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Report on Events Related to the Capsizing & Sinking of L'acadien Ii

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Report on Events Related to the Capsizing & Sinking of L'acadien Ii REPORT ON EVENTS RELATEDTOTHE CAPSIZING & SINKING OF L’ACADIEN II OFF THE COAST OF CAPE BRETON 28/29 MARCH 2008 Published by: Fisheries and Oceans Canada Canadian Coast Guard Ottawa, Ontario K1A 0E6 http://www.ccg-gcc.gc.ca/ Cat. No Cat. Fs154-15/2008E-PDF ISBN 978-1-100-11382-1 © Her Majesty the Queen in Right of Canada 2008 EXECUTIVE SUMMARY engineers boarded the L’ACADIEN II to assess the damage, concluding that the rudder could not be On the morning of March 29, 2008, a sealing vessel, the repaired at sea L’ACADIEN II, capsized after hitting a large chunk of ice while being towed by a Canadian Coast Guard vessel The DES GROSEILLIERS was then called to a higher in the Gulf of St. Lawrence. Four men lost their lives in priority Search and Rescue (SAR) case and departed. the accident – three victims were recovered from the Around 1500, the L’ACADIEN II was advised to seek overturned hull and one victim was lost at sea. assistance from Coast Guard Radio in Sydney to request an escort. Although there were several The Canadian Coast Guard commissioned this communications with the L’ACADIEN II, it was hours independent investigation to report on the sequence before the full extent of L’ACADIEN II’s damage was of events that led to the accident; the events that understood as well as the level of assistance it required. happened directly afterwards; whether Coast Guard policies and procedures had been followed and By 1859, Sydney Coast Guard Radio and the JRCC whether they were adequate. The investigation was (Joint Rescue Coordination Centre) in Halifax more to also make recommendations to the Coast Guard to fully understood the urgency of the situation that was prevent, to the degree possible, such a tragedy from developing on the ice. Of particular concern were the happening again. number of damaged, ice-bound vessels and the weather forecast warning of a potential gale and A tremendous amount of research was conducted onshore winds. After deliberations with a variety in the preparation of this report. Eyewitnesses were of Coast Guard offices, the JRCC dispatched the interviewed and detailed transcripts were reviewed . Canadian Coast Guard vessel, CCGS SIR WILLIAM Because there was no video record of the accident, ALEXANDER, to the scene. these eyewitness accounts were key to the investigation. The CCGS SIR WILLIAM ALEXANDER began towing the L’ACADIEN II at approximately 2250. The CCGS Additional research was also conducted to fill in any SIR WILLIAM ALEXANDER also took another sealing gaps in the recollections of the witnesses as well as vessel, the MADELINOT WAR LORD, under escort since to shed further light where accounts of the accident it had been damaged in the ice and was taking on varied. A naval architect was hired to focus on ship water. The three vessels traveled in an easterly stability and assess potential scenarios that could direction at a slow speed, averaging 2.6 knots (4.8 have caused the L’ACADIEN II to hit the ice and Kph, 3 Mph), through pack ice that was often 8/10ths capsize. Six separate towing trials were conducted concentration. at sea to better understand the dynamics of the tow during the accident and the potential causes of the The towing of the L’ACADIEN II continued for over vessel’s capsize. two hours, proceeding slowly through challenging ice conditions until 0100 in the morning on March 29, The chronology of the accident is presented in full when the three vessels entered an open lead in the detail in the report. On the morning of March 28, ice. Soon after, the L’ACADIEN II sheered on the port the L’ACADIEN II (home ported in Cap aux Meules on quarter (the left side) of the CCGS SIR WILLIAM the Magdalen Islands) was on the east coast of Cape ALEXANDER, struck a large chunk of floating ice and Breton attempting to reach a large concentration capsized. of seals, when it suffered rudder damage while manoeuvring in heavy ice. Unable to continue unassisted, the master of the L’ACADIEN II called for assistance at 