Chapter 6 — Observations and Recommendations

The preceding sections of this report have delivered context, detail and analysis of the events which frame the capsize of L’ACADIEN II. The intent in the following paragraphs is to briefly touch again on the key concerns raised above and to describe the specific recommendations worth considering in the aftermath of the events of 28/29 March. The recommendations are arranged in three sections: those related to the conduct of the tow on the night of 28/29 March and the policies related to towing; organizational issues; and, thirdly, issues which fall outside the domain described by the Terms of Reference for this report but are worthy of further consideration by Coast Guard.

6.1 Conduct of the Tow and Coast Guard Towing Policy

Let there be no doubt, the Coast Guard will tow. That the organizations’ confidence has been shaken as a result of the L’ACADIEN_II incident is understood, but the vagaries of life at sea suggest that towing a small vessel, and in ice, remain a possibility. A clear, firm and concise towing policy is required. This should be augmented by a detailed and consistent guide to operators. As a complimentary effort, an assessment of the skills, training and equipment which is in place, and perceived to be required for future operations, should be undertaken. The capability of the Coast Guard’s seagoing community to conduct a tow is not fundamentally in doubt. Rather, the guidance, expectations and policy language, from management, through to emergency managers and the crew is currently inconsistent.

The following recommendation results:

1. The Coast Guard should conduct a full review of towing requirements, policies, processes, training and equipment. The following areas should be addressed:

1. Development, delivery and monitoring of a singular towing policy, across the Coast Guard, with linkages to the range of applicable reference material and pertinent documentation. These material should include such key guiding publications as the SAR Secretariat’s manual, which describes expectations for response in SAR, humanitarian assistance (HA) and non-SAR/HA situations;
2. Development of clear seamanship procedures, standards and techniques required for a towing scenario, while leaving room for the deviations forced upon operators by the conditions at the scene, as judged by the on-scene commander. For example, for the towing of small vessels by large Coast Guard platforms, such as was required in the case of L’ACADIEN II, the default guidance should be to require the towed vessel to reduce the number of crew onboard to the absolute minimum which still allows the towing evolution to be conducted safely. This would serve to take into account the significant risks at play with such hull/power disparities. Such defaults can never become black and white absolutes, but serve as a means of highlighting concerns, of enabling the conversation between mariners, and to facilitate cooperation so as to mitigate risk. While the guidance and the defaults must be clear, the conditions at hand must always be allowed to shape judgment and actions;
3. A review, in consultation with stakeholders, of the training, technology, equipment and fittings available and pertinent for future operations should be conducted. Implicit in this effort should be an assessment of the effectiveness of recent or emergent technologies such as the tensionometer, slack-hook arrangements and quick-release mechanisms. In turn, contribution to the development of modern, consistent and broadly held manuals and check-lists is in order;
4. As a continuation of the work performed by the naval architect, a research and development effort through naval architectural calculations, water-tank tests and live trials to establish and better understand the where and the why of safe operating limits in a towing environment, with and without an ice dynamic, is in order. This body of knowledge should better describe the margins of safe operating procedures than as compared to the literature and professional knowledge base today. Of particular interest will be the consequences of disparate vessel sizes in towing operations. This should offer operators a better appreciation of where the risks begin to escalate, along with the potential means for mitigating specific dangers; and,
5. Until the above efforts are ready for implementation, the establishment of an interim policy for towing and support of the sealing fleet should be formed and announced prior to the 2009 hunt.

6.2 Organizational Issues

Four key topics require consideration in developing the recommendations related to the organizational elements of this incident worth learning from. They include:

• the methods, technologies and protocols for communications and situational awareness;
• the jurisdictional construct;
• the organization’s capacity to deliver a relatively detailed inter-disciplinary process for risk-management based resource allocations, including pre-positioning of SAR assets for the fisheries; and
• organizational learning;

The following recommendations result:

2. Coast Guard should aggressively seek, implement and apply technological methods which deliver a “common operating picture.”

The Department of Fisheries and Oceans writ large and the Canadian Coast Guard in particular, highly tasked and resource limited, can no longer afford for units at sea, emergency operators or key resource managers to be largely unaware of the details of the shipping they are expected to oversee and protect, let alone remain uninformed of the real-time positioning of their own Federal assets. A real-time common operating picture, exploitive of AIS (Automated Information System) and satellite technology, with embedded geomatics and climatological data, that enhances situational awareness and effective decision-making, is in order as soon as is feasibly possible;

3. Coast Guard should conduct a reassessment of its east coast waters’ jurisdictional apportionment.

Described by some within the organization as Byzantine, an effects-based re-calculation and re-alignment of the layered boundaries present in the Quebec / Maritimes / Newfoundland geographic area should be urgently undertaken. While remaining cognizant of the many factors, from geographic to political to historic that are indeed relevant within this domain, a clear emphasis of priority on clients, safety and sea mobility would serve to define a more coherent, more effective construct than that which is extant. Given whatever construct which is arrived at, a clear set of protocols for information exchange, operational overlap, clarity of authority and of responsibility should be initiated in turn. Mechanisms for the identification and announcement of movements of individual vessels through the range of jurisdictional domain, whether geographic or functional, are in need of establishment.

4. Coast Guard should refine its organizational planning and risk management process for the oversight of east coast activities.

Evident from the discussions with regional staffs and a comparison of the planning processes utilized, it is time to consider development of a more dynamic and inclusive inter-disciplinary risk assessment, planning and decision-making processes. This could extend awareness, manage changing conditions and balance appropriate, or indeed limited, asset availability. In concert with the boundary re-alignments called for in recommendation 3, a review of the functional (engineering, ice, SAR) and operational (ships, sea days, communications) capacity to consider (plan, manage, predict) the regional demands should evolve to include cross-discipline participation within each HQ, and better interface with other HQs and National organization. It should be motivated by the desire to deliver a higher level of considered pro-active intervention or reactive capabilities, as opposed to the often reflexive and largely specialized or stove-piped processes which are currently apparent.

