On February 16, 2001 the Department of Fisheries and Oceans ("DFO") made the final decision to terminate the Rescue Diving Pilot Project which had been run by the Canadian Coast Guard ("Coast Guard") from CCG Station Sea Island ("Sea Island") since January of 1995. Tragically, early in the morning on February 18, 2001 a Richmond, British Columbia man, Mr. Sukhpal Sandhu, died after his car plunged into the Fraser River, 400 meters from the Sea Island base.

The Richmond Fire Department, Richmond RCMP, BC Ambulance Service and a Coast Guard hovercraft crew from the Sea Island base arrived at the scene within minutes of the incident involving Mr. Sandhu. When the hovercraft crew arrived there was an expectation on the part of the public, and Richmond Fire Department and Richmond RCMP personnel that Coast Guard would be able to provide rescue divers. As a result of the termination of the Rescue Diving Pilot Project Coast Guard personnel were unable to dive. This incident raised issues surrounding the process of the decision to cancel the Rescue Dive Pilot Project. Such issues form the basis of this report.

The sequence of events leading up to the termination of the Rescue Diving Pilot Project and relevant events afterwards are equally important. The Rescue Diving Pilot Project was established at Sea Island in 1995 after a series of high profile marine incidents in 1992 and 1993. These incidents resulted in discussion between and amongst members of the newly formed Underwater Rescue Review Committee, the Coast Guard and others concerning the need for rescue dive services. In the result the Coast Guard decided to establish the Rescue Dive Pilot Project.

The Rescue Diving Pilot Project became fully operational by June of 1995 after a sufficient number of rescue divers were trained at Sea Island. From June of 1995 until November 29, 2000 the Sea Island Rescue Diving Team (the "Rescue Diving Team") provided response to rescue dive incidents on a 24 hour per day, 7 day per week ("24/7") basis. A report on the operation of the Rescue Diving Team conducted at the two-year interval suggested the Rescue Diving Pilot Project be continued for an additional two years to allow sufficient time to evaluate its benefits. A subsequent internal report conducted at the four-year interval suggested that the program be entrenched as a permanent Coast Guard program.

Between 1998 and the summer/early fall of 2000, questions regarding the future of the Rescue Diving Pilot Project were being raised by Coast Guard management. In a Management Board Meeting in Ottawa in September 2000 Commissioner John Adams asked Regional Director Pacific Region, Mr. Mike Henderson, to consider whether the Coast Guard should be in the business of rescue diving. This question was asked in light of the policy in other jurisdictions including the United States and the United Kingdom where if rescue diving services were provided, they were provided either by local Police/Sheriff's or Fire Departments. It was known within the Canadian Coast Guard that the coast guards in the United States and the United Kingdom did not provide rescue diving services.

Between the September Management Board meeting and a subsequent meeting held on November 23 and 24, 2000 a third report on the Rescue Diving Pilot Project was prepared at the request Mr. George Horel, Regional Director Pacific for Fleet Operations. The report did not address the issue of the need for rescue dive services but rather focussed on operational aspects of the Rescue Diving Pilot Project including staffing and safety issues. The report identified specific problems with the pilot project and concluded that the Coast Guard should either commit sufficient resources to allow the pilot project to operate properly or should cancel the project. In addition to these two suggestions this report recommended ways to remedy problems with the Rescue Dive Pilot Project.

At the Management Board meeting held over November 23 and 24, 2000, again in Ottawa, it was made clear that management at the most senior levels did not believe Coast Guard should be in the rescue diving business. In spite of the clear statement as to this position, Regional Director Henderson, made the decision after consultation with Donna Petrachenko, Regional Director DFO, to suspend the program pending further review. The suspension of the program was made effective on November 29, 2000 when Jon Churchill advised that the Rescue Dive Team would no longer be dispatched. By letter dated December 4, 2000 Regional Director Henderson confirmed the suspension.

After the November 29, 2000 decision agencies affected by the decision to suspend the Rescue Diving Pilot Project, with the exception of the RCC, were not informed that the Coast Guard would no longer provide rescue dive services. In particular, notice was not given to senior representatives of the Richmond Fire Department, Richmond RCMP, Vancouver Airport Authority, Vancouver Police Department, Vancouver Fire Department, and the RCMP "E" Division Dive Team. Further, no such notification was given to the public.

Between January 23 and January 25, 2001 a further report was prepared. This report, which was a safety audit of the diving practices of Rescue Dive Team, confirmed that although there were deficiencies in the operation of the Rescue Diving Pilot Project, these deficiencies could be remedied.

On February 12, 2001 Regional Director Henderson met with members of the Lower Mainland Advisory Committee ("LMAC") where the issue of the future of the Rescue Diving Pilot Project was discussed. The LMAC was left, at the close of that meeting, with the impression that the future of the Rescue Diving Pilot Project was still under review. On February 16, 2001 Regional Director Henderson announced to members of the Rescue Diving Team assembled at Sea Island that the program had been terminated.

As was the case when the program was suspended no specific notification was made to the public or to representatives of relevant emergency response service providers after the Rescue Diving Pilot Project was terminated on February 16, 2001.

Although the decision making process was flawed this Reviewer agrees with the Coast Guard decision to cancel the Rescue Dive Pilot Project. The basis for the decision first to suspend and ultimately to terminate Rescue Diving Pilot Project will be discussed within this report. In particular this report will cover the following: the formation and operation of the Rescue Diving Pilot Project (alternatively referred to as the "pilot project"); reviews conducted of the pilot project; factors considered in, and the process of, the suspension and termination of the pilot project; lack of notice regarding suspension and termination of the pilot project; current rescue dive capability in Canada and in other jurisdictions; and, Coast Guard options with respect to rescue diving. Finally, this report will address the specific questions set out in this report's terms of reference.

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Introduction

1. Background

On January 31, 1995 National Revenue Minister David Anderson, on behalf of Transport Minister Douglas Young, announced the commencement of the two-year Rescue Diving Pilot Project for the provision of rescue diving services from the Canadian Coast Guard ("CCG") Station at Sea Island in Vancouver, British Columbia. Sea Island was selected because it was one of two CCG bases operating on 24/7 basis. The other was CCG Station at Kitsilano. Sea Island's 24/7 operation, combined its use of high-speed hovercraft and considering the density of pleasure and commercial vessels along with float-equipped and other aircraft in the surrounding areas, made that base an obvious location for the Rescue Diving Pilot Project. Coast Guard rescue diving services became available from Sea Island on June 20, 1995.

During the years following the initiation of the Rescue Diving Pilot Project a team of well-trained and dedicated divers was developed. Numbers of team members varied as individuals were added or elected to leave and by November 2000 there were twelve fully trained rescue divers available. Two of these divers were stationed at the CCG Station Kitsilano and the remaining divers were stationed at Sea Island. The rescue divers stationed at Sea Island were also members of that base's hovercraft crews. Accordingly, when rescue divers from Sea Island were dispatched by the RCC, Rescue Diving Team members played the dual roles of rescue specialists/first officers and rescue divers.

On December 4, 2000 Mike Henderson, Regional Director of the Canadian Coast Guard in the Pacific Region, announced that the Rescue Diving Pilot Project was to be suspended pending further review. Such reviews were conducted in January and February of 2001 and on February 16, 2001 the decision to terminate the Rescue Diving Pilot Project was announced. In the result, rescue diving by members of the Coast Guard was completely discontinued.

In part, arising from the tragic fatal incident involving Mr. Sukhpal Sandhu on February 18, 2001 in a place on the Fraser River very near to the Sea Island Hovercraft base, and some critical commentary with respect to the process of termination of the Rescue Diving Pilot Project, this review was commissioned.

2. Review Process

The Terms of Reference for the review are attached as Appendix C-1. They provide that the reviewer (the "Reviewer") is to review the basis of a decision made by DFO on November 23, 2000 and February 16, 2001 to terminate the Rescue Diving Pilot Project. They specifically provide that the Reviewer is to identify the information available to the Coast Guard at the time of the decision and to comment on the steps and procedures adopted by Coast Guard in reaching its final conclusion.

In addition, the Terms of Reference provide that the Reviewer is at liberty to consider what was being done in other jurisdictions in Canada or internationally. Finally, the Reviewer was authorized to conduct interviews with relevant CCG personnel or others involved/affected by the decision.

Coast Guard files and relevant documentation has been reviewed. The Reviewer has interviewed a number of individuals from Sea Island and CCG Station Kitsilano including members of the Rescue Diving Team. In addition, interviews have been conducted with members of the LMAC, representatives of lower mainland police and fire departments, representatives of police and fire departments in other jurisdictions and with coast guard officials in the United States and the United Kingdom.

Further, the Reviewer conducted in-person or telephone interviews with senior Coast Guard management including Commissioner John Adams, National Marine Programs Director Deborah Normoyle, Region Director Henderson and past and present Directors of the Pacific Region Marine Programs and Fleet Operations Sections. Further a visit to the Rescue Co-ordination Center in Victoria was conducted as were interviews with RCC personnel from both the CCG and Department of National Defence ("DND") contingents.

The Reviewer analyzed reports of reviews and investigations undertaken with respect to the Rescue Diving Pilot Project. These include the following:

The report prepared by Brian Stevens in August of 1997 (the "Two-Year Report") which recommended that the project be continued in order to develop a greater degree of experience data to assist in making the decision with respect to the future of rescue diving;
The report prepared by Brian Wootton, O.I.C., Coast Guard Rescue Dive Project, in October 1998 (the "Four-Year Report") which recommended entrenchment of rescue diving capability at Sea Island;
The report prepared by J. Nemrava, in October 2000 (the "Nemrava Report") which recommended that certain steps be taken if rescue diving was to continue at Sea Island; and
The audit of Rescue Diving Pilot Project prepared by Mr. Edey in concert with A.D. Skaalrud, a consultant to Coast Guard, in January 2001 (the "Edey Report").

(collectively, the "Reports")

3. Relevant Issues

The Reports consistently addressed a number of issues with respect to rescue diving generally and the pilot project in particular. In particular the Reports addressed the risk faced by rescue divers and the need to minimize such risk by adequate training, strong discipline, and adherence to policy and safety regulations.

The most important of the Reports for the purposes of this review, largely because of its impact on the decision of Coast Guard management to terminate the Rescue Diving Pilot Project, is the Nemrava Report. This report was delivered to the Coast Guard Regional Director a few days before the Management Board meeting in Ottawa at which the decision to terminate was made. The primary issue addressed in the Nemrava Report was the "long term delivery of rescue diving at Sea Island". The terms of reference required Mr. Nemrava to review policy and operational aspects including staffing, training, equipping and costing of a continued rescue diving program at Sea Island. Finally, Mr. Nemrava looked briefly at various alternatives to Coast Guard-provided service.

The Nemrava Report, which will be dealt with in more detail later in this report, indicates that a great deal of work and effort was expended by members of the Rescue Dive Team over the five-year life of the Rescue Diving Pilot Project. A detailed training program established with the assistance of the Calgary Fire Department and Rescue Dive International and a comprehensive Search & Rescue Diving Training Manual ("Rescue Diving Training Manual") prepared for in-house use at the Sea Island and various other procedures relating to personnel deployment and equipment were developed, essentially by volunteers. However, the Nemrava Report makes it clear that one of the greatest barriers to the success of the Rescue Diving Pilot Project was a lack of support for the program generally within the CCG and particularly at senior levels.

