5.2 Assessing Systemic Factors

A number of issues which contributed to events on the night of 28/29 March are worthy of discussion and fall into the category of organizational or systemic factors. None can be described as causal in any direct sense, but addressing any or each of these topics can certainly be viewed as potentially preventative. The issues have the potential of touching on a number of Coast Guard jurisdictions and perhaps those of organizations outside of the Coast Guard, Department of Fisheries and Oceans or Transport Canada. All are considered worthy of consideration and liaison with Departmental partners.

Of note, in exploring the Canadian regulations related to construction of vessels for operating in ice, only those engaged in the seal hunt were found to have, at least until 1993, defined regulatory standards. None were found to exist for general or commercial vessels working in ice, either occasionally or with consistency, such as ferries, tugs and the like.

Regulations governing the construction and inspection of vessels used in the Seal Hunt

Two aspects of regulation are applicable to the circumstances around the L’ACADIEN II tragedy and this year’s seal hunt as a whole; the validity of the rule-set which is in place and the effectiveness of the inspection regime in ensuring compliance. Neither issue resides within the authority of the Coast Guard, though clearly, Coast Guard assets and resources are the ones to respond, and their resources expended, whenever the limitations of the rule-set and inspection regime allow things to go wrong.

This year’s Gulf of St. Lawrence hunt was clearly disappointing, as viewed on the whole by sealers themselves, let alone the JRCC and seagoing Coast Guard community. It is worth considering if the small sealers such as L’ACADIEN II, MADELINOT WAR LORD and others found on the list of JRCC listing of SAR cases that weekend should ever have been allowed to engage in the hunt with ice conditions as bad as what was at hand, only to dash themselves onto the ice and risk expensive damage or worse. Alternatively, if permitted to hunt in the conditions experienced this year, then the level of support to their efforts must be augmented. Whether the statistics regarding the rate of inspections of sealing vessels bound for the ice can illuminate a possible trend regarding damage rates is uncertain. It is clear that the issue of the size and construction of vessels was pertinent and must be revisited.

Sealing Ship Construction Regulations

These regulations came into force in November 1954 and covered the construction and inspection of ships engaged in sealing. They were revoked in 1993 after Transport Canada concluded that they were obsolete. The Regulatory Impact Analysis Statement mentioned that legislation changes had made the regulations unnecessary given that the requirements were already covered by administrative policy or by other regulations and that technological developments had made them obsolete.

They specified special requirements for hull thickness reinforcements to resist damage from ice pressure and ice abrasion for wooden ships and required that steel ships be built in accordance with recognized classification society rules applicable to vessels navigating in ice. Furthermore, they specified the requirement for rudder and stern frame reinforcement, an increase to shaft and propeller diameter and special provision for cooling water system inlet and overboard discharge valves. Finally, the vessels were required to be dry docked every year for inspection.

Small Fishing Vessel Inspection Regulations

The seal hunt is considered a commercial fishing activity, therefore the vessels used for the hunt are now subject to the Canada Shipping Act Small Fishing Vessel Inspection Regulations. These regulations contain no provision for addressing the risk of ice damage posed to vessels that may operate in ice-covered waters, such as during the seal hunt. The majority of the fishing vessels involved in the hunt are constructed of wood, fibreglass or a combination of both. Some, a minority, are made of steel or aluminium. Typically, their hulls, shafts, propellers, and rudders are not strengthened or reinforced for navigation in pack ice, having been built for open-water fishing and outfitted temporarily for participation in the hunt. Pertinent to this discussion is a passage from the TSB Report on the sinking of the JUSTIN M on 29 March 2005:

A seaworthy vessel is fit for navigation on the sea or a navigable waterway. A vessel must not be put out to sea unless she is seaworthy. After a vessel is inspected by a maritime authority, a certificate is issued to certify that the vessel meets the applicable standards for construction and safety and is seaworthy. The vessel must be appropriately built, equipped and crewed for the task intended.

Transport Canada Ship Safety is aware that fishing vessels at Îles de la Madeleine are used in winter seal hunting in ice-infested waters. Fishing vessels that are used for fishing are not designed or strengthened for navigation in ice-infested waters. The practice is apparently tolerated by Transport Canada Ship Safety.

