Chapter 5 — Analysis

The analysis effort of this investigation has included an extensive review of documents, reports, testimony, and live demonstrations. The goal throughout was to understand the incident as fully as possible so as to deliver pertinent advice and recommendations to avoid such an incident in the future and to improve the conduct of Coast Guard operations in general.

The library of knowledge and experience that is represented by the reference material and expert opinion sought and engaged by the investigation team is immense, much of it listed in Annex B. In considering this body of knowledge along with the factors of the case, and in revisiting the Terms of Reference, it became apparent that two domains existed which required a degree of precise assessment in this report; the analysis of the events, actions and decisions leading up to, during and in the aftermath of the accident; and, systemic factors. The effort to asses if the conduct of the operation fell within the parameters of the good practices of seamen, even if risks were undertaken, was key to understanding the event and to allowing conclusions from which meaningful recommendations have been derived.

Commentary on this analysis of the incident is delivered below. To avoid repetition, narration of the events is limited in this analysis section, thus reference to the Chronology of Events above may be useful. The Analysis of the Accident is then followed by the section Assessing Systemic Factors which remarks on the larger scale of systemic factors which influenced the accident.

5.1 Analysis of the Accident - Events, Actions and Decisions Leading Up To, During and in the Aftermath of the Accident

The conduct of towing at sea is a complex activity with many inherent yet often acceptable risks. The acceptability is framed by the willingness or need of the towed vessel to give up much of the control over a vessel’s movements and the willingness of the towing vessel to take on the levels of responsibility embodied in the operation. Though there is a shift in decision-making responsibility and indeed power, the shift is never fully 100% and the evolution is, when both vessels remain manned, always one of a shared interest. What follows below is an analysis of many of the sub-elements of the course of events on the night of 28/29 March which assesses issues, considerations and decisions. These analytical observations and conclusions consider the full range of commentary from witnesses, experts and the reference material.

Assignment of CCGS SIR WILLIAM ALEXANDER

The tasking of the CCGS SIR WILLIAM ALEXANDER by the JRCC at 18:59 was the culmination of an afternoon of work by the Rescue Centre’s operators, taking in a number of reports and assessments through conversations with radio stations, Ice Offices and the ROCs in Quebec City and Dartmouth. A number of cases of a variety of types existed. Some were elevated to a place on the JRCC case file without representing actual distress situations, such as the L’ACADIEN II and her mechanical difficulties. Some, such as the MADELINOT WAR LORD and the fact that she had been taking on water, were seen as more urgent but again did not represent an immediate distress situation. In combination with the weather forecast advising of a potential gale, the gut feel in the JRCC⁴⁶ was that if there were no distress situations in progress at the moment, there was a distinct likelihood that some would develop overnight. Discussions with the ROC in Dartmouth confirmed this perspective and the decision was made to activate CCGS SIR WILLIAM ALEXANDER, already assigned to SAR response, and move the ship to an area to deal with the dynamic and growing issues of concern occurring in Sydney Bight. The tasking, delivered to the Officer of the Watch, spoke of the need for a tow and the alternate possibility of removing the crew⁴⁷.

MADELINOT WAR LORD was initially perceived as the vessel of priority as the CCGS SIR WILLIAM ALEXANDER left Sydney Harbour. It was at 21:30, as the details of the situation at sea became more evident, that the JRCC chose to prioritize the L’ACADIEN II and tasked the CCGS SIR WILLIAM ALEXANDER to tow the vessel clear of a lee shore. The conversation between JRCC and the Commanding Officer of CCGS SIR WILLIAM ALEXANDER is fairly succinct on this matter. The issue of the damaged steering, the aspect of the nearest port of repair and the primary language of the master of the L’ACADIEN II were all discussed.

It should be noted that the more common task assignment is to ‘render assistance’ as opposed to the more definitive task to tow, though this latter approach is not rare. The task to tow would serve to form the lens through which the Commanding Officer of the CCGS SIR WILLIAM ALEXANDER would form his assessment and plan. Though the Commanding Officer, the one on-scene, always has the authority to refuse the tasking, there is a natural reluctance to do so unless factors at sea clearly dictate otherwise.

Decision to Tow

Leaving aside all factors related to distress, a forecast gale, potential groundings or ice damage, the fundamental situation for L’ACADIEN II was that the vessel was, by definition, restricted in her ability to manoeuvre (RAM). The vessel’s master had declared himself damaged, ‘pas maitre de sa manoeuvre’⁴⁸, though he only ever requested an ice escort through his conversations with Coast Guard Radio while the actual need was for a tow⁴⁹. The damage to L’ACADIEN II’s rudder meant the vessel would require a tow, ice or no ice. No commercial enterprise was found to effect the tow, nor was it safe to request another sealer⁵⁰ to assist given the conditions of the ice and the many problems the boats in the area were already experiencing.

In assessing the sequence of events in the context of policy again, it can be stated that an effort to raise other fishing vessels to assist was not attempted nor was there time taken to seek commercial towing service to take up the work. On the first point, it is clear that the ice conditions and the number of vessels already in trouble in the area suggested that this option was untenable. The Commanding Officer already had one disabled vessel on a lee shore and had no intention of asking another vessel to move in closer to the coast; either to put itself at risk or to give himself a more complex problem should it too become disabled. As to a possible commercial tug, the speed/time/distance factors⁵¹ made a request at this juncture uncertain given the forecast. It would have been an option shore authorities had explored more fully than could ever be done from sea. Further investigation into this issue in the aftermath of the incident confirmed that commercial resources of sufficient capability are not resident in the area during the ice season.