It seems obvious to this Reviewer that a program, especially a pilot project, can not survive long without management support. With respect to the Rescue Diving Pilot Project, departmental policy and procedure concerning rescue diving was not created. The pilot project did not have official recognition from the National Directorate of Marine Programs and, to a great degree, it operated on an ad hoc basis from Sea Island largely due to the strong desire and dedication of those directly involved. The Rescue Diving Pilot Project was essentially a Coast Guard pilot project in name only.

In the course of this Reviewer's investigation a tension between Coast Guard branches became evident. Although such tension can promote healthy competition, it had a destructive effect on the Rescue Diving Pilot Project. In particular, those working on large ships (icebreakers and other large vessels) were said, to varying degrees, to resent those working small ship (search and rescue vessels). A further tension existed between these large ship and small ship factions and those working with the hovercraft group at Sea Island. This tension was exacerbated by the creation of the specialized rescue dive program run exclusively at Sea Island.

Although support for the Rescue Diving Pilot Project was lacking amongst Coast Guard managers it can not be said that the decision to suspend and ultimately to terminate the pilot project was made entirely without consideration of relevant factors. Consideration was given to health and safety and various other regulatory factors and well as to the reviews done of the project at the two and four-year intervals and by Mr. Nemrava. One senses that to a large degree those reviews were used to justify the decision to terminate the program based on the principal issues of staffing, individual diver personal safety, risk management and, to a more limited degree, the overall costs of providing the program in a multiplicity of jurisdictions. This Reviewer is left with the general impression that Coast Guard management believed the requirement for rescue diving was minimal as the chances of success in any given situation were relatively low.

While the above mentioned factors and the Reports provide sufficient justification for the cancellation of the Rescue Diving Pilot Project, there was a failure to take into account the effect of that decision on the present Coast Guard personnel at CCG Station Kitsilano and Sea Island. Further, it seems entirely likely that if the decision to terminate Rescue Diving Pilot Project is not reconsidered, the individuals who have dedicated time, effort and personal risk in an attempt to make the program successful will drift away from the Sea Island and Kitsilano bases. When this happens, any future effort to create a rescue diving program will not have the benefit of the accumulated rescue dive expertise.

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Rescue Diving Pilot Project

In order to properly evaluate the decision to cancel the Rescue Diving Pilot Project it is first necessary to review the steps in the pilot project's creation as well as the project's operation. The following section will discuss the evolution of Coast Guard policy with respect to diving, establishment of the pilot program at Sea Island, program design and training, tasking of rescue divers, risks to rescue divers, regulatory limitations and ongoing costs.

4. Background of CCG Diving Policy

Diving has been the subject of various CCG policies over a number of years although early policies were designed to apply to ship's or clearance diving. Ship's or clearance diving involved the performance of underwater work including maintenance of Coast Guard Vessels. Other types of diving include recovery diving, scientific diving and the very much more urgent and hazardous rescue or Type 2 diving. The Coast Guard stopped using ship's divers in 1992 but DFO continues to use scientific divers.

An early ship's diving policy was set out by the Coast Guard in Order 15, created in June 1968. Order 15 contained rules applicable to scuba diving and included a requirement for a second diver and use of a life line or buddy line. The Order set the maximum depth for scuba dives to 50 feet and established requirements for equipment and training. Order 15 continued to apply until 1992.

In 1986 Canadian Coast Guard Fleet Order 200.03 was issued. Order 200.03's stated purpose was to detail the policy for diving in the Canadian Coast Guard fleet. Although it did not distinguish between rescue diving and ship's diving it is generally considered today that its requirements with respect to training and dive procedures only applied to ship's or clearance divers and not to rescue diving.

The policy was set out as follows:

"It is the policy of the Canadian Coast Guard that where appropriate, a dive capability shall be provided to compliment the fleet's ability to meet mission requirements."

In accordance with the policy the larger vessels tasked for primary SAR operations were to have dive teams. Other ships were to have dive teams if warranted by the ship's role. In addition dive teams were to be maintained at all major Coast Guard bases to be ready to respond to situations for which onboard divers were not available. The policy provided for a designated regional diving co-ordinator and for training, certification and other standards and procedures referred to in the Canadian Coast Guard diving manual.

Coast Guard Fleet Order 200.03 and Order 15 were replaced by Coast Guard Fleet Order 203.00 in April of 1992. This Order read simply that "all diving activities performed by Coast Guard ships' divers are to be discontinued as of April 1, 1992. Subsequent diving operations being carried out on Coast Guard vessels are to be in accordance with the new policy". The new policy at Section 1.2 of the Order read as follows:

"It is the policy of the Canadian Coast Guard that, where diving services are required, qualified commercial diving services are to be employed."

The Order finally provided the following in paragraph 3.6 under the heading Exceptional Circumstances:

"In exceptional circumstances such as during SAR or hull searching, divers from DND, and the RCMP or from the local police force may be utilized."

Certain amendments were made to Fleet Order 203.00 in July of 1992 but essentially the policy remained in place until 1999 when it was cancelled and replaced by Section 7.D.16 in the Canadian Coast Guard Fleet safety manual (the "1999 Policy"). The 1999 Policy entitled "Diving Operations" was included in the section relating to development of plans for shipboard operations. The purpose of the 1999 Policy was to ensure safe conditions for all diving operations deployed from or in support of Coast Guard vessels including those performed by Coast Guard employees, departmental employees, members of scientific parties, members of charter groups who engaged the services of the ship, students attached to the department and commercial divers engaged by the department or the Coast Guard under contract of service.

The 1999 Policy also ensured that the Departmental Diving Safety Officer or his or her regional counterparts would supervise and approve scientific diving plans and other diving procedures taking place from Coast Guard vessels to ensure that the regulations and other safety aspects were being complied with. Some brief investigation has been conducted with respect to the availability of DND, RCMP and local police or fire department divers for SAR or hull searching activities. Comment in this regard will be included elsewhere in this report. However it can be stated that from the information available at this time neither local police or fire fighters nor RCMP had a mandate to engage in rescue diving.

5. Establishment of the Rescue Diving Pilot Project

Three tragic but prominent incidents occurred in the waters of Southern British Columbia in 1992 and 1993. Two concerned submerged automobiles where a total of seven fatalities resulted and the third concerned a vessel that capsized as result of a collision with another ship where six fatalities resulted. These incidents focussed the public's attention on rescue diving.

One of the submerged automobile incidents, in which a van tumbled from a British Columbia Ferry Corporation loading ramp into the water, resulted in an inquiry headed by Judge Nathan Nemetz. In the course of the Nemetz inquiry the issue of underwater rescue was raised. Although Judge Nemetz found that his mandate did not include such considerations, he did recommend that "the Provincial Emergency Plan authorities convene a task force made up of the various agencies involved in waterfront emergency plans, and including the major users of harbours in British Columbia, to review the question of the provision of underwater life saving personnel and equipment."

In the result the Underwater Rescue Review Committee was established with representatives of the Coast Guard, the RCMP, Vancouver and Nanaimo Port Corporations and the Ministry of the Attorney General. The chairman was the Director of the Provincial Emergency Program ("PEP"). The Committee reviewed material, consulted with various experts and reached the following conclusion:

"Though inquiries were made with both the Canadian and American Coast Guards, the RCMP underwater recovery team, and other marine authorities, the committee was unable to substantiate one case in West Coast waters where a life was saved through the use of established diving resources. Based on the information provided by Dr. John Hayward and a review of known cases, the committee concludes that the possibility of established diving resources rescuing underwater victims in sufficient time to allow them to recover is extremely low."

When the Committee conducted its investigation no actual rescue diving service was available except from the DND 442 Squadron in Comox and therefore the comment must be taken to relate to a time when resources to supply the particular service of rescue diving were extremely limited.

The Coast Guard also undertook a review of rescue diving and the feasibility of establishing a rescue diving program. A working group with representatives from CCG headquarters and the Pacific Region examined operational safety, legal and financial aspects of rescue diving and consulted with various members of the Canadian and international search and rescue community including DND, municipal police, the U.S. Coast Guard, the Royal Navy and commercial and government agencies involved in diving.

The Coast Guard working group concluded its assessment during a three-day meeting in Calgary in January 1994. As well, a diving roundtable was convened at Vancouver on June 7, 1994 where 25 representatives of Coast Guard and Pacific Region Coast Guard service providers such as Rescue Co-ordination Centre Victoria, Sea Island base and lifeboat station representatives attended. Views of those in attendance were recorded. These varied considerably from full south coast implementation of rescue diving at Sea Island, Ganges and Kitsilano to use of commercial divers and to use of non-diving rescue specialists. Notes to the file indicated that "clearly consensus in any form was not reached".

Even in the face of this rather uncertain support by groups that had specific input to give on rescue diving services, the Minister of Transport proceeded with the pilot project in January of 1995.

6. Program Design and Training

Almost immediately after establishment of the pilot project, Brian Clements became heavily involved. Mr. Clements had been in the North Sea as a commercial diver and came to the Coast Guard on contract in 1991. He brought with him extensive diving experience in many areas of the world including the Arctic. When the Rescue Diving Pilot Project was initiated Mr. Clements offered to assist and became a valuable resource. Mike Carson, a first officer at the Sea Island base, as well as a number of others, assisted Mr. Clements. One of their first goals was to put together the very extensive Rescue Diving Training Manual.

The Rescue Diving Training Manual contains fourteen modules; each covering a specific area of expertise required for different rescue dive situations. This includes modules concerning capsized vessels, submerged automobiles, float planes and others. The capsized vessel module includes a stability and engineering analysis prepared by a firm of Vancouver architects and marine engineers.

Mr. Clements taught the modules as divers became available to the Sea Island base. He advised the Reviewer that it took six to eight weeks to train dive team members depending on their previous experience. According to Mr. Clements diver trainees displayed an admirable level of dedication.

In addition to the training completed at the Sea Island Mr. Clements and Mr. Tim McFarlane, another member of the rescue dive team, became certified as trainers after taking required courses at the Colorado training centre for Dive Rescue International and other taking other courses with respect to medical aspects of diving. This training was in turn provided to divers at Sea Island.

33 officers and crew from Sea Island and CCG Station Kitsilano were trained to provide rescue diving services. Of those 33, 12 remained on the active dive list up to November of 2000 when the pilot project was suspended. Of those 12, two are first officers on hovercraft crews at Sea Island, eight are rescue specialists at Sea Island and two are rescue specialists at CCG Station Kitsilano. In his November 2000 report Mr. Nemrava concluded that with 12 rescue divers Sea Island had been able to maintain a full dive team on standby the majority of the time. Neither Mr. Nemrava nor this Reviewer has carried out any actual audit of the logbooks at Sea Island to confirm determine if there were times when sufficient dive capability was not available.

Although internal reviews of the Rescue Dive Pilot Project, including the Nemrava and Edey Reports, indicate documentation with respect to training was lacking, testamentary evidence implies that the training process at Sea Island was very complete. In the words of at least two divers, rescue diving training was the only actual skill-training given to them while they were working for the Coast Guard. These individuals stated that in their earlier Coast Guard roles they brought existing skills with them when they were posted. In any case, it is apparent that over the years that the pilot program operated, members of the team exhibited a great deal of dedication.