Of note, the hull of L’ACADIEN II was strengthened for ice. The robustness of her rudder appears simply to have been inadequate for the conditions in which she found herself operating⁷⁹.

2007-2008 Statistics

The winter of 2007/08 recorded 43 SAR cases which had been opened for vessels involved in the seal hunt out of which 4 were lost and one abandoned. It is worth noting the caveat that not all damage scenarios are reported in the SAR system.

The TSB investigation report on the sinking of the JUSTIN M reports that:

Between 1990 and 2005, during the months of March, April, and May—some 48 months of sealing activity—227 occurrences involving fishing vessels operating in ice-covered water were reported through CCG radio stations. The majority of these involved hull damage, with a total of 21 vessels lost, although there was no loss of life. The investigation also revealed that many more incidents are not reported.

Department of Fisheries and Oceans Monitoring

The seal hunt is closely monitored and tightly regulated. The mandate of Fisheries Officers deployed to the ice is to monitor sealing activity, ensure humane harvesting practices and enforce regulations and licence conditions. They conduct surveillance of the seal hunt by means of aerial patrols, at-sea patrols, dockside inspections of vessels at landing sites and inspections at the point of purchase and processing facilities. The Department of Fisheries and Oceans also regulates the number of sealing licences, allocates quotas, limits the size of vessels that can participate and specifies the opening and closing dates of the annual seal hunt. The location of the seal herd is determined by a combination of the over flights and Advanced Research and Global Observation Satellite (ARGOS) buoys deployed by the science sector of the Department of Fisheries and Oceans. The information is provided to the Fisheries and Aquaculture Management offices for the purposes of resource allocation, conservation and protection, and in turn is communicated to sealers and holders of observation licenses upon request, to various levels of detail and precision depending upon the need.

Canadian Coast Guard Support to the Seal Hunt

The Coast Guard is charged with supporting legal seagoing commerce of all types, including the fishery and the seal hunt. As an organization, it exists essentially to ensure the safe use of Canadian waterways, and to facilitate and support the smooth functioning of the Canadian ocean-going economy. This responsibility resides within a spectrum of goals and missions which include sovereignty, SAR, research and aids to navigation maintenance, amongst several others. The availability of resources and the demands of sometimes shifting priorities determine the type and duration of effort applied to each endeavour.

In considering the issue of Coast Guard support, particularly as it applies to the seal hunt, it is pertinent to express the frustrations on the part of a number of stakeholder witnesses. For part of this community at least, expectations of service appear not to have been met in recent years. Of concern has been consistency and duration of Coast Guard vessel presence, information sharing, as well as actual levels of assistance for ice escort. It appears that inadequate communications, at least as described by the small sampling of sealers from the Magdalen Islands engaged during this investigation, have some sealers wondering why they are being moved in one direction and not another, let alone why they don’t know where the heart of the seal heard may be. In essence, this points to the question of whether the Coast Guard and the Department of Fisheries and Oceans exists, at least in part, to aid and abet the hunt or not.

Icebreaking

The Atlantic winter weather can bring harsh challenges for ships navigating on the east coast of Canada. Two metre thick ice and six metre high ridges are common off the north-east coast of Newfoundland and in the Gulf of St. Lawrence. Canadian Coast Guard icebreakers provide services to a variety of vessels in Canadian waters, including the Gulf of St. Lawrence. To reduce risks, icebreakers escort ships and organize convoys through ice-infested waters; they free trapped vessels, maintain shipping channels in fast ice and stand by in areas where requests for route assistance are likely. During the ice season, the Coast Guard icebreakers provide secondary support to other Department of Fisheries and Oceans/Canadian Coast Guard programs, namely;

• search and rescue coverage in ice covered waters and response to marine emergencies;
• provision of Marine Navigation Services in ice-covered waters, i.e. repositioning winter spar buoys to mark channels; and
• support to the Science and the Conservation and Protection Programs.

The Canadian Coast Guard receives numerous requests for assistance from vessels during the seal harvest. The icebreaking program priorities are detailed below as dictated by policy and must be considered in an operational context when delivering the service;

• all distress and emergency situations take precedence;
• service requests from ferry services provided in accordance with the Terms of Confederation/Union will be given priority; other ferry services will receive priority as deemed appropriate by the Canadian Coast Guard;
• ships with vulnerable cargoes (i.e. pollution potential of cargo, dangerous goods, perishable) and vessels transporting cargo which is vital to the survival of communities; and
• marine traffic and fishing vessels.