On the night of 28 March, the decision to tow was based first and foremost on the request by the L’ACADIEN II for assistance in clearing the coast given a concern for being run aground or, more likely, crushed in the growing ice pressure borne by a strong onshore wind and set. This perspective was reinforced by the fact that JRCC had in fact tasked CCGS SIR WILLIAM ALEXANDER to tow the vessel as opposed to rendering a broader assignment to merely provide assistance. The JRCC’s concern for potential issues in the ice was validated by the evening forecast received aboard the CCGS SIR WILLIAM ALEXANDER, and shared by the Commanding Officer. Though not keen on the prospects of a tow⁵², if the icebreaker did not act now to extricate the L’ACADIEN II the Commanding Officer could find himself forced to act in several hours as a result of the weather, and in deteriorating conditions. The option of abandoning the vessel was not considered in depth and was seen as an extreme course of action in the circumstances⁵³. Considering the weather forecast, the risks and the Commanding Officer’s experience in towing in ice previously, taking up the tow fell within the spectrum of assistance described by Coast Guard policy, aligned with the task from JRCC and was a reasonable if risky approach to circumstances which presented risks in every option available.

Leaving the Crew of L’ACADIEN II on Board

Hindsight brings particular scrutiny to the decision to leave the crew aboard the vessel during the tow and for the majority of the crew to be sleeping in the accommodation space. There are a variety of perspectives in the references and according to subject matter experts. The environmental conditions and the size of the vessel towed are key aspects in determining a course of action. A number of case studies demonstrate the vulnerabilities of manning a towed vessel, though sometimes without a final determination of the best approach. One Coast Guard publication suggests “the crew of the stricken vessel should be evacuated only when staying aboard could compromise the safety and well-being of the crew”⁵⁴ though this is not a Coast Guard policy per se. On the night of the accident, the perspective of evacuating the crew was balanced with concerns for endangering crewmembers in the transfer across the ice or accidents should the decision somehow limit the reaction to problems with the tow or other aspects of the safety of the L’ACADIEN II.

Several elements are key in considering this issue. First is that of culture. A master is naturally reticent to zero-man his vessel, even in risky conditions, if not because of them. Similarly, he is disinclined to break up his team without strong justification. Masters, in this case the Commanding Officer of CCGS SIR WILLIAM ALEXANDER, are also reticent to dictate to other commanding officers how to do their business, such is the respect held for the ultimate authority of a commander at sea, even in this modern age.

A second conditions is that risks at play on the ice at the time the tow was taken up on 28 March. As can be seen in Figure 14 below, the darkness of the middle of the night in pack ice may not be the time to be asking tired crewmembers to transfer from one vessel to another. The factors of fatigue, the limitations of spot-lights and the dangers of the pack ice, including the very real risk of someone falling through the ice, made this a risky proposition.

Figure 14: Example of Night-time Conditions on the Ice

We know that CCGS DES GROSEILLIERS had effected a transfer of her two engineers by crane earlier in the day and SAR Techs were later transferred from one vessel to another by the sealing ramp. This was done in daylight and without the sense of urgency imposed by the forecast and the requirement that several vessels had to be reached through the night. In this light, it was reasonable to leave the crew of the L’ACADIEN II on board their vessel.

What remains however is the question of how well the masters and crews understood the risk scenario they were facing. Both survivors described a sense of relief on board felt with the arrival of the icebreaker⁵⁵. Neither sensed significant concern over the initial stages of the towing evolution nor had perceived misgivings with the relative scale of the two vessels. The decision on board L’ACADIEN II to allow four of the crew to be asleep in the accommodation below does suggest that the potential for a sudden incident was not well recognized. The Commanding Officer of the CCGS SIR WILLIAM ALEXANDER was not aware of the location of the L’ACADIEN II’s crew nor had there been a conversation directing or advising against being asleep below-decks. A more complete conversation about the tow and the risk to consider may well have delivered a different scenario altogether.

With the benefit of hindsight, we can dispassionately assess the risks involved, particularly in towing a vessel of such relative dimensions. In such cases the default decision should now be to require minimum or zero manning in the stricken vessel, assuming conditions allow transfer of the remaining crew, and that those aboard should be alert and prepared to evacuate should the situation require.

Type and Length of Tow

In consultation with a commercial towing company, it was concluded that the best approach for dealing with the L’ACADIEN II’s steering failure and the risks facing the two vessels would be to hoist the stricken vessel clear of the water by crane and transport her clear of the ice. Risky in its own right, generally unaffordable by a small fishing or sealing enterprise, this technique was beyond the capabilities of the CCGS SIR WILLIAM ALEXANDER and her equipment.

The Commanding Officer and Chief Officer of the CCGS SIR WILLIAM ALEXANDER assessed the conditions at hand and the means available for bringing the L’ACADIEN II to open water at least, and if necessary to the nearest accessible port of repair⁵⁶. It was decided to rig a tow-line from the afterdeck⁵⁷ utilizing a 1½ inch diameter hawser of double-braided synthetic nylon construction similar to a Samson Braid. To restrict the movement and yaw of the towed vessel, seeking to keep it snug astern and to avoid wide movements and excessive contact with the ice, a bridle was utilized. Common practice and well described in a variety of references, the bridle is designed to impart corrective strain on the towed vessel, imparting a correcting movement as soon as a yaw is felt, thus keeping the towed vessel as near to the centre-line of the intended track as possible⁵⁸. The effectiveness of this technique was borne out again and again in a range of towing trials which were performed to aid this investigative report.

Because of the pack ice and concerns for ice under pressure to close in rapidly astern of the advancing CCGS SIR WILLIAM ALEXANDER⁵⁹, it was determined that the length of the tow should be the minimum possible while seeking to mitigate for excessive strain on the line, the possibility of the towed vessel overtaking and striking the CCGS SIR WILLIAM ALEXANDER and, perhaps most importantly, precluding vertical strain on the fairleads and bits on board the L’ACADIEN II, lest they be forced to work beyond their design specifications and fail catastrophically⁶⁰. A short tow was planned for and a tow length of approximately 27 m⁶¹ was chosen as the two vessels got underway and the tow settled in. After accounting for such factors as vertical separation, the bridle being partly used to take turns in securing it to the bits aboard L’ACADIEN II and the element of stretch in such line, a stern to bow distance between the two vessels was calculated to range between 22-25 m.