The training that was given to Coast Guard rescue divers was also provided to DND SAR techs from 442 Squadron at Comox and other public diving organizations. Correspondence from representatives of 442 Squadron was glowing in its praise of the training materials and operational sessions. In particular, the authors of the congratulatory letters were supportive of Mike Carson and Brian Clements who were said to be "able to impart knowledge gained in their respective Coast Guard and commercial diving backgrounds easily and effectively." They were described as "excellent instructors".

7. Tasking of Rescue Divers

As the Rescue Diving Pilot Project continued to develop RCC came to realize that the Rescue Diving Team provided an available SAR resource that could respond faster than the RCMP, city or municipal fire or police departments and, in many cases, much faster than the DND divers at Esquimalt or 442 Squadron at Comox. In the result, the Rescue Diving Team was tasked on a regular basis. Statistical material provided by Coast Guard SAR indicates that divers were dispatched in approximately 91 incidents from 1994 to 2000. Of these, 10 were recorded as rescue and the others, recovery, technical or other designation. The Sea Island records show a total of 41 dives during the term of the project.

As advised during interviews with various divers, a significant proportion of the total number of incidents where persons were submerged or were potentially submerged involved automobiles in the Fraser River. Various Coast Guard managers questioned whether this type of incident in the Fraser River fell within Coast Guard jurisdiction. Rescue Dive Team members indicated that they would go to any place where their services were required and where they could have a possible beneficial effect on the outcome of an incident.

8. Risk and Rescue Diving

In the course of interviewing divers, the Reviewer was told of many incidents which occurred prior to the establishment of the Rescue Diving Pilot Project. In those cases the divers were neither trained nor equipped as rescue divers. Nonetheless out of a strong desire to save lives, they went into the water without equipment and without the knowledge that makes trained rescue divers so much more valuable and secure. First hand accounts were provided of instances where Coast Guard members used rocks or other heavy objects to assist them to sink to the depths of a submerged car or vessel to determine whether they were occupied. This strong desire to save lives was incorporated into the pilot project.

Although rescue diving is admittedly an inherently risky activity this Reviewer heard evidence that dive team members were at times either willing to, or did, put themselves at too great a risk. One of the principal elements of the dive training is a continual emphasis on risk assessment and safety for each of the members of the dive team. Various divers interviewed advised of the consultation that would take place at the dive scene on any particular mission and the determination that would ultimately be made by the on-scene commander and the diver himself as to whether the dive would proceed. The need for constant and enforced discipline in order to ensure that divers did not go beyond the prescribed perimeters was discussed with dive team leaders including Mr. Clements and Mr. McFarlane as well as with team members.

It spite of the recognition of the importance of ensuring their own safety it was apparent to this Reviewer that the divers' desire save lives in some cases resulted in a willingness put themselves at risk. For example, in one case divers planned to dive well beyond established depth limits and in other cases interpreted regulations so as to expose themselves to greater risk than is apparently permitted by diving safety rules. Such rules including those of Human Resources Development Canada ("HRDC") which will be discussed below.

9. Specific Regulatory Limitations on Rescue Diving

Of major concern are to the dive safety requirements contained within the Canada Occupational Safety and Health Regulations (the "HRDC Regulations"). Regulation 18.48, enacted in 1998, requires that when a danger of entrapment exists a second dive team must be onsite before the first diver exposes him or herself to the risk. Several members of the Rescue Dive Team suggested that entrapment relates specifically to risk associated with pressure differentials which usually exist in the case of a dam or a water out-fall but in any event, relate to moving water. Accordingly, these team members felt that Regulation 18.48 should not apply to rescue diving involving capsized vessels or automobiles where such pressure differentials do not exist.

Comment was received from Bruce Townsend, Departmental Diving Safety Officer with the DFO with respect to interpretation of the HRDC Regulations. He provided some background information on the interdepartmental committee's consideration of amendments to the HRDC Regulations in 1998. In the first instance he advised that pressure differential, as an issue in diving, was very much a focus of the committee as it redrafted the then existing rules. The need to address this issue had resulted from the loss of a police diver in Cambridge, Ontario trapped as a result of a pressure differential. The concept of entanglement had not been specifically dealt with until there was a surge of activity when the CCG joined the committee shortly before the final regulations were approved. The Requirement for a second dive team in Regulation 18.48 came as a result of Coast Guard concerns regarding the possibility of entrapment for Type 2, that is, rescue divers. Accordingly, the genus of Regulation 18.48 appears to support the suggestion that the definition of "entrapment" in that Regulation includes the possibility of entanglement of divers in submerged vessels or automobiles.

The position of Rescue Diving Team members at Sea Island was that even if Regulation 18.48 applied it could be adhered to if a backup dive team had been dispatched and had an ETA earlier than the time when the first diver's air would be exhausted. It is clear to this Reviewer that the HRDC Regulations do not provide for this method of backup, although interestingly, the Rescue Diving Training Manual does.

Furthermore, there is considerable confusion as to what steps were actually taken with respect to a dive team backup. It appears that the standing instructions for the RCC were amended so that each time the Rescue Diving Team was despatched a backup team was to be automatically deployed unless notification was received from the dive team that a backup team was not required. While the records of RCC have not been reviewed in this regard, it is understood that the procedure was never put into effect and that in numerous, if not all cases, no backup dive team was dispatched unless specifically requested by the Rescue Diving Team. This failing with respect to proper use of a backup dive team is difficult to accept given the potential danger to the rescue divers and the specific requirements of the HRDC Regulations.

10. Pilot Project and Ongoing Costs

Information with respect to the costs of the pilot project has been taken from various reports and in particular with respect to possible future costs from rough estimates given by individuals who would have been responsible for determining the costs as the program went ahead.

The Four-Year Report of the Rescue Diving Pilot Project, authored by Brian Wootton who at the time was OIC of the Rescue Dive Team, observes that one-time start up costs, including training and spares, totalled $50,000. Since that time the project had expended approximately $35,000 per year for equipment maintenance, diver training and the $700 per year diving allowance paid to each Rescue Dive Team member.

The Report also makes reference to the "hidden" costs of co-ordinating the training and equipment maintenance for the divers. For this purpose, Brian Wootton estimated that the program cost approximately $60,000 per annum.

In any case it appears that efforts were made to minimize costs. As indicated in the Nemrava Report, divers at the Sea Island base participated in the pilot project on a volunteer basis. The allowance of $700 a year was paid to Rescue Divers on hovercraft crews only. No allowance was available to those in the officers group.

Generally there were few if any complaints about the cost aspect of the Rescue Diving Pilot Project except for the hovercraft and vessel time used in training. It was acknowledged by each of the Coast Guard directors interviewed that cost was not the overriding factor in reaching the decision to suspend and ultimately terminate the program. Concern was expressed with respect to cost if the pilot project was to be operated in accordance with national Coast Guard policy and the safety regulations.

George Horel, Regional Director Pacific for Fleet Operations, was not unexpectedly concerned about the potential for costs of the Rescue Diving Pilot Project escalating. He felt that in order to overcome the health and safety regulatory difficulties it would be necessary to increase the number of Dive Team Members which would, of course, increase costs. He had calculated that five new staff would cost between $400,000 and $500,000 per year. Mr. Horel also made reference to the possibility that other areas of British Columbia and Canada could demand rescue dive services if Coast Guard established a national program for rescue diving. This would, in his view, significantly increase the costs of delivering the service, particularly where it was to be done on a 24/7 basis.

Mr. Horel indicated that the Coast Guard had not completed a written cost analysis. He stated that it was a difficult task to separate the Rescue Diving Pilot Project from other costs associated with the operation of CCG Station Sea Island including the hovercraft operation.

This Reviewer did not conclude that cost was a significant factor in the decision to suspend and then cancel the Rescue Diving Pilot Project but acknowledges that a rough analysis of anticipated expense was performed.

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Reviews of Rescue Diving Pilot Project

Several reviews of the Rescue Diving Pilot Project had been completed when the decision to terminate the pilot project was made in February of 2001. The resulting reports were available to senior Coast Guard management including those attending the Management Board meetings in Ottawa. For example, Deborah Normoyle, as Director General of Marine Programs, had read the Four-Year Review before the November 2000 Management Board meeting, although she had not seen the Nemrava Report, which was summarised by Mike Henderson at that meeting.

11. Two and Four-year Reports

As previously stated the rescue diving project was established as a two-year pilot project. Although announced in January of 1995 operation of the pilot project did not commence until June 20, 1995 when a sufficient number of divers had successfully completed training.

In August of 1997 a two-year internal review was conducted by Brian Stevens resulting in the production of the Two-Year Report. That report canvassed cases requiring rescue diving services, the question of lives saved versus lives lost, some fiscal issues, a subjective appraisal of operational effectiveness, and an assessment of the appropriateness of the Sea Island location for rescue diving. Mr. Stevens' basic conclusion was that there had not been sufficient incidents to allow a fair and reasonable assessment of rescue diving capability. Nonetheless the information resulting from Mr. Stevens' analysis is helpful. For example, he was able to determine that the average response time for all dive incident taskings was 21 minutes and the range of response times for the three cases where rescue diving services were actually required had been 10, 13 and 22 minutes. He also observed that the dive team responded to seven cases of automobiles sighted or located in the river but in each of those cases it was concluded that the vehicles had been stolen and deliberately dumped into the river unoccupied.

Mr. Stevens also noted that the Rescue Dive Team had maintained over 99% operational readiness with only 10 shifts during the two-year period where no rescue diving capability was available. In the result, Mr. Stevens recommended that the pilot project be continued to enable collection of more definitive information.

A further internal review of the Rescue Diving Pilot Project conducted during the fourth year of the project by Brian Wootton, then officer in charge of the rescue dive project, resulted in the production of the Four-Year Report. In the letter delivering the Four-Year Report Mr. Wootton noted that no terms of reference had been identified for a final assessment of the project and therefore that he had prepared his review on the basis of the most obvious criteria available, including diver safety, SAR demand for divers and cost. The report includes a review of a number of operational experiences.

In describing the operational record, Mr. Wootton noted that the Rescue Diving Team had maintained operational capability in excess of 90% over the pilot project's four-year history. He also pointed out that there were no incidents where the Rescue Dive Team could not be tasked due to a lack of operational capability.

The Four-Year Report stated that in December of 1998 the Rescue Diving Team was made up of seven rescue specialists and eight hovercraft officers with others standing by for training. Mr. Wootton reported that the Rescue Dive Team has responded to three capsized vessel and 18 submerged vehicle incidents to that date. In addition, the team responded to 13 cases of submerged persons who had fallen from docks or vessels. Finally, seven underwater searches were mounted for missing scuba divers and three bodies were recovered.

The Four-Year Report also considered the training system and the need to keep divers "current" by conducting as much in-water training as possible. Mr. Wootton found that the efforts in this regard were satisfactory. He also noted other diving activity conducted by the Sea Island divers, where commercial divers would otherwise be used, had resulted in considerable savings to the Coast Guard. This other diving activity included diving for debris control and recovering of submerged objects such as navigation aid batteries.

Mr. Wootton addressed operational limits including experience with respect to depth where he concluded that pilot project experience suggested that 10 metres is a typical search and rescue dive profile. He conceded that some incidents might occur in depths greater than 20 metres which is the maximum permissible by Coast Guard policy and applicable regulations. The Four-Year Report also dealt with questions of submersion time and the practice of the rescue dive unit not to undertake a dive mission if the submersion time of the victim was in excess of 90 minutes.