Canadian Coast Guard vessels assigned to a fisheries role will regularly help vessels manoeuvre out of ice fields so as to approach the herd, with other vessels sometimes using the resultant open track in the ice for easier passage. Like any other Canadian Coast Guard vessel, they are also available for response to SAR when called. In respect to the 2008 Gulf of St-Lawrence Seal Hunt, the Canadian Coast Guard had assigned a dedicated vessel, the CCGS DES GROSEILLIERS, to support Fishery Officers in the enforcement role, requiring them to be near the seal herd to monitor sealing activities.

SAR Vessels

Primary SAR vessels are a specially designed, equipped and crewed platform that has SAR as its main responsibility. These vessels are stationed in areas that have a high risk of SAR incidents. Multi-tasked SAR vessels are other Canadian Coast Guard vessels that are tasked to deliver the SAR Program and at least one other operational program. They have to remain within a specific SAR area while they are multi-tasked to the SAR Program and maintain all SAR operational standards. Multi-tasked vessels increase efficiency and, to some degree, reduce operating costs.

On 28 March, Canadian Coast Guard resources in the Gulf of St-Lawrence area were as follows:

• Two SAR Lifeboats on the south coast of Newfoundland and one on the east coast of Cape Breton;
• Three multi-tasked High Endurance Vessels - two on SAR and Ice Operations (CCGS SIR WILLIAM ALEXANDER and CCGS GEORGE R. PEARKES) and one assigned exclusively to ice operations (CCGS EDWARD CORNWALLIS);
• One Medium Icebreaker (CCGS DES GROSEILLIERS) on Conservation and Protection (Seal Hunt) and SAR; and
• One Heavy Icebreaker (CCGS LOUIS S. ST-LAURENT) on SAR and Ice Operations.

Rescue Centres

The JRCCs/MRSCs are responsible for the planning, co-ordination, conduct and control of SAR operations. JRCCs/MRSCs have highly trained staff, detailed operational plans and an effective technical communications network. Once a JRCC/MRSC is notified that a person(s) is in danger, the SAR Coordinator begins to organize the rescue. All available information about the person(s) in danger is gathered and recorded and the positions of potential assisting resources in the area of the incident are determined. SAR Coordinators are trained to evaluate various situations and send the most effective resources to deal with a particular incident. In complex and major incidents, many resources are often tasked or diverted to assist, with priority given to saving life and limb.

The degree of urgency, the type of emergency, the availability of resources and the location of the incident are all key elements that determine the type of response in a given situation. Some of the most common alerts received from fish harvesters are:

• vessels taking on water, on fire, or running aground and with hull damage;
• medical emergencies;
• person in the water;
• failure to arrive at an intended destination, return to port on time, or generally considered overdue; and,
• other, often preventable, urgent situations, including disorientation, mechanical failure, steering problems, and fuel shortages.

Non-Distress Incidents

Marine incidents are not always life threatening. Each situation must be evaluated carefully and treated differently as there is always the potential that what appears to be a benign event may evolve into a life-threatening situation. Each situation is subject to the judgment of the rescue coordinator. If assistance is required, the following options will be considered:

• ensure that every attempt has been made by the vessel to arrange commercial assistance;
• assist the disabled vessel in arranging commercial assistance;
• if no commercial assistance is available and/or it is determined that an incident is about to develop into a distress situation, a SAR resource will be tasked to assist; and
• if towing assistance is required, the vessel will be towed to the nearest safe haven and released in accordance with the national SAR towing policy/Canadian Coast Guard Fleet Safety Manual.

The National SAR manual has specific comment regarding such non-SAR cases and the potential for towing. Specific extracts include:

ASSISTANCE TO DISABLED/ABANDONED VESSELS

7.14 Search and rescue units (SRUs) often provide assistance in operations not directly related to a search and rescue (SAR) incident, which if not carried out might result in a definable potential endangerment to life, and/or might result in undue hardship to the interests involved. Examples of the types of assistance provided typically include the provision of aid such as towing, dewatering, firefighting or escort assistance. Subject to SAR priorities and paragraph 7.15, rescue co-ordination centres/maritime rescue sub-centres should facilitate the participation of SRUs in these types of operations, and assign an appropriate incident classification to the activity.