Though towing theory for Arctic operations favours a towed vessel being "snugged up" into what is described as a V-stern⁶², sometimes found in specialized towing vessels purpose-built for Arctic operations, the hull configuration of the CCGS SIR WILLIAM ALEXANDER precluded this approach. Given the two vessels in question and the equipment available, both the length of tow and the use of a bridle in the arrangement were appropriate to the circumstances. The size of the towing hawser itself was not ideal in that it was very nearly impossible that it would part under strain, given the light displacement of the towed vessel. While normally a positive attribute, this disinclination to part, along with the fact that no breakable links, tensionometer or manual quick-release mechanisms existed in the towing rig, meant that the singular means of parting the tow in extreme circumstances and under strain was the use of an axe on the afterdeck. While the towing arrangements themselves were satisfactory and in accordance with Coast Guard policies, this single point of control would become of paramount importance at a key point in the evolution.

Speed and Direction

A key factor in the conduct of the tow and the mitigation of the risks at play resided in the choice of speed for the transit. Recorded data from the CCGS SIR WILLIAM ALEXANDER’s navigation systems were available which delivered readings based on satellite-based Global Positioning System information⁶³. Records inform us of a range of speed, spanning from the commencement of the tow through to the accident, of 2.5 to a maximum of 4.1 knots (roughly 2.87 MPH/4.62 km/h through to 4.71 MPH/ 7.58 km/h). These speeds are from the raw data and are corroborated by and coincident with the observations and testimony of witnesses. It must also be noted that these satellite readings represent speed over the ground and not through the water⁶⁴. With an easterly current of 1 knot on average around the time of the incident, speed through the water, and relative to a stationary object such as ice, which is flowing with the current, was 1 knot less than indicated.

The speed recorded by CCGS SIR WILLIAM ALEXANDER at the time of the accident was 2.8 knots over ground (3.22 MPH / 5.18 km/h, and 1.8 knots through the water – a walking pace), decelerating in advance of the incident from the maximum of 4.1 knots somewhere in the minutes prior. There clearly followed a rapid and marked deceleration in speed, confirming the application of a powerful astern movement as reported. None of these speeds denote excessive or reckless conduct and were described by one subject matter expert as being reasonable and the minimum expected to make way through the ice conditions experienced that night.

Figure 15: Satellite Ice Imagery Off Cape Breton for 27 March 2008

In the case of the L’ACADIEN II, it is clear that the bridge team⁶⁵ of the CCGS SIR WILLIAM ALEXANDER, in particular the helmsman and the Commanding Officer who himself was at the throttles, worked to balance the speed required to make headway in the prevalent ice conditions with the finesse required by the risks of towing such a small vessel through ice. Even as the trio came across an open water lead where the absence of ice allowed a surge of 4.1 knots (7.59 km/h), the maximum speed attained during the 2½-hour passage, speed was reduced almost immediately to 3 knots (5.55 km/h) to allow the tow to settle into these new conditions, with concern given again to observing the potential movement of the towed vessel.

The courses selected through the night allowed the CCGS SIR WILLIAM ALEXANDER first to rendezvous with the MADELINOT WAR LORD, making an easterly heading and then one more south-easterly, all the while making for open water as depicted in the satellite information available to the Coast Guard, illustrated in Figure 15. The path immediately opened the distance from the lee shore and closed the distance to Sydney, the nearest port where CCGS SIR WILLIAM ALEXANDER could take L’ACADIEN II for repair.

Bridge Watch in CCGS SIR WILLIAM ALEXANDER and Actions of the Bridge Team

The bridge manning in CCGS SIR WILLIAM ALEXANDER on the night of 28/29 March consisted of three personnel: Commanding Officer, Watch Officer and Helmsman. This represents two deviations from the norm: first, in that the Commanding Officer is not normally on the bridge during normal night transits and, second, a second seaman is usually called for as lookout. It is clear that the complexities of the tow and risk at play in manoeuvring a towed vessel through ice called for the Commanding Officer’s experience and decisions explaining why he was on the bridge and kept the con⁶⁶ throughout the evolution. Additionally, it had been decided that the towing watch, normally a single seaman keeping watch on the stern of the ship, would be doubled in view of the conditions and the complexities of towing in ice. Given the dearth of traffic, the creeping speed and low risk of collision danger, the investigation considers this to have been a reasonable balancing and prioritization of limited personnel resources during the conduct of the tow.

Subsequent to the accident, it should be noted that the demands of responding to the capsize of the L’ACADIEN II completely consumed this small bridge team. The team was then required to raise alarms, handle the ship, communicate with authorities ashore, brief their personnel, launch the FRC, record events and plan for contingencies. They were operating at the full extent of their capabilities and according to priorities as they perceived them. An additional seaman would not have helped manage this load, as he would most likely have been immediately released from duties on the bridge anyway, the better to apply his seamanship skills to launching the FRC or working the boat hoist or crane.

VHF communications next became very active including calls from the MADELINOT WAR LORD advising of concerns as the collision with the ice was occurring, facts which were already known in the wheelhouse of the CCGS SIR WILLIAM ALEXANDER. Because the bridge team was actively engaged in manoeuvring the vessel and many other aspects of bridge management, and were sometimes unable to break in on the channel in response, the bridge team, including the Commanding Officer, undertook higher priority activities until they were able in due course to resume communications with the vessels in their vicinity.

Cause of the Sheer to Port

Apart from the decision to engage in the act of towing itself, the centre of interest for the investigation team lay in the cause of what appeared to be a sheer to port experienced by L’ACADIEN II. According to the eye-witness testimonies⁶⁷, this movement occurred once in open water and just prior to the L’ACADIEN II colliding with the single cake of rafted ice on the port quarter of CCGS SIR WILLIAM ALEXANDER. Indeed, without this movement to the quarter⁶⁸, and possibly beyond the wake astern and broad onto the quarter, the collision with the ice would likely not have occurred.