1400. The Canadian Coast Guard vessel, DES GROSEILLIERS, responded to the call and two I REPORT ON EVENTS RELATEDTOTHE CAPSIZING & SINKING OF L’ACADIEN II Two of the six crewmembers on board the L’ACADIEN II • promote the concept of record-keeping and escaped and were rescued by the nearby MADELINOT analysis, as well as the value of shared WAR LORD. Four crewmembers were missing and a professional lessons learned frantic rescue effort ensued, lasting for several hours. • renew and reinvigorate engagement of the Search and Rescue Technicians from Canadian Forces client base Base Greenwood arrived to assist, and four divers • propose and participate in a coherent conducted a series of dives, recovering three victims alignment of cross-Departmental jurisdictional from the overturned hull. One victim was never found. domains within Canada’s east coast waters • propose a review of the regulatory process, A number of key observations emerged from this standards and inspection regime for vessels investigation and are covered in detail in the report: working and operating in ice with the the risks taken during the tow; how the tow was applicable authoritative partners in the conducted; the factors that caused L’ACADIEN II to appropriate Departments strike the ice and the factors that caused it to capsize. The eight recommendations listed above consist of From these key observations, the report arrives at both systemic and functional recommendations, each eight recommendations for the Coast Guard to one described more fully in the report. Survivors, consider: witnesses, family members, and the maritime • conduct a full review of towing requirements, community at large, all have a stake in their policies, processes, training and equipment implementation, as do the many people who • aggressively seek, implement and apply contributed to the report. While nothing can reduce technological methods which deliver a the risks of life at sea to zero, the advice offered is “common operating picture” meant to enhance operations and mitigate these risks. • conduct a reassessment of east coast waters’ jurisdictional apportionment • refine organizational planning and risk management processes for the oversight of east coast activities II TABLE OF CONTENTS Executive Summary . I Table of Contents . III Chapter 1 – Introduction . 1 1.1 Assistance to the Investigation . 1 1.2 Brief Summary of the Incident . 1 1.3 Terms of Reference . 1 Chapter 2 – Context for the Incident . 3 2.1 Factors at Play on 28 March . 5 Chapter 3 – Concepts at Play . 11 3.1 Perspective . 11 3.2 The Safe Practice of Seamen and Risk . 11 Chapter 4 – Chronology of events . 13 4.1 The initial Voyage of L’ACADIEN II . 13 4.2 Damage and Connecting with Coast Guard . 13 4.3 Arrival of CCGS DES GROSEILLIERS . 13 4.4 Assignment of CCGS SIR WILLIAM ALEXANDER . 14 4.5 Setting the Tow and Making for Sydney . 15 4.6 TheCapsize ..............................................................................18 4.7 The Rescue Effort . 20 4.8 Securing L’ACADIEN II and Considering Cutting into the Hull . 21 4.9 The Dive Teams and Recovery of Casualties . 22 4.10 Repatriation of Survivors and Initiating Search Reduction . 23 4.11 Releasing the Hulk . 23 4.12 Repatriation of the Deceased . 24 4.13 Issues in the Aftermath . 24 Chapter 5 – Analysis . 25 5.1 Analysis of the Accident - Events, Actions and Decisions Leading Up To, During and in the Aftermath of the Accident . 25 Assignment of CCGS SIR WILLIAM ALEXANDER . 25 DecisiontoTow ...........................................................................26 Leaving the Crew of L’ACADIEN II on Board . 27 Type and Length of Tow . 28 Speed and Direction . 29 Bridge Watch in CCGS SIR WILLIAM ALEXANDER and Actions of the Bridge Team . 30 Cause of the Sheer to Port . 31 Use of Engines by L’ACADIEN II Upon Colliding with Ice . 33 The Collision with Ice . 34 Location and Actions of the Towing Watch . 34 Utilization of Lights . 37 The Decision to Cut the Hull . 37 The Decision to Dive and to Complete Dive Operations . 38 The Decision to Depart the Scene . 39 III REPORT ON EVENTS RELATEDTOTHE CAPSIZING & SINKING OF L’ACADIEN II 5.2 Assessing Systemic Factors . ..
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