboard of the upper lid of the conning tower by 0.06 m, as shown in the following table.  Therefore, restoring full buoyancy would have a negligible impact on the freeboard of the conning tower.

Figure 8 - Table of Conning Tower Freeboard

58. The Commanding Officer of HMCS Chicoutimi testified that he did not intend to restore full buoyancy prior to slowing down or running opened up.  In his opinion he considered that by being trimmed down aft the submarine experienced less motion.  The Board heard evidence that having 4 main ballast tank flooded would reduce the motion of the submarine. 

Restoring full buoyancy to the submarine would have increased the freeboard of the conning tower by only a negligible amount.  Also, the submarine will experience less motion with 4 main ballast tank flooded.  Therefore, the Board finds that the Commanding Officer’s decision to not restore the submarine to full buoyancy was not unreasonable.

Consider Sentries

59. Another possible step that could be taken to mitigate a risk of water ingress is to place sentries on the conning tower hatches while running opened up.  The Commanding Officer testified that he considered that the two-man repair party would act as hatch sentries, as this was normal procedure for a submariner.   Testimony received from members of the repair party indicated that they clearly understood they were safety sentries for each other, although they had received no specific direction to act as hatch sentries.  Despite the lack of specific direction, the repair party members stated that it was common sense to assume that they would also act as hatch sentries and indeed indicated that neither of them would have left the hatches unattended. 

The Board finds that adequate consideration was given to hatch sentries and that the repair party members did in fact perform that function.

Running Opened Up

60. The Board heard testimony from the CO that, having considered all of the factors discussed above, his intention was to run opened up with two caveats.  First, there would be people in the tower while the work progressed ready to shut either lid if required.  Second, the plan would be to run with one of the hatches shut as much as possible, but that there may be times when both of them had to be opened.

61. In this case the choice was made to run opened up in order to repair the vent.  That same choice could have been made on 5 October for other reasons.  In fact it is possible that the submarine could have been run opened up in preparation to dive later in the day.  Deciding how to operate the conning tower is a decision that submarine Commanding Officers must make frequently.

62. The CO testified that on the morning of 5 October his intention was to run opened up but to minimize the amount of time both hatches were open by having one lid shut as much as possible.  He stated that he communicated his intentions for hatch control to the Petty Officer supervising the repair.  That supervisor testified that he was not involved in any discussion about the conning tower or hatch control.

63. The Master Seaman who was the head of the repair team testified that he spoke to the CO who was at the base of the tower when they entered.  He said that he asked the CO if he was going to shut the lower lid behind him, knowing that the repair could be completed in this manner.  The upper lid had to be open to accomplish the job of taking apart the vent, cleaning and reassembling it, but the lower lid did not.  After looking through the periscope, assessing the sea state to be suitable, the CO is said to have replied, “no, we will be all right” or words to that affect and ordered the boat opened up at 1052.

64. When asked if the details for hatch control were passed to the Officer of the Watch the CO testified that he did not recall having a discussion with him.  The order to run opened up was passed to the Officer of the Watch without specifying the intention to have one lid shut as much as possible.  The Board received no evidence that would indicate that the CO’s intention of having one lid shut as much as possible was communicated to anyone.  The upper lid was opened most of the time, occasionally shut by the repair party for the repairs.  The lower lid remained opened throughout the process until it was shut in an attempt to limit the ingress of water.  Ultimately the submarine was run opened up (option C) to repair the upper lid vent, a fact that is not contested.

65. The CO’s plan also envisioned having the technicians act as sentries on the lids, thereby ensuring that they could be shut if required.  He testified that he did not give specific directions to have sentries on the hatches and stated, “…by having two people dedicated to [the maintenance] in the tower, was understood by those carrying out the repairs that that step had been taken”.  This was in fact implemented.  The two men in the tower considered themselves to be safety monitors for one another.  Neither was employed exclusively as a hatch sentry, but as experienced submariners they understood that working on a hatch at sea includes being a sentry.  Both members of the repair team testified that they were keeping an eye out for waves and were fully prepared to shut the hatch if required.  During the half hour they spent working on the vent the waves remained at the base of the tower some six to eight feet below them.  They further testified that they never did, and never would, leave the hatch unattended.

66. The repair team began working together on the upper lid.  One half hour later as they were completing the repair by tightening the last lock nut one of the repair team went below for a screwdriver and wrench.  The technician testified that as he was transiting through the lower hatch, half in and half out of the tower, a combination of sea and swell resulted in a large up welling of water inside the fin that overflowed into the tower and onto the worker who was just at the lower lid.  Despite the efforts of the repair team to close both lids, an estimated 2000 litres of seawater poured into HMCS Chicoutimi at approximately 1115.

67. The up-welling above the conning tower was not typical of the effect of the wave action being experienced by the submarine that morning.  For approximately half an hour before the water ingress, and over three hours after the fire broke out, the submarine ran opened-up, during which time no water entered the submarine.

The Board is unable to determine that the CO’s intentions regarding conning tower operation were in fact communicated to key members of his team.  The submarine was run opened up throughout the repair with technicians in the conning tower ensuring that the upper lid was not left unattended.

Monitor Repair

68. The cabin of the CO of a Victoria class submarine is located in the Control Room adjacent to the conning tower.  Other than meals and ablutions, he spends most of his time at sea in the Control Room where he is aware of conduct of the watch on the surface or dived.  He is continuously listening to the ongoing discussion as well as all internal communications on VICES, which he monitors from his cabin or from his chair in Control.  He could hear the normal communications between the Officer of the Watch and the Petty Officer of the Watch and was available to either of them at all times.