Speed of the tow has the potential to impart yaw on a towed vessel, as does an engine movement on the part of the vessel being towed. The former is addressed by the use of a bridle; the latter is simply avoided by good practice. There is also the possibility, albeit slim, that a smaller body of ice might have become caught up on the hull of L’ACADIEN II, changing the dynamics of how the vessel was moving through the water, and causing a movement to port. The description of comparatively open water at the time of the accident argues against this possibility and an addition to the trailing weight, or drag, would serve to mitigate against a sheer rather than increase it.

In considering the possibility of a sheer, thought was given to whether the ice cake with which L’ACADIEN II collided had in fact been sucked into the wake of the Coast Guard ship to cause contact directly astern as opposed to on an angle on the port quarter. The slow speed of the ships, some 2.8-3 knots (5.18-5.55 km/h) on approaching the particular ice cake, would provide very little suction effect along the hull of the CCGS SIR WILLIAM ALEXANDER. The hull form of an icebreaker is specifically designed to push ice away with the intent of leaving the path astern clear of ice, all the better to conduct escort work.

The size and weight of the ice, some 10 m across, sufficient to snag the L’ACADIEN II and remain comparatively stationary despite the pull of the icebreaker, similarly speaks to the unlikely effect of suction into the wake. Thus, it is illogical to surmise suction effect as the cause of the convergence. These factors, along with the majority of testimony from the eyewitnesses in L’ACADIEN II and the CCGS SIR WILLIAM ALEXANDER, confirm that the L’ACADIEN II moved into the path of the ice as opposed to the ice moving into the path of the fishing vessel.

Tremendous scrutiny was given to the fact that a sheer to port may have served as the means of allowing the L’ACADIEN II to strike an ice remnant that was passing clear down the port side of the icebreaker. The means by which the sealing vessel moved to port, sat steady on the port quarter for some moments, perhaps only seconds according to several accounts, and failed to react to the corrective influence of the port bridle provided a quandary in analysing the events.

Testimony confirmed that while ahead and astern movements were used in an effort to address tension or slack in the towing cable on several occasions, no active use of power was purposely applied in L’ACADIEN II in the moments prior to the accident, apart from a burst of full power when the collision with the ice was immediately imminent, in the hopes of smashing the ice and breaking through it. Conversely, a passive towed vessel, one generating zero speed from within, cannot have moved in the way observed to a position as far off the quarter of CCGS SIR WILLIAM ALEXANDER. The physics do not to allow for it. The scenario where ice may have caused the movement exists in the spectrum of possibilities, but represents an extremely unlikely possibility. Witnesses from all three vessels commented on the fact that the three ships had entered an open lead, with one survivor commenting that the only ice he saw at the time of the incident was the one L’ACADIEN II struck.

In seeking the cause of the sheer, six separate towing trials were conducted as described in Annex F. In five of those trials, a Coast Guard vessel of dimensions equivalent to the CCGS SIR WILLIAM ALEXANDER served as the towing vessel. In one trial conducted in Arctic summer ice, a larger platform than the CCGS SIR WILLIAM ALEXANDER was employed. The towed vessels included a 47’ (14.3 m) rescue cutter, a 42’ (12.8 m) cutter, a sister ship to the L’ACADIEN II and, finally, an unmanned utility barge⁶⁹ used to safely demonstrate ice collisions.

The first trial was inconclusive as it was not possible to recreate the sheering due to a dissimilar hull form, size and rudder arrangement⁷⁰. The second trial, which towed a vessel of similar dimensions, confirmed the value of the bridle in dampening any yaw and demonstrated that the only means of replicating a sheer to port, sufficient to achieve a position where collision with ice such as occurred was possible, included engine power on the part of the towed vessel. Even minimum idle speed proved sufficient to initiate the movement to port, the key point being the differential between the speeds, however minor, of the towing and the towed vessel. Also important was the element of sustained momentum, achievable only with engine power of the towed vessel, where trials of unpowered towed vessel always demonstrated the useful effect of the bridle and an inclination to stay in a position astern after use of helm or external forces.

In the two early trials, rudder alone was unable to impart the necessary movements, giving pause to consider if the large blade of the L’ACADIEN II’s rudder might have been sufficient to impart the manoeuvre on its own. With this lingering question, a third trial with a sister ship, a vessel as near in shape, dimension and construction as was possible to find, was arranged and conducted. Here again, with no engine power and the rudder amidships, the bridle acted as per the theory, holding the towed vessel in a relatively position aligned astern. Subsequent application of the rudder, even full helm, caused only slight and momentary deviation from the centre-line, the effects of the bridle serving to overcome the motion imparted by the blade of the rudder. Use of engine alone, even idle speed, served as the only means whereby a yaw to port of sufficient degree and duration was replicated. With greater engine power, this yaw became a sheer.

The barge towed in ice did not contribute in a measurable way to a better understanding of the physics of the accident and was limited by the inability to replicate with any precision the size and mass of the ice floe of the night of the accident. From an investigatory re-creation perspective, the effort succeeded in demonstrating the wide variability of factors which ice can deliver. However, the main value in conducting the trial lay in delivering footage of the impact of ice collisions of a small vessel while under tow by large one. That the context for this last trial included manipulations and manoeuvres which were unrealistic as compared to the actual accident cannot be overstated, and in turn again speak to the forces required to produce the collision.

The fifth and sixth trial sought to replicate the observations of the previous trials and to collect a wider range of footage to illustrate the observations. In one case, as towed vessel of only 10 tons was utilized illustrating the different characteristics of such a light craft.

The conclusion to be gleaned from the range of trials suggests that it was impossible for a towed vessel to reach the position in question through passive means alone. In no trial was it possible to achieve the position of L'ACADIEN II reported by the wheelhouse survivor or by the witnesses in CCGS SIR WILLIAM ALEXANDER. It appeared that power of some sort was the required, key element.