NOTE: Vessels or other craft abandoned during the course of a SAR incident may require assistance from SRUs until the owner or other responsible agency assumes control.

7.15 SAR activity taken under the above paragraph shall be in accordance with the Canadian Coast Guard Towing Policy (Annex 7A), when applicable, and in any event shall not be performed in competition with commercial salvage interests. However, it is recognized that many areas of each search and rescue region are remote and isolated and that there are no commercial salvage firms operating within these areas which can or will respond to the incidents.

The Limitations of the Regional and Organizational Construct

The functional and spatial, or geographic, boundaries which exist within any organizational structure are inevitably the result of events which have occurred and decisions which have been made in the past. The current construct of the Coast Guard, Department of Fisheries and Oceans and the Federal agencies concerned with maritime affairs in general were largely shaped by the Government reorganizations of the 1990s. The organizational shock of the amalgamation and realignments of that decade have given way to what remains essentially a work in progress, a continued evolution of the multitude of activities and functions in an ongoing rebalancing effort, often in response to ongoing variations in the need for services.

Figure 19: Overlay of Organizational Jurisdictions for Department of Fisheries and Oceans and Canadian Coast Guard Activities

In the context of the organizations which influenced events leading up to the L’ACADIEN II’s accident on 29 March and its aftermath, it is clear that many elements and offices, and indeed several departments, had a hand in marshalling information, awareness, communications and decisions. In focusing on the zone in which the events played out, the chart above at Figure 19 is illustrative of the complexity of the organizational model which was charged with overseeing and managing events on that busy night. Though not exhaustive in its representation of agencies involved, the image cannot help but conjure up a sense of misalignment and incoherence. Functional, geographic, natural, political (provincial) and even linguistic dynamics were at play. It must be asked if all concerns were being addressed as efficiently as possible. Certainly, they are not all being dealt with in a holistic and systemic fashion as a result of a variety of silos which exist.

The zone concept is popular in the east coast context for viewing issues on a larger scale. The reality is that this lens is suitable only for some at the management level, and particularly from the National point of view.

Unfortunately, as gleaned through the majority of interviews conducted⁸¹, it has on the whole failed to permeate the working level of the organization, within individual programs or local offices. Examples related to this incident include confusion in the two Ice Offices in Quebec and Dartmouth as to when and which vessel CCGS DES GROSEILLIERS was providing assistance and a seeming disconnect between icebreaking policy levels of service and priorities as compared to JRCC’s categories for describing cases and assigning rescue units.

Communications & Data Management

To those engaged in serving Canadians by providing surveillance and situational awareness to the operations centres and units at sea, as well as the managers and decision-makers charged with prioritizing and delivering efficient and effective capabilities, maritime domain awareness is a primary objective, long sought but seldom achieved in full. A spectrum of satellite tools, communications equipment, display systems and the talented people to utilize them all to positive effect are required to deliver real-time awareness of events on Canada’s oceans. This is an evolving and multi-agency field of endeavour. The current reality falls short of the goal.

Because a common, multi-use display or picture of the data available on the night of the L’ACADIEN II incident was lacking, and the facility to instantaneously share common data did not exist, radio transcripts again and again illustrate confusion and misinterpretation regarding vessels and issues taking place on 28-29 March.

The voyage of the CCGS DES GROSEILLIERS is particularly illustrative of the inadequacies of boundaries, organizations, data display and protocols. Assigned to the seal hunt and reporting to offices ashore in Quebec City, there was no awareness of her presence on the east coast of Cape Breton by some employees of the Sydney Coast Guard Radio, the ROC in Dartmouth or the JRCC in Halifax. Because no live positioning data such as AIS (Automatic Identification System) or satellite positional data are being exploited currently by Coast Guard, CCGS DES GROSEILLIERS “was a mystery” to JRCC just as the SAR scenario was beginning to intensify⁸².