Mr. Wootton addressed the issue of demonstrating a demand for rescue diving. He noted that the waters surrounding metropolitan Vancouver and Georgia Strait are amongst the busiest in the country and that they result in the highest concentration of marine distress cases occurring annually in the Pacific Region. Mr. Wootton went on to conclude that "on this basis the demand criteria was established - albeit for trial purposes".

The Four-Year Report also dealt with responsibility for rescue diving and regulatory compliance. Mr. Wootton concluded that there was no rescue diving capability, except to a limited degree from the RCMP or fire agencies along the British Columbia coast. He acknowledged that RCMP officers will attempt rescue dives but they are often hampered by response times that are longer than the survival potential of the drowning victims. He cautioned against the use of commercial divers since they are not trained in capsized vessel stability or generally for SAR applications. The Four-Year Report acknowledges that DND divers meet the criteria to operate effectively in a rescue mode, however Mr. Wootton noted that the DND's large area of coverage and potentially longer response times, were a handicap to success.

With respect to regulatory compliance the report is unclear on the status of compliance with HRDC Regulations.

Mr. Wootton acknowledged that the two options with respect to continuation of the pilot project were to abandon all diving activity or to adopt rescue diving at the Sea Island. He recommended that the rescue diving capability should be entrenched at Sea Island and provided some suggestions with respect to steps that would have to be taken as well as the costs of doing so.

It is not entirely clear from the information available how the Four-Year Report was received by Coast Guard management. The opinion of Coast Guard management, including the Regional Director Pacific Region, was sought subsequent to that reports completion but the question of the fate of the Sea Island Rescue Diving Pilot Project was not answered in any meaningful way until the second half of 2000.

12. The Nemrava Report

The issue of rescue diving surfaced at the meeting of Management Board in September of 2000. This was the first meeting for Mike Henderson in his new position as Regional Director Pacific and also for Deborah Normoyle in her new position as Director General of Marine Programs. It appears that there may have been some pressure to decide the fate of the Rescue Diving Pilot Project both from the Commissioner of the Coast Guard and others at the September meeting. However, the issue was put over to the November meeting for further consideration.

In the intervening period George Horel, Regional Director Pacific for Fleet Operations, initiated a review. Mr. Nemrava, a hovercraft first officer at Sea Island was asked on November 3, 2000 to conduct a review on the "long term delivery of rescue diving at Sea Island". Terms of reference were provided to him and he was asked to complete the project by November 15, 2000 so that a report on the human relations options and costs could be presented at the November 23, 2000 Canadian Coast Guard Management Board meeting. Mr. Nemrava did well to complete his review and report in the few days allowed to him.

Mr. Nemrava pointed out in the introduction to his report the report made no attempt assess the need for rescue divers, the degree of service required, or the Canadian Coast Guard's responsibility to provide divers as part of its mandate. These issues were presumably to be left with the Marine Programs Acting Director, Jon Churchill. The report therefore was to be confined to those issues relevant to fleet operations.

The Nemrava Report began with the issue of due diligence, health and safety and made the point that in order to prove due diligence the employer must ensure that a number of things are done. These things included meeting regulatory requirements, identifying risks and hazards in the operation, providing and maintaining equipment, ensuring that written procedures are approved and in place, providing management policy and direction and finally, ensuring that there is a sufficient number of employees trained and capable to perform the task. The report begins with the statement that "diving in general is one of the higher risk occupations. Rescue diving in particular must be considered as a high risk activity". Mr. Nemrava made reference to a report produced by RCC Victoria in December of 1996 in which various factors facing the rescue diver were discussed.

The Nemrava Report specifically referred to Part 18 of the HRDC Regulations concerning diving. Mr. Nemrava observed that the Rescue Diving Training Manual, developed for in-house use at Sea Island, did contain detailed procedures for dealing with reasonable and foreseeable high risk activities but failed to incorporate specific procedures in Part 18 with respect to rescue diving. He concluded as follows:

Specific requirements of rescue diving need to be captured in the Departmental Diving Procedures Manual and Fleet Safety Manual. This should include operational training, experience, team composition and equipment requirements. Without this in place it may be difficult for management to show due diligence on their part. This lack of policy also leaves the individual divers in a position where they are required to interpret and apply the regulations on their own."

The report then goes on to deal with the HRDC requirement in Regulation 18.48. Mr. Nemrava correctly pointed out that the regulation required a second dive team to be on-site before the rescue diver was exposed to any danger of entrapment. He also observed that the divers at Sea Island were interpreting the requirement in accordance with the Rescue Diving Training Manual which authorized a dive in order to save a life provided another dive team is enroute. It was noted that the Rescue Diving Training Manual was neither a Coast Guard approved or controlled document. Mr. Nemrava goes to point out that there is no requirement in the manual as to when the second dive team should arrive. In other words, there is no requirement that the arrival time of the second team must be within the air time available to the rescue diver.

Mr. Nemrava notes that the responsibility to dispatch a backup team in all cases where Sea Island divers are tasked, fell to RCC in Victoria. However, his review of the case logs for diving incidents at RCC for the calendar year 2000 revealed no record of a backup team being arranged when the Rescue Dive Team had been despatched.

This failure to ensure the proper availability of the second dive team was confirmed by other evidence. This shows a serious lack of communication between the RCC controllers or their superiors and the senior representatives of the Rescue Diving Team that may have led to a incident which would have occurred in violation of the existing HRDC Regulations.

The Nemrava Report also points out a second breach of the HRDC Regulations by the Rescue Diving Team whereby the second, standby diver was routinely allowed to enter the water in capsize vessel calls and to remain near a vessel opening in order to feed the communication and tether line of the rescue diver into the submerged vessel. While the practice seems sensible, it does result in the depletion of the standby diver's air while he is assisting and is in contravention of the HRDC Regulations that require the second diver not dive until needed.

Only after Mr. Nemrava issued his report in November of 2000 did some members of the Rescue Dive Team express their interpretation of the word "entrapment". They indicated that entrapment refers only to the condition that would result from a pressure differential caused by moving water. Both Nemrava and Drew Edey, who prepared the report in January of 2001, believed that entrapment would apply to entering a submerged vessel as well as to pressure differentials which are dealt with separately in the HRDC Regulations. It was somewhat disconcerting to this Reviewer to have many Rescue Dive Team members and rescue dive proponents argue that "entrapment" did not include the possibility of "entanglement" within a submerged vessel. Rather, these individuals took the rather technical position that entrapment only included such condition as results from a difference in pressures caused by the movement of water at a dam or in or near a pipe flue. The need for safety is paramount and even if the dive team interpretation is a correct one the HRDC Regulations do not distinguish between entrapment and entanglement and in the Reviewer's opinion must be taken to apply to both circumstances.

The Nemrava report also dealt with the training experience at Sea Island. It was observed that the Departmental Diving Safety Manual was silent with respect to training and experience requirements for rescue diving. However, as previously mentioned in this report, while proper documentation with respect to rescue diver training may have been lacking, the training procedures put in place by Brian Clements, Mike Carson and Tim McFarlane were excellent and were designed to ensure a disciplined and reasoned approach to diving hazards.

The Nemrava Report also dealt with the possibility of utilizing surface supplied air as opposed to scuba (self-contained underwater breathing apparatus) and noted that this was also a recommendation in a report on rescue diving prepared by the RCC. Mr. Nemrava concluded that to switch to surface supplied air would require an increase in the number of dive team members from three to four as in his view an extra team member would be required as a manifold operator. The staffing levels at Sea Island in November of 2000 were not sufficient to provide such an extra person. In discussing this recommendation with Bruce Townsend, with DFO this Reviewer was advised that the surface air operation could be done with a four-man hovercraft crew.

The Nemrava Report then dealt with human resource/staffing considerations and reviewed the options for providing a continuous dive rescue service on a 24/7 basis. He found that the current staffing levels at Sea Island were just sufficient to provide 24/7 rescue dive service. Further he commented that in order to guarantee such service the requirement to become a member of the Sea Island Rescue Diving Team could possibly have to be written into the job descriptions for positions at Sea Island.

The Nemrava Report also considered the possibility of continuing membership on the Rescue Diving Team on a voluntary basis in the same way that it had previously been provided. Mr. Nemrava concluded that even continuing the program on that basis would require that proper policy, funding and auditing to be put into place. He suggested that no additional personnel costs would be required except the salary of a dive supervisor. It is clear from the Nemrava report that the greatest danger from an operational and safety perspective in maintaining a volunteer team was the possibility that the Rescue Diving Team would dive without the required numbers of divers. He noted that there can be extreme pressure from the public, the media and other agencies for individual members of the dive team to take action and referred to at least one instance where three Coast Guard crew members were lost in a rescue boat accident in Middle Cove, Newfoundland.

The Nemrava Report referred to alternative methods of delivering rescue dive services including use of commercial divers. Further the Report mentioned an RCMP report that considered the possibility of providing dive service by establishing partnerships with other agencies such as police and fire departments. The reviewers in the RCMP report concluded that the opportunities were limited but Mr. Nemrava concluded, correctly in the Reviewer's view, that there is a likely potential for such partnerships either with RCMP or with other agencies in the Greater Vancouver area.

Mr. Nemrava's conclusion reads as follows:

"During the five year period of the pilot program considerable expertise in diving has been gained at Sea Island. This pilot program has however gone on long enough. The department is putting itself at risk by not having approved policy and procedures in place. A decision needs to be made as soon as possible to entire endorse diving as a CCG activity or get out of it entirely. However, management should not feel that this is an all [meaning 24/7 - rescue dive service) or nothing proposition].

Continuing to provide diving using the current staffing method (volunteers) at Sea Island is a viable option provided clear departmental policy and procedure is in place. This option was presented as the best option in the year four internal review and should be looked at as a serious option. Using this option the department maintains the expertise gained during the pilot while leaving the door open to either expanding or cancelling diving in the future, while at the same time protecting the health and welfare of its employees and the department from liability."

When interviewed Mr. Nemrava acknowledged that he had offered both options to Canadian Coast Guard management. He also advised that, while he was writing the report, he met with Jon Churchill, the Acting Regional Director of Marine Programs, and advised Mr. Churchill of the HRDC backup dive team issue. Mr. Nemrava specifically remembers telling Mr. Churchill that the regulatory and other difficulties described in his report could be remedied.

Finally, in the course of the interview Mr. Nemrava disagreed with the comment that underwater diving was not part of Coast Guard's mandate. He stated that "if it takes diving to save a mariner from drowning then it should be done". Of course, he acknowledged that one must also consider the practicalities and the appropriate regulation.

The remaining report prepared by Drew Edey will be discussed in the section below concerning the Coast Guard decision to suspend and ultimately cancel the Rescue Diving Pilot Project.

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Coast Guard Decision to Suspend/Terminate

The Decision to suspend and then formally terminate the Rescue Diving Pilot Project must be considered from the national and regional Coast Guard management perspectives. The following section will review decision-making process with respect to rescue diving at both the national and regional levels. Further, the question of the need for dive services and public consultation in that regard will be briefly addressed.

13. Ottawa Opinion

Over the years a controversy has continued with respect to whether Coast Guard should supply diving services as part of its mandate. In fact, some say rescue diving is not part of the CCG mandate for SAR. Documentation in the Coast Guard files in Ottawa shows that the question of the expansion or reduction of diving services has been a difficult one for a number of Coast Guard commissioners over the years.