In considering this, and accepting at face value the testimonies confirming that no active engagement of engine power was put into play on L’ACADIEN II, the potential for clutch slippage or an inadvertent shift to idle, serve as possible explanations for the manoeuvre observed. Alternatively, a notable jostling of L’ACADIEN II by a smaller block of ice, witnessed by one observer in the MADELINOT WAR LORD, may have caused inadvertent engagement of the throttle, the drive linkages or caused some other mechanical impetus to the engine which was not recognized by those in the wheelhouse of L’ACADIEN II. Whatever the source of power, unconfirmed as it is, it remains that multiple attempts in four trials demonstrate that only engine power could replicate the movements of the L’ACADIEN II on the morning of 29 March just prior to the collision with the ice which caused the capsize.

In sum, the reason for the sheer cannot be absolutely known. What is clear is that the CCGS SIR WILLIAM ALEXANDER lost control of the tow at a critical moment, whatever the reason, allowing the L’ACADIEN II to come into contact with a dangerous ice cake.

Use of Engines by L’ACADIEN II Upon Colliding with Ice

When first sighted by the wheelhouse crew of the L’ACADIEN II, off the port side of the CCGS SIR WILLIAM ALEXANDER in the darkness of the midnight watch, it appeared as if the ice cake would pass clear without incident. It was moments later that the risk of collision was apparent, indeed imminent. As reported by the wheelhouse witness in L’ACADIEN II, a full application of ahead engine power was applied through the throttles in the very instant before the collision with the ice. Having seen the ice mass and having concern for its size, clear potential for parting the tow, or worse, became immediately evident.

Unable to steer to starboard because of the steering’s mechanical failure and deciding that steering to port would only exacerbate the situation, a decision on ahead or astern motion had to be made. In an instant, it was determined that a full ahead motion would be used in an effort to shatter the ice and break through so that the tow could be continued. This clearly did not result as intended.

With perfect hindsight, an astern movement might have been a better choice, though it is uncertain if even such a major application of astern power would have changed events significantly, applied at this juncture. What is clear is that the ahead movement did not in itself cause the collision with the ice, which was imminent and inevitable at the point of decision, nor did it contribute in any measurable way to the method in which tension was subsequently applied on the tow-line, resulting in the capsize. To clarify, this ahead movement was neither effective in avoiding or minimizing the collision, nor did it contribute to the final capsize motion of the L’ACADIEN II.

The Collision with Ice

The specific physical forces at play during the moments from the collision with the ice through to the capsize of the L’ACADIEN II were considered important in understanding the accident and for the potential of lessons learned. The issues of physical forces, stability and vessel construction required such significant analysis that the services of a naval architect, were retained to deliver a full analytical report. The calculations had to take account of a range of possibilities given that witness testimonies differed about the L’ACADIEN II’s contact with the ice cake and the subsequent girding⁷¹ action and capsize. The analysis considered a range of plausible scenarios as recounted by the witnesses, including the variables of the location of the L’ACADIEN II relative to the icebreaker’s stern, the angle of the tow-line off the bow of the L’ACADIEN II, and the degree to which the sealing vessel’s hull was immersed in water or riding on the ice.

The analysis first confirmed that the 3.8 cm (1.5”) diameter tow-line was exceedingly robust for the towing arrangement and the size of vessel being towed and would never have acted as the point of failure for the tow. This meant that even under the maximum strain which might be experienced during the towing operation, it would not be the tow-line which failed or parted. It would not serve as the weakest link. Second, the analysis concluded that the ice was the crucial factor in causing the capsize and that the bridle arrangement in open water, in concert with the inherent stability of the L’ACADIEN II, would not be the cause of a girding action.

In calculating the range of possibilities at play that night, the angle of the tow-line, the degree of emersion imposed by the ice, and even the angle of contact on the ice, were considered. It was assessed that once the L’ACADIEN II was restrained by the ice and tension on the tow-line increased, stability was compromised and the angle of pull shifted from ahead of the L’ACADIEN II to the diagonal or even the perpendicular. It was similarly concluded that, with the forces involved given a constant towing speed of 2.8 knots over the ground (5.18 km/h), the period of time from contact to capsize would range from 1 second to 18 seconds, depending on the scenario, with the scenarios described by the majority of witnesses pointing to a 1 to 7 second time-span from contact to capsize. This represents the window available for realizing, deciding and acting to avoid a disaster.

Location and Actions of the Towing Watch

As the tow of the L’ACADIEN II commenced, it was determined that the environmental conditions, the duration of the tow, the risks and complexities of the evolution combined to require an augmented towing watch of two seamen as opposed to the normal single lookout/sentry on the afterdeck. This conclusion had been arrived at by the Chief Officer and the Bos’n, and had been briefed to the Commanding Officer. The two-man watch was set as the tow settled in shortly after 23:00 on the night of 28/29 March.

The two seamen were briefed on what to expect during their watch, advised of the communications protocols and the VHF working frequency to be utilized (VHF Ch19) and directed to cut the tow without further direction from the bridge should the need arise to address any problems with the tow. The two, with a VHF handheld radio and an axe placed at the towing fairlead, took up their vigil and kept watch on the tow. Some moments of concern occurred early in the tow as the L’ACADIEN II was pulled by the tension of the tow-line in the sliver of clear water close astern of CCGS SIR WILLIAM ALEXANDER. On at least one occasion, a close call and a near decision to use the axe because of tow-line tension was not reported to the bridge. In hindsight, it is clear that it should have been, the omission was the result of a reticence to engage the bridge on the part of the seamen and, in part, an inaccurate assumption that the situation was both visible and known by the bridge personnel⁷².

As time went on, occasional slams against the ice border occurred and at times the tow-line seemed to be under some severe strain, but on the whole the evolution proceeded without incident. At 00:30, the oncoming watch was awakened, making their way aft for their handover at about 00:50. They were advised of the condition of the tow, the communications arrangements and the occasional anxious moments during the past two hours. Noting the glare of the three fixed floodlights illuminating the waters directly astern, the oncoming watch switched off the series of small overhead lights above the towing area, the better to see into the darkness abeam and ahead. They verified the placement of the axe alongside of the towing fairlead and checked the battery charge on the radio, calling to advise the bridge of the change of the watch⁷³. It should be noted that one point was missed with one of the oncoming seamen who was not or does not recall being advised of the directive to cut the towline if necessary should a problem arise. This omission was inconsequential however, as in testimony this experienced seaman felt it was simply common sense to cut the line should the situation demand — that is what he was there for⁷⁴. This raises the question of whether ‘common sense’ is sufficient as compared to formal procedures and acknowledged roles.