The full spectrum of involved agencies, from management, to operations centres, to JRCC, to Engineering - and inclusive of stakeholder groups when appropriate - should be considered as partners in the processes of plan development, contingency consideration, risk event pre-positioning, on through live issue management. An appropriate flexible model could be utilized at four levels; local, regional, zonal and National, adapted to the perspectives of each level and the demands of each situation.

5. Coast Guard should promote the concept of record-keeping and analysis, as well as the value of shared professional lessons learned.

Not embodied within the context of the incident but a feature perceived through the investigation process, it is noted that the capacity for record-keeping, incident analysis and the broad sharing of lessons learned is, on the whole, not yet a broad cultural reality within the Coast Guard. Though digital audio and video recorders are ubiquitous in Canadian society and business, their presence at sea within the Coast Guard is inconsistent and their formal and mandated use is not espoused in any constant policy. The dossier of missed opportunities that this represents for incident reconstruction, analysis and lessons learned is immense. The capturing of these analyses, the sharing of lessons learned and a compilation of a reference database appears lacking as a professional tool.

Inculcation within the culture of Coast Guard of the importance of record-keeping, using modern tools such as video and audio recording devises, subsequent analysis and professional dialogue should be a conscious change agenda issue. Enhancing the process of lessons learned and of promoting the dialogue around unique successes, near misses and events gone wrong is the sign of a healthy organization which is cognizant of the risk environment within which it must operate, every day of the year. The value of systemizing a process by which each individual is not required to personally make each of the thousands of possible mistakes to learn from its lessons cannot be overstated.

6.3 Considerations Beyond the Terms of Reference and Beyond Coast Guard Authority

This segment of the recommendations touches on areas not explicitly called for by the TORs but considered worthy of mention in the final report.

The Canadian Coast Guard is a civilian Special Operating Agency within the Department of Fisheries and Oceans. Its structure, authorities and responsibilities have been evolving since the middle of the 1990’s. In assessing the larger scope of factors which were in play during the L’ACADIEN II incident, it is evident that some issues for which the Coast Guard was responsible that night do not reside within their domain of authority to adjust or resolve. Of the three recommendations which follow, one represents an area where the Coast Guard is able to act within its mandate. Two represent issues with clear implications for Coast Guard responsibilities and resources, but which fall outside of the Coast Guard’s authorities and within those of other Federal agencies.

The following recommendations result:

6. Coast Guard should renew and reinvigorate engagement of the client base.

Coast Guard should engage the spectrum of customers affiliated with the eastern Canadian littoral, focusing on two key goals: to educate the public and commercial domain on the current roles, capabilities and limitations of the Federal fleet and to derive an understanding of trends and expectations as seen from the perspective of this customer base. Topics for engagement include;

1. The state of the fleet and other Coast Guard assets and plans for future construction;
2. The policies in place and the real-world constraints on the delivery of assistance in SAR and non-SAR situations, including risk issues, seamanship, equipment and communications;
3. The interface between Coast Guard and the various enterprises on the waterways, from the pleasure boater through the fisheries and over to the large commercial fleets. This effort would include the aim of achieving an ameliorated degree of mutual understanding, of alignment of jargon, terminology and technical language not evident today;
4. A special emphasis on ice operations, Coast Guard support and expectations. As well, consideration should be given to the realities of how the spectrum of Federal agencies, from climatologists to conservation teams through to the SAR Secretariat, can provide assistance to those on the ice conducting their legal enterprises in a more coherent fashion than is being delivered today.

7. Coast Guard should propose and participate in a coherent alignment of cross-Departmental jurisdictional domains within Canada’s east coast waters.

A corollary of Recommendation 3, above, this recommendation serves to acknowledge that Coast Guard does not operate in isolation and that other agencies have interests and authorities within the greater region in question. To be effective, any effort at realignment must be cognizant of these other domains and seek to initiate the refinement of boundaries on that larger scale. Liaison with external partners should be initiated so as to generate the appropriate motivation and cooperation.

8. Coast Guard should propose a review of the regulatory process, standards and inspection regime for vessels working and operating in ice with the applicable authoritative partners in the appropriate Departments.

It can be fairly said that this issue was unanimously commented upon. Seamen, sea-going officers, sealers, towing professionals and staff all viewed this area as a significant vulnerability for safety at sea. While the regulatory responsibilities reside outside of the Coast Guard’s authority, largely within the domains of another department, Transport Canada and other sectors in the Department of Fisheries and Oceans, the level of concern and strong advice received in conversation with witnesses demanded that the topic be addressed in this report.

As noted, Coast Guard should endeavour to initiate a review process of the participation and practice of ice navigation. This effort should include the full spectrum of ice operating vessels and consider the methods by which Coast Guard has in recent years been successful, or unable, to influence norms and practices overseen by other agencies and departments, in essence giving light to any responsibility/authority mismatch.

Of particular interest is the potential development of a sliding scale for access to the ice, for whatever type of vessel or activity, founded on actual ice conditions, suggesting that size or robustness of a platform should be consciously matched to conditions in affording access to the challenges, risks and dangers of working the ice. This is not dissimilar to the current ice regime utilized in the Arctic. Safety and environmental issues can form part of the calculations, as should commercial requirements, species quotas and licensing. Stakeholder engagement for this undertaking is vital, while their full concurrence, particularly on matters of compulsory safety standards, is not.

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