John Adams, who was appointed Commissioner in December of 1998, was briefed on the Sea Island Rescue Diving Pilot Project when he first visited the West Coast. Mr. Adams had some background knowledge about diving and understood the risks. He indicated that it had been discussed from time to time and, in particular, that he had raised it at the Management Board meeting in September of 2000. He asked Mr. Henderson, who was attending his first meeting as Regional Director, to consider what Coast Guard was doing in the business of rescue diving. He indicated that the question would come up again at the November meeting. In the interim Mr. Adams studied the file material for the early 90's and the available reviews with respect to the pilot program. Mr. Adams spoke with Mr. O'Neill, president of IMO, who confirmed that other coast guards around the world were not doing rescue diving.

When interviewed, Mr. Adams indicated, as did others in Ottawa, that there was very little support in the Coast Guard nationally for rescue diving. To a great degree it appeared that rescue diving proponents were located only on the West Coast at the Sea Island Coast Guard base. This lack of support in Ottawa and at the management level in British Columbia, and apparently in other provinces, was probably fatal to the continuation of the Rescue Diving Pilot Project at Sea Island. The flaws in the pilot project could have been fixed if support for development of a national policy and recognised and approved safety and training manuals had been undertaken by senior Coast Guard management. To the contrary, it appears that many of the senior management had come to the conclusion that Coast Guard should not be involved in rescue diving and accordingly the pilot project was bound not to have a future.

Without positive endorsement in Ottawa, or support in the Pacific Region from Marine Programs with respect to demonstrating a need for the pilot project, or support from Fleet Operations with respect to policy, funding and staffing, the pilot project could not justify its continued existence.

Deborah Normoyle was appointed Director General Marine Programs of the Coast at a meeting on September 5, 2000. Ms. Normoyle confirmed that the question of rescue diving was raised at the September 5th meeting but that detailed discussion was put off until the next meeting in November on the basis that some further review was to be done by the regional office. Still, at the September 5th meeting the question of the Coast Guard policy on rescue diving was discussed briefly but it appeared that there was very little support for rescue diving.

14. Regional Office Opinion

On his return to British Columbia Regional Director Henderson put the question whether the Coast Guard should be in the rescue diving business back to George Horel and Jon Churchill. As previously mentioned, Mr. Horel commissioned the Nemrava Report on November 3, 2000.

Although the responsibility for staffing and funding of the pilot was Mr. Horel's evaluation of the need for a rescue dive program was Mr. Churchill's responsibility. Accordingly, Mr. Churchill's consideration in this regard is of importance.

Mr. Churchill had been involved in a number of areas within Coast Guard over his thirty-four years of service. These included search and rescue, fleet personnel, employment management for students, aids to navigation, navigable waters protection and environmental response. He indicated that when he became Acting Director of Marine Programs in April of 2000 he noticed very little in the way of reports on the Rescue Diving Pilot Project.

Mr. Churchill recalls that the rescue diving issue began to heat up in July of 2000 but it came to a head in September. Although Mr. Nemrava did not interview Mr. Churchill during the preparation of the Nemrava Report they did discuss the report on two occasions after it was issued.

During the Fall of 2000, prior to the completion of the Nemrava Report, Jon Churchill, George Horel, Mike Henderson and the other members of the Regional Management team met weekly and discussed the question of the Rescue Diving Pilot Project. After the delivery of the Nemrava Report that report was also discussed. Ultimately, of the two options contained within the Nemrava Report, that is to cancel the program or to provide additional funding and support to entrench it, the managers felt that the program should be cancelled.

A number of factors relevant to the operation and continuation of the Rescue Diving Pilot Project have been discussed with members of the Regional management team. Although they are not the subject of any particular report or written memorandum that has been seen, the Reviewer is satisfied that the below factors are relevant and either were or should have been considered as the Rescue Diving Pilot Project was being reviewed. They include the following:

The international mandate for rescue

SOLAS and other international agreements provide that Canada as a signatory should provide search and rescue services on its coastlines. No specific reference is made to rescue diving but the general inference is that all possible steps should be taken to rescue persons in peril on the sea. The lack of activity in this area in the United States and the U.K. appears to have had some influence on the CCG in this respect. Although it is not clear to what degree this issue was considered by Coast Guard management the issue was mentioned during this Reviewer's interview with John Palliser, Superintendent of the RCC.

Requirements for a national program

The Marine Programs directorate of Coast Guard has as its responsibility creation of programs by which Coast Guard will deliver its services to Canadian citizens where there is a perceived need for such services.

Some Coast Guard managers suggested that it would be necessary to have rescue dive services available as a national program. This does not mean that all areas of Canada must have the same program at the same time but that it should at least be possible to deliver the program in all areas. However, it was generally agreed that the requirement to implement a program nationally was not itself fatal. Still, it was apparent that Coast Guard managers were concerned that if it became necessary to expand provision of rescue dive services outside of the lower mainland the cost of providing rescue dive services would increase significantly over what was being expended during the pilot project phase.

Human Resources issues

This factor was considered in the Nemrava Report and by George Horel in his assessment of the future viability of the rescue dive program. Mr. Horel has been Regional Director of Fleet Operations since November of 1998. In this capacity Mr. Horel is responsible for the ships and equipment, for training and staffing and for safety management on an operational and costing basis. His area of responsibility includes Coast Guard's obligation with respect to SAR and the Human Resources aspects at Sea Island and Kitsilano.

Mr. Horel evaluated the Nemrava Report and both he and Jon Churchill met with HRDC representatives. Mr. Horel considered the issue of the number of people required to provide a full 24/7 rescue dive service and concluded that it would not be possible to properly staff a rescue diving unit without an increase in crew of about 25%. He noted the difficulty of crewing hovercraft at Sea Island while supplying sufficient divers to satisfy the HRDC Regulations. Further, he noted that even if sufficient rescue divers could be provided in the short-term difficulty would arise in the long-term when hovercraft crew subsequently decided they no longer want to dive. Further, Mr. Horel also believed that increased training time and better record keeping were essential to any future rescue diving program at Sea Island.

Risk and safety regulation

During the fall of 2000 the conflict between requirements of the Rescue Diving Training Manual and HRDC Regulations became a focal point in the discussion on the future of rescue diving. This issue was addressed with in the Nemrava Report and was the subject of discussions between Mr. Horel and Mr. Churchill leading up to the decision made at the Management Board meeting on November 23 and 24.

As previously mentioned the HRDC Regulations did not permit a diver to enter a submerged vessel where there was a risk of entrapment until a second team was on site. This Regulation had the effect of undermining the ability of the Sea Island team to respond quickly in order to assist a person trapped in a submerged vessel.

Loss of experience and equipment

This factor was certainly in the minds of rescue divers and others including the Lower Mainland Advisory Council and the Western Marine Community. A great deal of work had been done in creating the training modules and the Rescue Diving Training Manual and, even if amendments had to be made, not utilising these valuable tools in the best interests of search and rescue seemed to many to be a waste. It is not clear to what degree Management considered this issue.

Success of program

Although most agree that one cannot measure the success of the Rescue Diving Pilot Project in simple terms of number of lives saved, it seems clear that the lack of statistical results influenced members of the Management Board. The minutes of the November meeting contain the statement that "the Department is putting itself at risk for a program of marginal utility". The issue of the need for rescue dive services is also of relevance and will be discussed in a separate section below.

Coast Guard morale

Clearly, both from reading the Reports and from interviews conducted of a number of the individuals in the Rescue Diving Pilot Project, there is a great reinforcement of the morale of those involved in Coast Guard Search and Rescue resulting from the ability to do everything possible, including rescue diving. A sense of accomplishment and resulting pride is a great benefit. This benefit was acknowledged in the Reports but, if considered by Management, does not appear to have been an important factor in their decision. In interviews after the fact it was conceded that there was a good deal of pride and camaraderie amongst the hovercraft crews at Sea Island.

Public confidence

There does not appear to have been any real consideration given in the November 2000 Nemrava Report to issues of public demand and public confidence in the Coast Guard's delivery of SAR services. This issue was canvassed to a greater degree in Edey Report prepared in 2001, after the Management Board's November decision to terminate the Rescue Dive Pilot Project.

It is clear though that no significant effort was made to determine the views or the wishes of the public prior to the cancellation of the Rescue Dive Pilot Project. In fact, opinions that were offered in support of the project seem to have been ignored.

This subject, in the context of the Coast Guard's consultation with its Lower Mainland Advisory Committee ("LMAC") on February 12, 2001 will be discussed below.

Rescue Diving in other jurisdictions

Coast Guard Management considered this issue. In particular, Management was aware that the United States Coast Guard and the Coast Guard in the United Kingdom did not provide diving services. This information had been with them for some time. The Reviewer saw no evidence of specific research in this area, but the accuracy of the conclusions has been confirmed by discussion with Coast Guard officials in those jurisdictions. Provision of rescue dive services by the RCMP and police along with fire departments, including particularly the Richmond fire department and DND, was considered by Coast Guard management although the willingness of these agencies to provide such service was not discussed with them.

15. Need for Rescue Diving

In addition to those mentioned above one of the most difficult and important issues in deciding whether a rescue dive program should or should not be provided is the need for dive services. Simply stated, the position of Coast Guard divers, other emergency response organizations and members of the marine community, including the LMAC, is that there is a need for dive services and that the Coast Guard should provide such services. It is clear to this Reviewer that Coast Guard management was largely unconvinced that there was a need for rescue dive services and felt that even if such services were needed, the Coast Guard should not be responsible for providing them.

Almost universally divers interviewed advised in an articulate and passionate way that rescue diving is a necessary service that should be provided by the Coast Guard especially from Sea Island where fast amphibious vessels and aircraft are available. Divers related many instances to the Reviewer, some before and some after the creation of the Rescue Diving Pilot Project, where their skills have been called upon for rescue purposes.

In an interview of approximately 12 people at the Kitsilano Coast Guard station the Reviewer was advised of the attendance by Kitsilano Coast Guard members on a submerged car in False Creek on December 1, 1994 where two individuals from the crew of the attending Coast Guard vessel duck-dove, without scuba equipment, in an attempt to determine the state of the lone occupant of the car. Others described numerous other instances of similarly brave but perhaps risky conduct in the course of the interview. The point that they are demonstrating by describing such instances is that where Coast Guard divers are properly equipped and properly trained they can satisfy their own and the public need to do everything possible to save the lives of the people in the submerged vehicle or vessel. Without training and equipment any attempt to save a life, whether permitted or not, is far more risky.

When one raises the question as to the number of lives saved, Rescue Diving Team members correctly point out that to measure on the basis of lives saved alone is not necessarily appropriate. The more important factor, particularly in the view of those who do the actual diving, is being able to take every possible step and use every available skill in furthering the SAR mission so that at the end of the day they are able to clearly state that they did their best to rescue people and attempt to save lives. This theme was put forward with great passion by dive team members Chris MacKay and David Percy both of whom had experience with incidents both before and after the Pilot Program was initiated. Mr. Percy and Mr. McKay, along with their compatriots, had felt the pride of doing a job well and the sorrow and compassion where their rescue efforts were not successful in saving a life.

Coast Guard managers, not in favour of rescue diving as a Coast Guard activity, tend to measure the risk of rescue diving against the successes. While acknowledging that success is not necessarily measured in terms of lives saved, they conclude nonetheless that the rescue diving program was one of "marginal utility".

When Mr. Nemrava was asked by George Horel in November 2000 to prepare a report on the long-term delivery of rescue diving at Sea Island he specifically, and probably appropriately, left the question of need to Jon Churchill. Thus, Mr. Nemrava prepared for Operational Services a report on his review of training and equipment requirements as well as the human relations options but did not address need.