Left on their own, the pair of seamen spent the initial portion of the watch on the starboard side of the tow-line storage drum. One seaman eventually moved to a position to port of the towing fairlead, just forward of the centre-line floodlight looking aft. The second seaman moved from one side to the other, generally forward of the towing drum, so as not to straddle the towline on the occasions that it was under strain. He was on the starboard side as the L’ACADIEN II seemed to sheer to port just prior to the accident⁷⁵.

The aft seaman moved towards the port quarter of the afterdeck as the L’ACADIEN II sheered to a position on the quarter of the CCGS SIR WILLIAM ALEXANDER, noting a large mass of ice coming out of the darkness just seconds before L’ACADIEN II collided with it. With strain coming on the tow-line and bridle, a reflex concern over the line parting determined that he would warn the bridge of how the L’ACADIEN II was being dragged sideways so that speed would be taken off prior to the situation worsening. Turning back after the radio call, seconds later, and seeing that the sealing vessel was falling off the ice and rolling over, he grabbed the axe and cut the line with a single stroke. Looking back again, he saw that L’ACADIEN II had capsized.

Ship Details

Official Number: 607685
Vessel Type: High Endurance Multitasked Vessel - Light Icebreaker
Port of Registry: Ottawa
Region: Maritimes
Home Port: Dartmouth, NS, Canada

Complement

Officers: 12
Crew: 15
Total: 27
Crewing Regime: Lay Day
Available Berths: 9

Physical Dimensions and Statistics

Length: 83 m
Draft: 5.75 m
Hold 1: 840 m3
Hold 2: 0 m3
Main Deck Area: 210 m2
Forcastle: 78 m2
Gross Tonnage: 3727.17 grt
Cruising Speed: 13.7 kts
Cruising Range: 6500 nm
Fuel Consumption: 6.5 m3
Fresh Water: 112.3 m3

Breadth: 16.2 m
Freeboard: 1.7 m
Hatch Size 1 (l x w): 5.5 m X 5 m
Hatch Size 2 (l x w):
Boat Deck Area: 168 m2
Afterdeck Area: 133 m2
Net Tonnage: 1534.61 nrt
Max. Speed: 16 kts
Endurance: 120 days
Fuel Capacity: 784 m3

Figure 16: Stern view of CCGS SIR WILLIAM ALEXANDER and diagram of after towing deck

It is clear through documentation, the radio check-ins and by the level of detail in the testimony of the seamen, that the pair of two-man watches were appointed, on deck and observant of the situation leading up to and at the time of the incident. It is equally clear that they were not always visible to the wheelhouse crew of the L’ACADIEN II or MADELINOT WAR LORD through the duration of the tow.

A possible reason the oncoming watch may not have been visible may be related to the fact that the overhead lights were turned off as they assumed the watch, though both observed the glare from the MADELINOT WAR LORD’s working lights shining up at them. More likely, their location on the aft towing deck may well have shielded them from view, with one seaman predominantly located by the storage drum forward and the second, when at the stern-rail, standing just forward of the centre-line flood-light, essentially within the strong bright glare of the light.

Figure 17: View of CCGS SIR WILLIAM ALEXANDER from approximately 25m astern, depicting the three fixed floodlights and deckhead lighting

Utilization of Lights

In the urgent moments immediately following the capsize of the L’ACADIEN II, witnesses in MADELINOT WAR LORD perceived that the spot-lights on CCGS SIR WILLIAM ALEXANDER were turned off, just as the MADELINOT WAR LORD was attempting her approach on the overturned L’ACADIEN II to rescue survivors.

It was in fact the three floodlights aft, with fixed projection astern that were illuminating the tow, not the search light arranged atop the helicopter hangar (that was actually never used that night) nor the ones that are fitted on top of the wheelhouse that can only be pointed forward of the vessel.

As the L’ACADIEN II was seen to bear down on the ice cake and the accident was about to occur, full power astern was put on the engine throttles by the Commanding Officer, causing the stern of the CCGS SIR WILLIAM ALEXANDER to swing to port. This caused the effects of the three flood-lights to dim as their fixed beam swung about. As the swing progressed, the flood-lights would appear to go out, apparently with timing to suggest that the MADELINOT WAR LORD was just on the verge of arriving atop the hull to effect rescue.

MADELINOT WAR LORD herself had powerful working lights mounted fairly high in her rigging, in effect providing illumination on at least a portion of the scene, enabling CCGS SIR WILLIAM ALEXANDER in turn to approach the site of the capsize.

The Decision to Cut the Hull

One of the more demanding and stressful decisions made in the early hours of 29 March concerned the option of cutting into the hull of the L’ACADIEN II in the hopes of reaching potential survivors. It must be understood that the salvage equipment on board CCGS SIR WILLIAM ALEXANDER was limited⁷⁶. Though the hull of the capsized vessel was reasonably well secured by strops and lines, the hold was tenuous and the list felt by the CCGS SIR WILLIAM ALEXANDER as a result of the weight only confirmed the risks at hand.

The rescue manuals all recommend against cutting into an overturned hull, lest the stricken vessel be lost with survivors trapped inside, or crewmembers become caught in the cabling and dragged to their deaths in what might become a sinking hulk. Although the Commanding Officer was not concerned about capsizing the CCGS SIR WILLIAM ALEXANDER, there was a real risk of damage to the crane and cabling as well as potential injury to his crew. These factors weighed on the Commanding Officer as he consulted with Coast Guard management ashore about cutting into the hull.