69. He stated that while sitting on his bunk doing paperwork he heard the distinctive sound of the conning tower lids being shut.  He testified that this was an indication that his plan that the lids be shut as much as possible was being followed.  One member of the repair team testified that they did in fact shut the upper lid at least three times while working on the vent. 

70. The Commanding officer testified that he monitored the conditions through the periscope as the repair unfolded.  He knew that the Officer of the Watch, who had charge of the submarine, would be monitoring the seas and would contact him should there be any change in the conditions.

71. The Officers of the Watch both testified that they were monitoring the conditions as required in the Captain’s Standing Orders and that they would have called the CO had the conditions changed or had they had any concerns with respect to running opened up.  Both officers also stated that they briefed their lookout to maintain a watchful eye on the repair team in the fin.

The Board finds that the Commanding Officer and the Officers of the Watch monitored conditions as the repair process unfolded.

Conclusion

The Board concludes that the risk assessment, risk mitigation, and the conning tower option selected by the CO and implemented by the Officers of the Watch were reasonable.

72. Life at sea is hazardous as the environment itself is never benign.  Moreover the inherent unpredictability of the sea is the principal factor that challenges rules about best practices to safely control the environment at sea - even routine activities.  The Commanding Officer must prepare the crew to fight in that environment, by day and night, on the surface and below it, in all circumstances and weather, through effective preparation, practice, and command appreciation of the risks.  The CO’s task at sea is to remove any impediments be they technical, operational or human, which may inhibit his or her vessel from achieving its full effectiveness as a fighting unit.

73. A Commanding Officer will always be responsible and held to account for actions taken, especially in matters of safety.  Commanding Officers, taking action in their demanding duties in a sea environment, may find their decisions questioned, particularly with the benefit of hindsight.  The real issue however is whether or not a decision was reasonable under the circumstances in which they found themselves. 

74. In this case, HMCS Chicoutimi’s Commanding Officer, an experienced submarine CO who had acquired his submarine experience in the Canadian Oberons and two Victoria class submarines, took an action and suffered an ingress of water.  He weighed the risks and opted to run opened up in order to repair the upper lid vent.  This would allow him to dive the submarine as scheduled.  The outcome of the water ingress that was suffered by the Captain and his crew on 5 October 2004 – fires and casualties, including a death – was as unpredictable as the sea itself.  For that reason and the fact that no rules were broken, the Board concluded in its 17 December Report that no one was personally responsible for the tragic outcome.

75. In hindsight, had the CO selected the option of running shutdown to effect the repairs water would not have entered the submarine.  However, this approach would have rendered the repair more difficult to complete in a timely manner.  As poor weather approached, the Commanding Officer made a risk assessment of his tower control options.  In the conditions present he did not consider it necessary to run shutdown for the repairs, a fact born out over the thirty some minutes that both lids were open for the repair before the water ingress occurred. 

76. The Board received evidence from experienced Victoria class Commanding Officers on how they would approach the management of risks in running opened up.  Their approach was similar to that taken by the CO of HMCS Chicoutimi on the morning of 5 October. 

77. The CO had completed his command assessment.  He had an off-ramp: personnel by the hatches with his team watching the seas.  Although the Board could not confirm that the CO communicated his intent, the Board finds that the risk assessment, risk mitigation, and the conning tower option selected by the CO and implemented by the Officers of the Watch were reasonable under the circumstances.

78. This incident highlights two important issues.  First, the requirement for rigorous standard operating procedures for conning tower operation and water control measures in the Control Room.  Second, the training of Victoria class Commanding Officers and watch-keeping officers in the seakeeping characteristics of these submarines.

Part III – Recommendations

In addition to the recommendations contained in the report submitted on 17 December 2004 the Board of Inquiry recommends the following:

1. As listed in our report of 17 December 2004, 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

2. It is 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.

Annexes

Annex A – Reconvening Order

3371-1080-1 (CMS/RDIMS 37784)

1 February 2005

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RECONVENING OF BOARD OF INQUIRY -
HMCS CHICOUTIMI INCIDENT OCTOBER 2004

References: A. Board of Inquiry Report 17 December 2005

B. 1080-1 (CMS) Terms of Reference 8 October 2004

C. DAOD 7002-1 – Boards of Inquiry

1.  I have reviewed the contents of the report delivered by the Chicoutimi Board of Inquiry (reference A). I recognize the Board addressed each of the areas that I requested to be examined in the original terms of reference (reference B) and I commend the board members for the work they did in preparing an extensive report on what was a complex and difficult matter. However, I have determined that the need exists to obtain additional information relating to decisions made and actions taken in respect of making repairs to the upper lid vent. While the board examined this issue, I require greater clarity and context before I can conclude my review of the BOI.

2.  The Board will, therefore, reconvene and prepare a supplementary report that will provide a 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 and actions were taken. The Board must examine and report on all relevant facts that they consider essential to providing context and support for the findings and conclusions that they may make.

3. While some flexibility is required, I ask that you complete your work with due diligence. I cannot perform my review duties until I have received the supplementary report. I request that you deliver to me your supplementary report no later than 8 March 2005. You are to advise me as soon as possible if you cannot meet this date.

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

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