Mr. Churchill, upon receiving the Nemrava Report, wrote about the need for diving in his November 29, 2000 memorandum to Mike Henderson and others announcing the suspension of the Rescue Dive Pilot Project. This memorandum was written after discussions with the Pacific Region Directors and approximately one week after the Management Board meeting in Ottawa on November 23rd and 24th. The close proximity in time between Mr. Churchill's receipt of the Nemrava Report and the Management Board meeting and ultimately the decision to suspend the program implies that there was not much consideration given by Mr. Churchill to the need for dive services.

In any event, in his brief report to Mike Henderson, Mr. Churchill notes as follows: "The original raison d'être of the project was to provide a rapid mobile marine response for underwater rescues. The move in this direction was largely prompted by a few high profile incidents in the early 1990's. From the start the need for such a response was not recognised or supported by the National Marine Program's Directorate or the National Search & Rescue Branch and so it remains an activity outside of the Coast Guard's core mandate.

Today the need for the Coast Guard to have a rescue diving capability is no more certain than it was five years ago. While the availability of having such a resource was valuable on a few occasions, the risk to the department of having a program in place that isn't resourced 'to do it right' is very high."

Mr. Churchill then observes that there are neither the resources nor the national support to continue the project and therefore it is time to bring it to an end.

16. Likelihood of Saving Lives

In addition to the need for rescue dive services the likelihood that such services can be provided in time is of great relevance to this report. The ability of the Coast Guard to save a life using rescue divers is directly related to its ability respond to dive emergencies in time. Response time issues include distance to incidents, the existence of air pockets in capsized vessels or automobiles and the resuscitation window for drowning victims. It has been the consistent opinion of members of the Rescue Diving Team that the team was able to respond within an acceptable period of time.

Proponents of a Rescue Diving Team point out the numerous possibilities for tragedy, particularly in the lower mainland/Georgia Strait area. These possibilities arise from, for example, vessel and floatplane traffic on the Fraser River and Burrard Inlet, air traffic at the Vancouver Airport and commercial vessel, ferry, and pleasure boat traffic in surrounding areas. With respect to responding to incidents, this Reviewer believes that the hovercrafts at Sea Island are the ideal vessels to provide fast and versatile response to emergencies in the lower mainland/Georgia Strait where rescue dive services may be required. The larger of the two hovercrafts based at Sea Island, the SIYAY, travels at speeds of up to 60 knots and therefore has a response area larger than other surface vessels.

With respect to the existence of air pockets, the Reviewer has been advised that the existence of an air pocket in a capsized vessel may provide a far greater chance, over a longer period of time, of successfully saving the life of an individual trapped beneath such a vessel. Accordingly, in the case of a capsized vessel the ability to save a life and therefore the need to have a fast response Rescue Diving Team is enhanced. The Reviewer was further advised that it is unlikely that such an air pocket will exist in the case of a submerged automobile. The question of whether there is a reasonable chance of resuscitating an individual trapped underwater is somewhat controversial. Although brain damage will generally ensue within four minutes of an individual's heart stopping, medical advances have extended the potential resuscitation window in drowning incidents to well beyond 60 minutes. Successful resuscitation depends on factors including water temperature, the age of the victim and the existence of other trauma. The members of the Sea Island Rescue Diving Team selected 90 minutes as a response window on the basis that individuals submerged within the waters off of the British Columbia coast could potentially be resuscitated within that period of time. It should be noted that to the degree that the ability to resuscitate drowning victims was considered, it appeared that Coast Guard management considered the norm rather than the exception in terms of defining a resuscitation window and measured useful response time in minutes rather than a longer period of time.

17. Public Consultation

As discussed above, the view of the public with respect to the need for rescue divers has not been fully measured by this review except in a limited way as presented by various groups with a particular interest in Coast Guard activity. That being said, it was clear to this Reviewer that the Coast Guard decision to cancel the Rescue Diving Pilot Project did not take into account the position of the group designed to provide public opinion, the LMAC. The LMAC, consisting of residents of the lower mainland with relevant background in marine matters, was intended provide input to the Coast Guard with respect to its programs and activities.

Interviews were conducted with Gary Thompson, Chairman of LMAC and other LMAC members who were present at various meetings including the meeting on February 12, 2001 attended by Regional Director Henderson. Mr. Thompson advised of his experience in the insurance industry over many years and also of work that he had done with Coast Guard auxiliary and SAR on a volunteer basis. Mr. Thompson explained that LMAC was a group of interested parties representing various sectors of the marine community including the Regional Recreational Boating Council, the United Fishermen and Allied Workers Union, Vancouver Airport and Richmond Fire Department. Through these individuals LMAC is able to express opinion on various Coast Guard issues to Coast Guard representatives who also attended the meetings.

In the February 12, 2001 meeting members of LMAC questions were raised regarding seaplane movements and boating safety in Greater Vancouver. Gary Thompson advises that there was no question that the LMAC position was strongly supportive of rescue diving. Given the strong belief of members of LMAC that rescue diving should be continued and that the Coast Guard's formal decision to terminate the program was made on February 16, 2001 (four days after the February 12, 2001 LMAC meeting) it appears that the brief public consultation process was for the most part cosmetic. Further, it should be noted that although it appears that the decision to cancel the Rescue Diving Pilot Project was all but made at the Management Board meeting in November of 2000 the LMAC was not advised of that fact at the February 12 meeting. Rather, LMAC members have indicated that when the meeting was closed they were left with the distinct impression that the decision regarding the continuation of the pilot had not been made.

It seems clear that the very strong opinion of the LMAC was disregarded almost entirely by the decision-makers in reaching their conclusion to discontinue the dive project and not provide for any future component of rescue diving in the Sea Island base activity.

A number of the members of Rescue Diving Team, past and present, have made strong statements with respect to public expectation. One appreciates that the anecdotal advice comes from times and circumstances of great stress where often a child or other family member is submerged in a motor vehicle or vessel. However, the image created by divers interviewed was that when the "big red boat" arrives on scene the immediate reaction is something like, "Thank God, you're here. Get your divers in the water". The inability to accede to that request is one that places considerable stress on the individual members of the hovercraft crew including, in particular, the divers but even more so, is met with disbelief by the public

Other public bodies including the Western Marine Community Association, local police and fire departments, Council of BC Yacht Clubs, Pacific Coast Fishermen's Mutual Marine Insurance Co. and The British Columbia Marine Trades Association (representing approximately 300 boat and accessory manufacturers and dealers, yacht brokers, fishing resorts and dive operators) have expressed support for the continuance of rescue diving at Sea Island.

Difficult as the process of public consultation may be, there does not appear to have been a particularly great effort to seek public input on the issue of the future of rescue diving at the Sea Island base. One would have expected a more formal approach to organizations such as the Western Marine Community Corporation, the Vancouver Airport Authority, the Richmond and Vancouver municipal authorities including police and fire department and others concerned with safety on the river or in the tidal waters of southern British Columbia. The interviews conducted in the course of this review show strong support for continuation of the rescue diving capability.

18. The Decision to Formally Terminate

Much of the background leading up to the decision, which was made at Management Board meeting in November of 2000, is set out above. George Horel received the Nemrava report by e-mail on the 17th of November. He passed that document to Regional Director Henderson and to Jon Churchill. Mr. Churchill advised that the Pacific Region Directors group met prior to Regional Director Henderson's departure for Ottawa and discussed the issue of rescue diving. At that time Mr. Churchill provided his view that any mandate for such activity was lacking and accordingly, given the "safety" issues and other factors, it was determined that Mike Henderson would recommend the termination of the project.

At the November 23/24, 2000 meeting in Ottawa, Mr. Henderson gave a brief summary of the report to the members of the Management Board who were quite familiar with the project. There was limited discussion and no review of pros and cons. The Reviewer was advised that the decision reflected a belief by the Management Board that rescue diving was not within the Coast Guard mandate and did not include an analysis of whether it should be part of that mandate.

Regional Director Henderson, on reporting to Donna Petrachenko, Regional Director of DFO, decided to commission a further review of the safety issues surrounding rescue diving before implementing the decision of Management Board. Therefore, although the Management Board decision to terminate the program had already been made, on November 29, 2000 Jon Churchill issued notice that the program was suspended and required that rescue divers should no longer be tasked. At that time RCC was instructed not to despatch the Rescue Dive Team and dive equipment placed in storage.

The circumstances of the initial advice to the divers of the suspension of the program were unfortunate. It became necessary for the Coast Guard officer in charge at RCC to stand-down a dive team which had been despatched to Campbell River on a SAR mission. In fact, the orders came when the team was on-scene and was preparing to make a dive. It is interesting to note that if the team had proceeded to dive, the dive would have been at depths much greater than those permitted by the HRDC Regulations or the limitations in the Rescue Diving Training Manual.

In furtherance of the wish of Regional Director Henderson and Donna Petrachenko to have additional information concerning the safety issues before actually terminating the pilot project, Drew Edey was appointed in early January to conduct a review. It was intended to have HRDC perform an audit but, as they refused given the suspension of the program, Mr. A.D. Skaalrud was asked to conduct an audit and evaluate the diving practices at Sea Island to determine if the HRDC safety requirements were being met.

Mr. Edey and Mr. Skaalrud attended at the base from January 22 to January 24, 2001 and reviewed the equipment, maintenance, administration, initial diver training and continuation training along with the regulations and operations. The jointly prepared Edey Report was issued on January 25, 2001 in which it was concluded that there was "no doubt that deficiencies and room for improvement exist within the current practices of the dive project and relative to regulation". Although it recognized serious deficiencies the Edey Report pointed out that the current HRDC Regulations for type 2 diving and, in particular, the need for a second dive team on site, could be met using outside resources. Further, the Edey Report indicated at the same time that management should evaluate the impact on rescue dive project effectiveness resulting from the need to postpone the dive process until a second team arrived.

Mr. Skaalrud found a number of deficiencies including with respect to equipment maintenance, records, continuation training and compliance with regulations. Conclusion and recommendations indicated that the divers at CCG station have invested considerable effort to make the pilot project function safely and efficiently. However, sections 18.14 and 18.48 of the HRDC Regulations were in conflict with indicated practice and procedure. Further, the report concluded that through changes to existing procedure and documentation the conflicts could be addressed and made recommendations for the correction of administrative and operational deficiencies. It is not clear what the distribution of the Edey Report was after it was issued on January 25th or whether any subsequent discussion took place with the Sea Island personnel in terms of individual items.

At the meeting of February 12, 2001 attended by Regional Director Mike Henderson and six members of the LMAC, Henderson explained the Coast Guard position including the results of the Edey Report. Henderson acknowledged the feedback from the members of LMAC their strong support for maintaining a rescue diving capability. Mr. Henderson acknowledged that Gary Thompson, the chairman, and Roger Boshier were outspoken and insisted that rescue diving be maintained. Mr. Henderson advised LMAC members that it was a difficult decision and further indicated that the U.S. Coast Guard was not in the rescue diving business and that only Vancouver was doing rescue diving in Canada. He discussed the health and safety issues and he stated that rescue diving was not a Coast Guard mandate. As well, there was some discussion concerning the DND rescue diving efforts and the response time that was required. At the close of the meeting Mr. Henderson advised that a decision would be made in approximately two weeks.

