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