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Report on Events Related to the Capsizing & Sinking of L’ACADIEN II Off the Coast of Cape Breton 28/29 March 2008
[PDF: 1.2 Mb ]
Table of Contents
- Executive Summary
- Chapter 1 — Introduction
- Chapter 2 — Context for the Incident
- Chapter 3 — Concepts at Play
- Chapter 4 — Chronology of events
- 4.1 The initial Voyage of L’ACADIEN II
- 4.2 Damage and Connecting with Coast Guard
- 4.3 Arrival of CCGS DES GROSEILLIERS
- 4.4 Assignment of CCGS SIR WILLIAM ALEXANDER
- 4.5 Setting the Tow and Making for Sydney
- 4.6 The Capsize
- 4.7 The Rescue Effort
- 4.8 Securing L’ACADIEN II and Considering Cutting into the Hull
- 4.9 The Dive Teams and Recovery of Casualties
- 4.10 Repatriation of Survivors and Initiating Search Reduction
- 4.11 Releasing the Hulk
- 4.12 Repatriation of the Deceased
- 4.13 Issues in the Aftermath
- Chapter 5 — Analysis
- 5.1 Analysis of the Accident - Events, Actions and Decisions Leading Up To, During and in the Aftermath of the Accident
- Assignment of CCGS SIR WILLIAM ALEXANDER
- Decision to Tow
- Leaving the Crew of L’ACADIEN II on Board
- Type and Length of Tow
- Speed and Direction
- Bridge Watch in CCGS SIR WILLIAM ALEXANDER and Actions of the Bridge Team
- Cause of the Sheer to Port
- Use of Engines by L’ACADIEN II Upon Colliding with Ice
- The Collision with Ice
- Location and Actions of the Towing Watch
- Utilization of Lights
- The Decision to Cut the Hull
- The Decision to Dive and to Complete Dive Operations
- The Decision to Depart the Scene
- 5.2 Assessing Systemic Factors
- Regulations governing the construction and inspection of vessels used in the Seal Hunt
- Sealing Ship Construction Regulations
- Small Fishing Vessel Inspection Regulations
- 2007-2008 Statistics
- Department of Fisheries and Oceans Monitoring
- Canadian Coast Guard Support to the Seal Hunt
- Icebreaking
- SAR Vessels
- Rescue Centres
- Non-Distress Incidents
- The Limitations of the Regional and Organizational Construct
- Communications & Data Management
- Marine Communications and Traffic Services
- Towing in the Canadian Coast Guard
- 5.3 Further Potential Mitigations to Risk in the L’ACADIEN II Scenario
- 5.4 Reflections on the Analysis
- 5.1 Analysis of the Accident - Events, Actions and Decisions Leading Up To, During and in the Aftermath of the Accident
- Chapter 6 — Observations and Recommendations
- Closing Commentary
- Annex A - Terms of Reference & Conduct of the Investigation
- Annex B - References
- Annex C - Methodology & Sequence of the Investigation
- Annex D - Summary of Recommendations
- Annex E - Chronological Timeline
- Annex F - List and Description of Investigative and Technical Research Conducted
- Annex G - Background and History of Sealing
- Annex H - Lexicon