The traditional 12-hourly reports⁸³ still work their way through the system, but they are neither real-time nor readily available to JRCC or radio station personnel working a dynamic shift. Similarly, the inconsistency of protocols for vessels moving from one area of jurisdiction to another, and the fact that her tasking was related to the seal hunt in the context of a zone assignment⁸⁴, gave CCGS DES GROSEILLIERS no incentive to advise the local Coast Guard partners of her position and activities. Assumptions, incomplete transfer of information, lack of validation or corroboration, at times because of a lack of digging for the information, all contributed to inadequate understanding of issues at play in this operational area.

It is clear that the issues described above did not cause the L’ACADIEN II’s accident, they simply formed the context within which the incident occurred. It is worth considering however that some of these issues could one day become causal in only slightly different circumstances.

Marine Communications and Traffic Services

Marine Communications and Traffic Services (MCTS) is the Branch of the Canadian Coast Guard that provides communications and vessel traffic services to the sea-going public. MCTS monitors for distress radio signals, provides the communications link between vessels in distress and the JRCC/MRSC, sends safety information, handles public communication and regulates the flow of vessel traffic in some areas. MCTS is an important link in the SAR system.

Beginning on the afternoon of 28 March, Sydney Coast Guard Radio became engaged with the case of L’ACADIEN II. Lack of information and a common operating picture suggests that operators were fundamentally unaware of the movements of the CCGS DES GROSEILLIERS. It appears that an assumption was made that DES GROSEILLIERS was in fact tasked to assist the L’ACADIEN II by Quebec Region, though never verified or corrected. Once in contact with the sealing vessel, Sydney Coast Guard Radio’s efforts with the L’ACADIEN II were largely professional and effective. Delays in the dispatch of a Coast Guard vessel in response to the request for assistance from L’ACADIEN II were essentially a result of the initial confusion about the scene being played out on the ice.

It is pertinent to address the issue of language used in the communications between L’ACADIEN II and the agencies ashore. Because events were occurring off Cape Breton, direct radio contact with a Quebec-based Coast Guard Radio station and a link to MRSC Quebec where access to a French-speaking operator was virtually guaranteed was precluded. Instead, the communications fell to the bilingual operators of the Gulf and east coast of Nova Scotia. Upon taking up communications with and acknowledging the needs of L’ACADIEN II, every effort was given by both Sydney Coast Guard Radio and JRCC to deliver the services required. It can be fairly stated that this effort was successful.

What can be gleaned from various radio recordings is that while the service was at the advertised standard, it was not always equivalent to some of the exchanges engaged in with English-speaking vessel operators in the same area. In essence, issues of context and depth of explanation were either not offered or not as fulsome when engaging with L’ACADIEN II. This likely occurred due to the lack of facility with the language as well as the time and level of effort required which was a challenge for busy communications centres. This had no impact on the services offered, though clearly did contribute to levels of frustration as L’ACADIEN II waited hours for help while not fully understanding why.

Towing in the Canadian Coast Guard

Since 1960, in support of safety of life at sea, the federal government has published policies and procedures for the provision of technical assistance, including towing of disabled vessels, on a limited basis and not in competition with commercial or private interests.

Over time, the documents have been reviewed, amended and published in various formats and publications. The latest renewal was initiated in 2002 following concerns raised by commercial towing and salvage services and at the request of Canadian Coast Guard regional personnel who highlighted deficiencies in the procedures as published in the National SAR Manual (NSM). Consultations and analysis were undertaken to ensure these federal services were provided in a standardized and consistent manner across the country. Further, the principle that "federal assistance to disabled vessels which are in no immediate danger only be provided as a last resort in situations when commercial or private assistance is not available", was reaffirmed.

In 2004, the Canadian Coast Guard Management Board approved renewed procedures for the provision of assistance to disabled vessels by the federal government or its agents such as the Coast Guard Auxiliary⁸⁵. These procedures came into force Monday 3 May 2004.

To facilitate the implementation of these renewed procedures, communications plans were put in place targeting owners and operators of vessels which could potentially request towing assistance. While these renewed procedures provide guidance for sound and transparent management and decision making on what the Canadian Coast Guard and its Rescue Centres will do and when it will do it, they remain very high level and do not include specific steps or guidelines on how to deliver the service at the ship level. Such information should include the minimum controls, capabilities and requirements and provide guidance to the persons involved in the operation. Despite this renewed policy, the consistency of application between Regions and at different Centres was not apparent through the interviews conducted for this investigation.