Figure 18: Bringing the circular saw into action

These risks were considered on balance with reports of knocking from inside the hull of L’ACADIEN II and vocal insistence from MADELINOT WAR LORD to take the risk while time still permitted possible success in helping a trapped crewmember. The potential option of diving to effect rescue represented the best scenario available at that juncture, but time was running out. The potential of the arrival of divers, a less risky approach to rescue, first convinced the Commanding Officer of CCGS SIR WILLIAM ALEXANDER to put off any attempt at cutting the hull, lest he lose the people he was hoping to save. But reports of a delay to their arrival77 and acknowledgement that the energies of any trapped crewmembers would be waning convinced him to engage in what can only be described as a desperate effort to rescue any trapped crewmembers.

Unfortunately, the attempt proved futile, as no crewmembers in fact had made their way to the engine compartment, the only space crewmembers of L’ACADIEN II could have reached from within the accommodation compartment which in turn could be reached by piercing the accessible section of the overturned hull.

The Decision to Dive and to Complete Dive Operations

Subsequent to the attempt at piercing the hull, the first of two dive teams to arrive onboard the CCGS SIR WILLIAM ALEXANDER by CORMORANT helicopter were hoisted down to the deck. The dive supervisor quickly took in the scenario, being made aware of many issues at the scene which augmented the information received before take-off and en route.

Key to the dive supervisor’s assessment were indications that rescuers had heard knocking from within the hull. Determining that the potential for survivors still existed, a decision was made to bring in the second dive team and undertake a full rescue effort. At great personal risk, two SAR Techs from CFB GREENWOOD joined the rescue effort by parachuting from their HERCULES aircraft directly onto the ice. The second dive supervisor confirmed the factors at play and supported the decision to dive. What is pertinent in this choice is the clear SAR policy that dangerous operations such as the penetration dive that was required in this scenario are only authorized in search of the living, not in an effort to recover the deceased. In this case, though the interval since the victims had become immersed in water suggested that chances of survival were slim, the report of knocking on the hull provided sufficient faint hope to justify the dive.

The level of risk taken by the dive team through four consecutive dives cannot be overstated. The possibility of entanglement or entrapment was significant. All suffered some degree of hypothermia in the ice covered waters. Their thin synthetic suits provided little thermal protection in these extreme conditions. The decision to cease diving operations was founded on the impact of the physical effects of the hypothermia, the augmented risks such physical debilitation now represented to the team, and the assessment that, having recovered three of the four missing crewmembers, the search effort could no longer presume the missing crewmember to be alive. Rather than continue to push the dive team against serious and elevating risk, it was decided to complete dive operations at the end of the fourth dive.

The Decision to Depart the Scene

Issues related to the potential salvage of the L’ACADIEN II had been referred to management ashore, as the case had now passed from the realm of Search and Rescue, both within the offices of the JRCC and in the context of the operations of the CCGS SIR WILLIAM ALEXANDER. Other cases and priorities in the region were putting demands on the limited sea-going units available.

From the perspective of the CCGS SIR WILLIAM ALEXANDER, three issues served to determine the course of action decided upon: maintaining the hull afloat with strops in fact presented risks to the ship and could not be sustained indefinitely; it was clear that she couldn’t salvage the vessel; and, the need to deliver the fatalities ashore to the appropriate authorities in a timely manner began to elevate in importance and priority.

After a series of deliberations with JRCC and Coast Guard management ashore, the CCGS SIR WILLIAM ALEXANDER was released from the active SAR cases of L’ACADIEN II and the MADELINOT WAR LORD. Thus, the departure of the CCGS SIR WILLIAM ALEXANDER for Sydney Harbour does not represent a decision to abandon the stricken hull, but represents the priority of transporting the lost sealers expeditiously and with dignity⁷⁸. The attempt to leave a marker beacon on-scene demonstrated the desire and the intent to track the hull.

Instructions for deploying the buoy were received from JRCC, who advised the CCGS SIR WILLIAM ALEXANDER to place the buoy on the ice. The intent was to have the buoy close to the L’ACADIEN II and preclude the buoy from being crushed if it was left afloat. The instructions were taken literally and the buoy was activated manually and then put on the ice beside the L’ACADIEN II. Because the buoy battery requires salt water activation, placing it on the ice did not activate the electronics and start generating the signal. Whether the buoy was damaged before it later fell into the water, or if the buoy was defective, is unknown. The signal on these particular buoys is not receivable in the CCGS SIR WILIAM ALEXANDER, so the crew never realized the signal had not been activated until informed much later.

 