The Reviewer interviewed Roger Boshier, a professor in the Department of Educational Studies at the University of British Columbia and a marine salvage businessperson. Mr. Boshier has had a number of years experience in the latter area and is interested both in the rescue and the sociological aspects of search and rescue. Mr. Boshier is a strong supporter of the Rescue Dive Project and was very disappointed with respect to the decision making process as well as the cancellation. In the course of the interview he said that "the concept of consulting the public and ignoring the opinion obtained is a well-established tradition in Coast Guard and Fisheries". In part this reaction stems from Mr. Boshier's view that Regional Director Henderson should have advised of his position that the dive program was to be terminated and openly discussed that decision. As it was, at least in Mr. Boshier's view, Mr. Henderson left the LMAC meeting with the impression that their points had been convincing and that he would make his decision within two weeks. The decision was of course made four days later. Mr. Boshier confirms that he had not met Mike Henderson prior to the February 12th LMAC meeting. He states that he was not aware of the suspension of the dive program in November.

In spite of the recommendations contained within the Nemrava Report and the Edey Report and the stated position of the LMAC, on February 16th a meeting was held at Sea Island where Mike Henderson advised of the Coast Guard's decision made that day to terminate the Rescue Diving Pilot Project.

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The Sandhu Incident

As stated in the introduction to this report, the unfortunate and tragic death of Sukhpal Sandhu resulted in a very high profile focus on the decision to terminate the Rescue Diving Pilot Project. In the course of this review numerous questions were asked with respect to the incident and, in particular, concerning the Coast Guard's response. Interviews were held with Mr. Sandhu's brother Mandip Sandhu, with a Coast Guard hovercraft crewmember/former diver as well as with representatives of the Richmond Fire Department and the Richmond RCMP. The Richmond RCMP was unable to provide detailed information, as was the Coroner's Office, while the investigation into Mr. Sandhu's death was ongoing.

It is not the function of this review to investigate the incident in detail or to reach conclusions with respect to the numerous questions that may well still be outstanding in the minds of Sukhpal Sandhu's family and others. However, the information concerning Mr. Sandhu's death is of some relevance.

Mr. Sandhu's car, which contained him and a passenger, went over the dyke on the south side of the Middle Arm of the Fraser River early in the morning of February 18th. The car landed in the River 20-30 feet from the shoreline. Mandip Sandhu advises that the female occupant of the vehicle was able to escape through the broken windshield and make her way to shore without great difficulty. He also confirms his understanding that the driver side window was open.

It appears that when the Fire Department arrived on scene they did not know that the Coast Guard no longer engaged in rescue diving, and advised those assembled that the Coast Guard would dive when they arrived. The ambulance service and the RCMP were also in attendance.

Times provided by various individuals are somewhat different, but the RCMP has advised that they received a telephone call from a citizen at 0336. The log of RCC indicates that the RCMP requested the hovercraft to respond to a submerged car at 0348 and the hovercraft was on the scene by 0355.

Julie DeGranpre, the Coast Guard rescue specialist on the hovercraft, advised that the car had not been found when they arrived. However, with the assistance of people on shore and hovercraft lights, the vehicle was quickly located and two firemen in rescuer swim gear swam out to the car. Although firemen managed to attach lines to the vehicle so that it could be pulled from the water they did not go beneath the surface to attempt to extricate Mr. Sandhu. Firemen were not able to dive due to the lack dive gear and the total lack of visibility and apparently stood on car prior to attaching the two lines.

By the time an RCMP diver arrived, approximately 40 minutes after the initial report, the car had been pulled from the water.

This image is a disturbing one for Mandip Sandhu. He told the Reviewer that it might have been better if none of the RCMP, Fire Department or Coast Guard had been present because perhaps some other bystander would have gone down to the car window to reach in and attempt to pull Sukhpal Sandhu free.

The confusion as to who would and who would not dive was unacceptable and extremely stressful for those involved. Ms. DeGranpre, as a Coast Guard employee, can not be criticised for following the Coast Guard directive not to dive.

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Lack of Notice Regarding Suspension and Cancellation

There was an unfortunate lack of notice provided to the public and to other emergency response service providers concerning the status of the Rescue Diving Pilot Project at Sea Island. This lack of notice represents a serious flaw in the process of cancelling the pilot project.

Representatives of agencies including the Vancouver Fire Department, Vancouver Police Department, Richmond RCMP, RCMP "E" Division Dive Team, Richmond Fire Department and the Vancouver Airport Authority have indicated either that they were not formally advised or have no recollection of being advised by Coast Guard management of its November 29, 2000 decision to suspend the program. Further, there was no formal notice given to those agencies of the February 16, 2001 decision to cancel the program. According to some of these officials the first real notice that the dive program had been cancelled came in the form of media reports to that effect after the death of Mr. Sandhu on February 18, 2001.

It should be noted that the dive program was officially cancelled on Friday, February 16th and that the Sandhu incident occurred on Sunday, February 18th. Accordingly, it would have been difficult to advise other agencies of the cancellation of the program prior to the Sandhu incident. Of course, notice of the suspension could have been provided any time after November 29, 2000.

The lack of notice of the suspension and subsequent cancellation of the Rescue Diving Pilot Project to the public and to other emergency response service providers is disturbing. Given that the dive program had been in operation since early 1995 it is entirely likely that there was an expectation after November 29, 2000, both from the public and from other emergency response service providers, that rescue divers from Sea Island were available to provide rescue dive services. This expectation was apparent when the Coast Guard attended at the Sandhu incident in Richmond British Columbia on February 18, 2001. Julie De Grandpre advised that with the exception of members of the ambulance team, both Richmond RCMP and Richmond Fire Department personnel did not know that Rescue Diving Pilot Project had been cancelled. Senior representatives of both the Richmond RCMP and Richmond fire department confirm that they do not recall receiving formal notice of either the November 29, 2000 suspension or the February 16, 2001 cancellation of the dive team.

A further example of lack of knowledge regarding the status of the Rescue Diving Pilot Project is found in the RCMP "E" Division dive team. Sergeant Dennis Erickson, head of the RCMP dive team, advised that as late as January of 2001, after the program had been suspended but prior to the Sandhu incident, he intended to contact the divers at Sea Island base to discuss co-operative training exercises. He first became aware that the program had been suspended from reports in the media after the death of Mr. Sandhu.

The Coast Guard decision to suspend the Rescue Diving Pilot Project removed a valuable and expected service to ensure public safety. The Coast Guard should have taken steps to so advise the public and the other organizations that might have been looked to by the public to provide rescue diving services in the Coast Guard's absence.

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Current Rescue Dive Capability in British Columbia and in Other Jurisdictions

As part of this review process this Reviewer contacted emergency response organisations in British Columbia and other areas including Calgary, Alberta, Toronto, Ontario and the United States regarding rescue diving. Given the limited time available it has not been possible to conduct an exhaustive review of rescue dive services provided outside of British Columbia. Accordingly, there may be instances where this review does not mention rescue dive service providers in other jurisdictions.

19. Rescue Dive Services Within British Columbia

The Rescue Diving Pilot Project at Sea Island base was unique in that it was the only program of its kind designed to provide emergency rescue dive services on a 24/7 basis; that is, 24 hours a day seven days a week. That being said, other organizations have provided rescue dive services on a less than 24/7 basis for many years. Currently, rescue dive services are potentially available from the Rescue Co-ordination Center; by the RCMP "E" Division Dive Team, although their divers are officially classed as "recovery divers", and by the British Columbia Provincial Emergency Preparedness (PEP) Dive Team situated in Terrace, British Columbia.

It should be noted that the Vancouver Police Department, the Vancouver Fire Department and the Richmond Fire Department do not provide rescue dive services. Although the Vancouver Fire Department currently does not have divers of any kind in its crews that agency did provide rescue dive services more than ten years ago. Due to difficulties maintaining its dive team, including staffing and safety issues, the team was disbanded. Approximately two years ago the Vancouver Fire Department considered re-establishing a rescue diving team but chose not do so due to concerns with respect to its ability to provide sufficient divers to comply with provincial safety (WCB) standards. Further, it is the position of the Vancouver Fire Department it is the jurisdictional obligation of the Coast Guard and not the fire department's to provide rescue dive services in waters surrounding Vancouver.

19.1 Rescue Co-ordination Center ("RCC"), Esquimalt British Columbia

Interviews were conducted of the Canadian Airforce officer in charge of RCC, Major Patrick McSorley with the DND, as well as with Superintendent John Palliser with the Coast Guard.

Current rescue dive capability is provided through tasking of Search and Rescue Technicians ("SAR Techs") from the RCC. Although DND is primarily responsible for provision of search and rescue ("SAR") services the RCC is jointly run by the DND and the Coast Guard. Currently RCC is administered on the DND side by Major Patrick McSorley who is assisted by Coast Guard Superintendent John Palliser.

The Coast Guard provides marine resources, including response vessels, rescue-coordination personnel and communications services for search and rescue operations. DND provides air resources which include fixed wing aircraft and Labrador helicopters, SAR Techs and rescue coordination personnel. SAR Techs, who are all trained divers, are attached to the 442 Squadron.

According to Major McSorley the RCC mandate with respect to non-aeronautical or maritime incident rescue diving is to assist provincial/municipal authorities when requested. Article 4.41 of the National SAR manual provides that where not employed in an aeronautical or maritime search and rescue incident DND and Coast Guard units may be dispatched to humanitarian incidents, formally called civil incidents, when properly requested and when such a request is approved by the RCC Officer in Charge. It appears that incidents concerning missing divers or vehicles in the water fall within the category of "humanitarian incident".

During the summer SAR Tech's are available to respond to emergencies, which includes dive emergencies, seven days a week between 0800 hrs and 1600 hrs. It is expected that SAR Tech's will be en route thirty minutes after being tasked by the RCC. During non-working summer hours SAR Tech divers are available on an on-call basis and are expected to be en route within 120 minutes of being tasked. During non-summer months SAR Techs are available on a thirty-minute response time basis, from Monday to Friday between 0800 hrs and 1600 hrs. During the remaining time periods SAR Techs are available on an on-call basis with an anticipated 120-minute response time. According to Major McSorley the average response time during non-working hours is 55 minutes.

In addition to SAR Tech divers, Navy Fleet Divers ("Fleet Divers") are also available to dive in emergency response situations if required. Where SAR Tech divers or Fleet Divers are not available suitably qualified commercial divers may be used to perform rescue dives. Current RCC policy is that commercial divers can only be used to conduct rescue dives if they follow Workers Compensation Board regulations and are properly briefed by Coast Guard personnel as to the potential hazards of a dive. This is of course a difficult condition to achieve.

Article 5.66 of the National SAR Manual addresses the issue of use of non-military divers. It should be noted that Article 5.66 states that RCC may, when required, use Department of Fisheries and Oceans Divers, RCMP Divers, divers from any provincial or federal agency willing to assist and where suitable government facilities do not exist, Commercial facilities.

Previously some SAR Tech divers received rescue dive training from members of the Sea Island Rescue Dive Team. According to Warrant Officer Steve Glenhill, currently with the Navy Directorate of Diver Safety, SAR Techs now receive rescue dive training at the Canadian Navy Fleet diving facilities in Esquimalt, British Columbia. In additional to standard navy diver training SAR Tech divers are able to take specialized courses including a course concerning live extraction from submerged vessels.