The CCGS SIR WILLIAM ALEXANDER arrived on scene to assist the L’ACADIEN II with a crew of 27 aboard. Typical of the Coast Guard fleet today, this is a vessel in the latter half of its service life. Manned by an experienced crew, they are knowledgeable and trained across a spectrum of skills but particularly buoy work, ice operations and SAR. Towing in ice tend to exist at the lower end of the proficiency spectrum since conducted less frequently. Though all crewmember aboard had participated in towing vessels to varying degrees, towing in ice was not the ice breaker’s forté in either skill or equipment. What is certain is that towing for the Coast Guard often occurs in less than benign circumstances, as was the case on 28 March.

5.3 Further Potential Mitigations to Risk in the L’ACADIEN II Scenario

In hearing testimony regarding the range of considerations, decisions and actions at play on the night of the incident and comparing them to reference materials, manuals and the observations of subject matter experts through consultation, it is inevitable that 20-20 hindsight should deliver certain potential mitigations which were not employed or deployed. Three such potential courses, not discussed in the paragraphs above are worth discussion:

On-scene Communications

It is evident from the recordings that the plan for effecting the rendezvous with the L’ACADIEN II and the method for passing of the tow was discussed and understood⁸⁶, with VHF radio communications serving as the means. It is also clear that the standing liability waiver was read to the stricken vessel and acknowledged. What is not clear is whether this latter radio transmission truly expressed the level of risk to the master of L’ACADIEN II or was seen more as standard procedure⁸⁷. Its value of the liability waiver in enhancing the safety of the tow is certainly questionable⁸⁸.

A better approach might have included a more fulsome discussion of the actual risks of the tow, including the issues of ice, the disparity in the size of the vessels and the potential, though remote, of girding. Clarity over the condition of the helm and the engines may also have been important. It is uncertain whether a better understanding of the evolution and its risks would have resulted in any changes in the actions of the crew of the L’ACADIEN II or their survivability. However, more fulsome conversation with precise expression of concerns and expectations is almost always a positive investment.

In a similar fashion, the internal communications aboard the CCGS SIR WILLIAM ALEXANDER, and particularly that of the towing watch, should have included reports on those moments when the towing watch almost chose to employ the axe, if only as a means of highlighting the degree of concern for all involved. All participants had a role in possibly using more pro-active communications than was the case that night.

Use of Drogues

Towed vessels often fall into a cyclic pattern of yawing from port to starboard while underway, with speed and hull-form being contributing factors. Manoeuvres, speed changes and obstructions, such as ice, interrupt these patterns and impart their own forces. A towing bridle, with points made fast on each bow of the towed vessel, are designed to counter this movement as the outboard bridle comes under increasingly greater strain the greater the yaw, imparting a corrective movement back towards the centre-line. Notwithstanding the slow speed of the tow, all witnesses noted at least some degree of yaw being experienced along the towed track of the L’ACADIEN II, with resultant concerns by some of the towing watch and observers in MADELINOT WAR LORD for how she was rubbing the ice boundary on either side of the track.

The use of a drogue, towed astern of the L’ACADIEN II, might have significantly dampened this movement and prevented the particular yaw or sheer to port which resulted in the collision with the ice. A reasonably specialized piece of equipment, it would have to be sturdy and equipped with a down-rigger, such as used for west coast salmon trolling, to make it effective and durable in the application in sea ice. It should be noted that such an appendage is viewed as counter-intuitive, even unnatural, to many accustomed to working in ice, as the theory suggests that gear which can be caught up in the ice and its dragging effects is to be avoided. Even if considered on the night of the 28 March as the towing gear was being prepared, the lack of a specific drogue on board would have required a jury-rig or ad hoc arrangement which, though potentially effective for a short period of time, would have had questionable sustainability in the conditions at play.

Astern Movement at Idle Speed

In the absence of a drogue, use of the L’ACADIEN II’s engine at a steady astern setting, at just above idle speed, might have made for an adequate alternative for managing the movement of the towed vessel. The key would have been to use consistent RPM at a low setting to avoid imparting any influence on the heading of the vessel with the propeller and, at the same time, preclude the placement of excessive strain on the towing hawser. This arrangement could have imparted a similar dampening effect on the tow as conveyed by a drogue, mitigating the extent of any yaw experienced. Concerns over engine cooling or potential over-heating of the clutch or gearbox arrangement would have to be taken into account, and might have limited the effectiveness and duration of this technique.