46 As described in interviews with a number of JRCC personnel, there was a great volume of information but it lacked clarity and precision. Tapping into a range of sources, the JRCC Watches were putting together a puzzle. A key element was the weather forecast describing the potential of a gale and the sense that this might have significant consequences for the vessels trapped in the ice. This made the presence of a primary SAR asset an imperative for the JRCC staff, resulting in the dispatch of CCGS SIR WILLIAM ALEXANDER from Sydney Harbour.
47 Electronic transcripts describe a pair of conversations between the JRCC and the CCGS SIR WILLIAM ALEXANDER. Each concludes with an understanding of the need to tow the L’ACADIEN II.
48 Literally, not master of his movements, or RAM in a legal sense.
49 Though seemingly semantics, the terms and definitions mattered, particularly while shore agencies were still attempting to develop a complete understanding of what was taking place on the ice. The request for a tow would have highlighted the damage to the L’ACADIEN II, thus likely giving rise to a non-distress SAR incident, which is in fact what the L’ACADIEN II case eventually became. The response to a request for escort was not within the JRCC’s area of responsibility, but was instead referred to the Dartmouth Ice Office where the case fell into a completely different set of priorities, at least until a better understanding of L’ACADIEN II’s circumstances emerged.
50 This perspective was held by JRCC, the staff of Sydney Coast Guard Radio and the Commanding Officer of the CCGS SIR WILLIAM ALEXANDER. The unanimous impression was that there were enough vessels in trouble and requesting the assistance of another undamaged sealer would only increase the level of risk.
51 In essence, the time to contact, hire and deliver a tug to the scene, if one was available, was beyond the time available with the current weather forecast. It was assessed that commercial assets would arrive too late.
52 In describing the decision to tow, the Commanding Officer of CCGS SIR WILLIAM ALEXANDER referenced the instructions he had taken from JRCC, the reticence he had with regards to the tow and the risks it represented. Previous experience towing in ice gave him the sense that he could mitigate the risks, bringing him to conclude that a tow could be undertaken.
53 The L’ACADIEN II and the crew of the sealer were not in immediate danger. There was no imminent danger to demand the abandonment of the vessel. The potential for successfully towing the sealer free of the ice seemed to argue against the need. The issue of minimum manning or an unmanned tow was never discussed during the radio conversations between the two vessels. Neither the Commanding Officer of CCGS SIR WILLIAM ALEXANDER nor the master of the L’ACADIEN II raised the issue.
54 Department of Fisheries and Oceans/Canadian Coast Guard Towing Policy and Procedures
55 The survivors spoke of their own sense of relief with the arrival of the “red hull”, the Coast Guard icebreaker. As well, they described the master of the L’ACADIEN II as being relieved at its arrival.
56 In accordance with Coast Guard policy, a disabled vessel such as L’ACADIEN II could not be guaranteed a return transit to home port. In the situation of 28 March, CCGS SIR WILLIAM ALEXANDER was assigned as the primary SAR asset to the east side of Nova Scotia, precluding movement to the Gulf of St. Lawrence or to Newfoundland waters.
57 Refer to the diagram at Figure 16.
58 A witness from L’ACADIEN II described the yaw through the early part of the towing evolution as being in the order of 3 meters either side of a line directly astern of the CCGS SIR WILLIAM ALEXANDER, no more.
59 Ice under pressure, whether caused by wind or current, will generally seek to close in over any open water.
60 Reference to the image at Figure 10 is useful. The fairleads and bits are designed for horizontal forces and have limited strength when subjected to vertical or upward pull. When taken beyond their design strength, they can fail catastrophically and be torn from the hull, presenting extreme danger to anyone in the vicinity or in line with the movement.
61 Measured by comparing the figures of the towing gear certificate provided by the manufacturer with the line remaining after the towing hawser was cut at the scene of the accident.
62 The V-stern is a unique design specifically for towing in the conditions of Arctic ice. The after end of the tug or towing ship has a V-notch constructed into the stern. The towed vessel is secured tight, or ‘snugged up’, with the towed bow sitting right inside the V essentially forming a single vessel. Ice pressure is mitigated and the two vessels move as one.
63 A pair of navigation systems on board CCGS SIR WILLIAM ALEXANDER utilized satellite positioning and an automated recording function. Ship’s position and movements were derived from this data.
64 Satellite positioning indicates a location relative to a fixed geographic grid, this position and speed is “over the ground”.
65 The bridge of the CCGS SIR WILLIAM ALEXANDER was manned by the Commanding Officer, Officer of the Watch and one seaman who acted as both helmsman and lookout.
66 While a Commanding Officer always retains command, control of the ships movements, or the con, is regularly delegated to a qualified Officer of the Watch. Difficult or demanding evolutions such as coming alongside, transiting narrow passages or demanding seamanship manoeuvres, will often see the Commanding officer take the con. Such was the case when towing the L’ACADIEN II.
67 All but one of the eyewitnesses observing from all three vessels involved, spoke about to some form of movement by the L’ACADIEN II from a position directly astern to a position astern to port or off the port quarter. The rapidity of the movement, the actual final placement astern and to port, and the duration of time which passed before the collision with the ice occurred varied to some degree, but the investigation found a degree of consistency which required further effort to understand. The decision to complete a range of trials to replicate the described motion was the result.
68


69 Similar to a small landing craft.
70 Though the lessons gleaned from the trial were useful, the different size, weight and hull form, as compared to L’ACADIEN II, left questions about the validity of what had been replicated.
71 GIRDING – A danger of capsize resulting from the disparate size of two connected vessels, normally a scenario with a small tug and a large towed vessel such as a tanker or bulk carrier. This is especially dangerous when a tug is towing on the beam and lack of awareness or judgement in such circumstances may manoeuvre the tug into a helpless position with danger of capsizing. The danger of girding arises when the smaller vessel is towed broadside by the tow rope and is unable to manoeuvre out of this position. The forces at play are immense and the resultant movements quick. Once girded, a vessel can capsize so quickly that crew members do not have the time to operate a tow-abort control, if present, or use the available life-saving equipment.
72 According to the seamen on watch, the situation aft did not warrant contacting the bridge. There was a sense that visibility from the bridge windows and outer wings was sufficient to observe the state of the tow.
73 The radio call from the after watch to the bridge was received, acknowledged and logged.
74 During an interview, this seaman was adamant that no guidance regarding the line was given. He said that he had been part of many towing evolutions and that this was just common sense, that he didn’t need the bridge to direct him to act in a safety situation.
75 Both seamen on watch commented on their perception that the L’ACADIEN II was overtaking the icebreaker, putting slack in the tow-line and bridle as the sealing vessel moved to port fairly rapidly. Both menperceived the L’ACADIEN II to be broad on the quarter, perhaps 45-60 degrees off the centre-line, when the collision with the ice cake occurred.
76 The Coast Guard has no mandate for salvage, an activity generally referred to commercial enterprises. Though every Coast Guard ship has damage control equipment, this is for self-preservation and fire and flood emergencies. No inflatable float bags were available and the lack of salvage equipment and expertise, suggested cutting into the hull was to be avoided.
77 JRCC advised that a failure in communications equipment had delayed the launch of the SAR Techs from CFB GREENWOOD.
78 Jurisdiction over the victims fell under the authority of the Nova Scotia Medical Examiner, whose agents, the RCMP, expressed the desire to move into that stage of their investigation. The families of the victims were also inquiring as to the expected delivery of the bodies to the Magdalen Islands so as to make funeral arrangements.

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