Taken at face value, none of these three elements - on scene communications, use of drogues and astern movement at idle speed - represent a profound change for the conduct of the towing evolution, nor do they offer guarantees to the success of a risky operation. They serve only as an additional potential means of reducing the risks, exactly what mitigation is supposed to offer.

5.4 Reflections on the Analysis

The analysis of systemic factors above can only touch on a portion of a range of large scale and complex issues which the Coast Guard can consider in seeking to improve the safety and service on Canadian waters. More important in this report, and more meaningful for those involved, including survivors of the L’ACADIEN II, families of the deceased, and the crew of the CCGS SIR WILLIAM ALEXANDER, are the assessments of the decisions and actions on the night of the tragedy.

Was there risk taken? Yes, there was risk as there always is at sea, from the moment the L’ACADIEN II left her berth in Cap Aux Meules and made way into the ice, through to the point where the three ships entered open water at 01:00 on the morning of 29 March. Had this type of risk been taken before? Unquestionably, in some form or another, by some of the people involved in this incident, but certainly not by all.

Was it reasonable for a Coast Guard icebreaker to take this comparatively small fishing vessel under tow? This is perhaps the most essential question and is shaped by the forecast of 28 March and the potential risks of leaving the sealing vessel to the elements. Yes, given that such a tow had been conducted successfully on a number of occasions previously, that there were no commercial vessels available, nor were there vessels nearby of a dimension similar to L’ACADIEN II with the capability to take on the role of a towing vessel. Circumstances will almost unquestionably demand it be done again, hopefully with a different approach as a result of the lessons learned from this accident.

Was there a possibility of disaster at the outset of the tow? Undoubtedly, but possibility should not be confused with probability. Judgement, mitigation and effective conduct all form part of the equation, as do the small errors, momentary hesitations and unforeseen elements that often align in accidents, particularly in hindsight. Despite the possibility of disaster, two and a half hours of a successful towing evolution through ice, challenging and stressful as it was, seems to suggest that there was in fact a possibility if not a probability of success, were it not for an unintended sheer to port at the very instant a dangerous ice remnant lay in the path of L’ACADIEN II.

 

79 A naval architect’s review of the construction drawings found a robust reinforcement scheme to the hull that represented effective ice hardening. The rudder arrangement, external to the hull, was not similarly reinforced nor equipped with a robust guard or shroud.
80 Since the organizational amalgamation of the mid-90s, the Canadian Coast Guard has sought to deliver services within a relatively fixed budget, striving to achieve the maximum efficiencies available with the resources at hand – dollars, ships and crews.
81 Interviews with regional office personnel, radio station operators, JRCC, and ship’s officers, served to illustrate the limitations of the Zone concept. Many did not perceive their place and role within it and did not feel that they had access to effective communications or information that covered the entire area.
82 As reported by the JRCC Watch Officers.
83 These reports offer positional data and activity updates by Coast Guard vessels at sea. They are submitted by FAX across available radio or telephonic frequencies.
84 From the perspective of the conservation effort to which CCGS DES GROSEILLIERS was assigned, the seal hunt was taking place in a singular zone in the Canadian east coast waters off Quebec, Newfoundland and the Maritimes. The means for integrating this zonal activity into the subdivided jurisdictions described in Figure 19 are not well described.
85 The Coast Guard Auxiliary is a volunteer organization made up of boaters, sailors, yachtsmen and fishermen. They serve as eyes and ears on the water and often engage in assisting vessels that are broken down or in distress. The assistance offered by Auxiliary members is always subject to their skills and capacity, and the prevalent conditions.
86 A standard form required by Coast Guard policy, it is either delivered and signed by the master of the towed vessel or, more commonly, transmitted by radio and acknowledged.
87 Witnesses from the wheelhouse of the L’ACADIEN II recall the master commenting that he had no choice but to accept the terms of the waiver if he was to receive the assistance he required.
88 The form speaks of issues of responsibility and liability, not of the conduct of seamanship or details of the risks.

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