SAR Tech divers, unlike Coast Guard divers are not required to conform to federal or provincial health and safety standards but conform instead to the general dive standards set out in Canadian Forces regulations CFP380 and CFACM 2605. Further, according to Warrant Officer Glenhill regulations specific to rescue diving are set out in Standard Operating Procedures for SAR Tech divers which were prepared using the Rescue Diving Manual prepared by members of the Sea Island Rescue Dive Team.

19.2 Canadian Coast Guard Rescue Swimmers

In addition to its other emergency response capabilities the Coast Guard uses Rescue Swimmers in the Pacific Region. Rescue swimmers are equipped with wet suits, fins, masks and snorkels but not dive gear. Accordingly, they are not able to perform rescue dive services.

19.3 The RCMP "E" Division Dive Team

An interview was conducted with Sergeant Dennis Erickson, the head of the RCMP "E" Division Dive Team (the "RCMP Dive Team").

The RCMP Dive Team in operation since approximately 1977 is mandated to perform search and recovery dives and to support RCMP investigations. Although the RCMP has no specific mandate to perform rescue dive services it is available on an on-call basis and will assist any other agency that requests its assistance in performing a rescue dive.

Sergeant Erickson is the only full-time member of the RCMP Dive Team. Its other members are regular members of the RCMP who dive on an on-call basis. The team is composed of a maximum of forty-five members (currently there are thirty members) situated in six regions in British Columbia including Vancouver Island, Prince George, Kamloops, Kelowna, the Kootney's and the Lower Mainland. Each of the six teams has a team leader.

When one of the RCMP Dive teams is required the relevant team leader is contacted and team members are dispatched. Several members of the Lower Mainland team have dive equipment in RCMP vehicles available to them at all times to allow for quicker response in an emergency.

Only certified divers are allowed to join the RCMP Dive Team. Training, completed in Regina or in this region, includes diving in capsized vessel and submerged autos. Once training is complete divers are required to train at least one day per month and complete a once week re-qualification once per year. The RCMP Dive Team is subject to HRDC diver safety standards but also conforms to its own Standard Operating Procedures that, according to Sergeant Erickson, are more stringent than the HRDC rules.

At present the RCMP relies on SCUBA dive equipment. According to Sergeant Erickson the RCMP Dive team will be 75% surface air supply trained by the end of June 2001. The RCMP expects to purchase the required surface air supply some time during the summer or fall of 2001.

19.4 Provincial Emergency Program ("PEP"), Terrace, British Columbia

We conducted interviews with Maurie Hurst, manager of the PEP regional office in Terrace and with Dave Jephson, head of the Terrace SAR Water Rescue Team.

The Terrace SAR Water Rescue Team is composed of volunteers who provide water rescue services including rescue dive services on an on-call basis. When requested by the RCMP or other provincial agency, and subject to PEP approval, the Terrace Water SAR Team will respond to rescue dive situations anywhere in the province. Under current guidelines the dive team will only respond if there is a qualified RCMP diver on scene. Team members are drawn from the local community, fire department and RCMP. Training is provided in-house by Dave Jephson as well as by members of the Calgary Fire Department Rescue Diving Team and in some cases by Rescue Dive International in Colorado. The team conducts training exercises at least twelve times per year. The team is subject to British Columbia Worker's Compensation Board safety regulations.

20. Rescue Dive Services in Other Parts of Canada

20.1 Calgary Fire Department

An interview was conducted with Mr. Dave Avramenko, Aquatics Rescue Co-ordinator for the Calgary Fire Department.

The Calgary Fire Department's Aquatic Rescue group is able to provide rescue dive services in Calgary and surrounding areas twenty four hours a day, seven days a week. The team has responded to rescue dive incidents throughout Alberta and in British Columbia. The Calgary Fire Department is paid a call-out fee by the RCMP for providing rescue dive services outside of its jurisdiction.

The Aquatics group has 54 trained divers divided between four platoons making it the largest trained dive team in North America. The divers are dispatched from one of three fire stations within the city of Calgary.

Dive team members all receive training in rescue diving Dive Rescue International as well as training in ice rescue, ice diving and med diving. Divers conform to Alberta workers compensation regulations. When a rescue diving team is dispatched a back-up dive team is routinely dispatched from one of the other stations.

20.2 Toronto Police Department

An interview was conducted with Sergeant Stephen Henkel, Dive Team Leader of the Underwater Recover Team attached to the Toronto Police Department's Marine Unit ("Toronto Underwater Recovery Team").

According to Sergeant Henkel Toronto is the only city in Ontario with a combined marine search and recovery dive team. Similar to the RCMP "E" Division Dive Team the Toronto Underwater Recovery Team is primarily mandated to conduct search and recovery dives but will when required conduct rescue dive operations. Dive operations are carried out in Toronto Harbour, local rivers, various ponds, reservoirs and sewage and water treatment plants and in some cases outside of the Toronto Area.

The team's eleven divers are divided between the four platoons comprising the Marine Unit and at any given time there may be one or more divers with any platoon. Divers not on shift remain available to respond to dive calls on an on-call basis.

The Marine unit responds using one of its twelve response vessels. Response times when divers are on shift is approximately thirty minutes, depending on the location of the call. On scene divers primarily use a surface supplied air.

Members of the Toronto Underwater Recovery Unit currently train at Seneca College in Ontario. Training in use of surface supplied air was provided by divers with the Canadian Navy. It is intended that in the future members will receive training from the New York based Life Guard Systems which provides courses concerning small and large area rapid deployment and vehicle extrication.

The Toronto Underwater Recovery Unit members are considered commercial divers under Ontario occupational health and safety legislation and accordingly are required to submit to those standards.

Sergeant Henkel advises that an Ontario inter-police department working-group met in February of 2001 to discuss standardized training and safety standards for police divers. This perceived need for such standards arises in part as a result of the incident where a police diver was killed in Cambridge, Ontario.

Further, Sergeant Henkel advises that the Toronto Underwater Recovery Unit is currently in the process of applying for a New Initiatives Fund ("NIF") grant from the National SAR Center. Grant funds, if received, are intended to be used to purchase more equipment and to increase the number of dive team members to increase search and rescue capability.

21. Rescue Dive Services in the United States

21.1 Police and Fire Departments

An exhaustive review of rescue dive services provided by police and fire departments in the U.S. was not conducted as part of this review process. Research in this regard consisted of a review relevant diving web-sites and interviews with United States Coast Guard officials. This research indicates that generally police and sheriffs departments or fire departments or both provide rescue dive services in the U.S.. For example, both the Seattle Harbour Patrol and the Seattle Fire Department provide emergency dive services. The United States Coast Guard does not provide rescue dive services.

21.2 United States Coast Guard

Interviews were conducted with Lieutenant Commander Andrew Connor, Assistant Branch Chief for SAR for the 13th District (Pacific Northwest) and with Lieutenant Ed Price, Dive Program Manager for the US Coast Guard ("USCG").

According these officers, the USCG mandate has never specifically included provision of rescue dive services. As recently as 1997 the USCG was asked to consider the provision of such services and determined that such services, provided on a national basis, would be cost prohibitive. The 1997 review was spurred by the death of crewmembers trapped underneath the capsized hull of the fishing vessel Heather Lynne II off the coast of Cape Anne, Massachusetts in 1996. In its review the Coast Guard mentioned that of nearly 50,000 search and rescue cases in 1995 only 6 involved capsized vessels.

The USCG currently has six dive teams. Three are stationed on icebreakers in the arctic and three as buoy tenders in Hawaii and Guam. Although the US National SAR Manual provides for rescue diving in some circumstances Lieutenant Connor commented that in nine years with the USCG he has not personally seen the USCG respond to a dive incident.

The officials interviewed point to the USCG mandate as set out in the US National SAR Manual. Section 6.A of Chapter 6 of the U.S. Coast Guard Addendum to the National SAR Manual states that:

"Though not mandated to perform underwater rescues, the Coast Guard is responsible for developing, maintaining and operating facilities for the promotion of safety under, as well as on and over, the high seas and waters subject to the jurisdiction of the United States; and , traditionally, the Coast Guard has assisted distressed persons wherever and whenever possible. The responsibility extends to civilian submersibles operating on scientific, industrial or other missions; capsized or sunken vessels; or crashed aircraft in which persons may be trapped."

With respect to persons trapped in capsized vessels Section 6.C provides that:

"Persons trapped under capsized vessels or in compartments [including automobiles] pose extreme safety risks to both the victim and the SAR responders ... Coast Guard SAR response resources may include SRU's which have rescue or surface swimmers. Rescue of persons trapped below the surface of the water must fully consider proper risk assessment and management. The situation could easily be of such extreme risk that it is imprudent to risk the lives of Coast Guard personnel when the lives of others are in peril."

With respect to the use of divers to rescue persons trapped under capsized vessels Section 6.C.2. provides that:

"Divers can be used to assist in rescuing persons trapped under a capsized vessel. Many state and local agencies have dive teams. The only Coast Guard units with divers assigned are located in Seattle (ice breakers), and Honolulu and Guam (buoy tenders) ... Reference (a) states that 'For diver operations in support of Coast Guard missions unit commanding officers will normally use [certified] Coast Guard divers ... However, situations may arise in which diving resources are required and a Coast Guard dive team is not available. In such situations, a unit commanding officer may request the assistance of other military divers, certified commercial divers or similarly highly trained diving resources, such as local police divers, through appropriate local channels...'" (emphasis added)

The U.S. Navy trains USCG Divers in Panama City Florida. According to Lieutenant Price Navy training does not specifically address rescue diving skills but rather trains on a variety of search skills.

USCG diving safety procedures are taken from the U.S. Navy dive manual and the Coast Guard Diving Policies and Procedures Manual. USCG Divers are exempt under the public safety diving exemption from the application of U.S. occupational health and safety regulations.

22. Rescue Dive Services in the United Kingdom

22.1 UK Maritime and Coast Guard Agency

We interviewed Mr. Bill Smith, Senior Operations Manager with the Maritime and Coast Guard Agency responsible for providing civil maritime search and rescue services. The Maritime and Coast Guard Agency currently has no rescue dive mandate and accordingly has no search and rescue divers.

The Maritime and Coast Guard Agency mandate includes the following: developing, promoting and enforcing high standards of marine safety; minimising loss of life amongst seafarers and coastal users; responding to maritime emergencies 24 hours a day; and minimising the risk of pollution of the marine environment from ships and where pollution occurs, minimising the impact on UK interests. The Agency has six main and twelve subsidiary maritime rescue sub-centers.

We are advised that the Agency will in the case of an emergency in which divers are required, request the assistance of local police divers that have dive capability. In addition to local police divers the Agency may request assistance from Royal Navy divers.

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Coast Guard Rescue Diving options

It is not within the scope of this review to suggest whether and by what agency rescue dive services should be provided. That being said, various alternatives with respect to the provision of rescue diver services were either directly discussed or became apparent during consultation with representatives of the Coast Guard and senior representatives of other emergency response service providers.

Stated simply it appears that there are three possible courses of action which the Coast Guard may take with respect to the provision of rescue dive services. They are as follows:

First, the Coast Guard could do nothing with respect to its current policy on rescue diving;
Second, the Coast Guard could attempt to create some form of co-operative arrangement with other emergency response service providers to provide rescue dive services with the Coast Guard providing, at a minimum, response vessels/hovercraft; or
Third, the Coast Guard could re-institute the Rescue Diving Pilot Project in a new form as a permanent program.

22.2 Do Nothing

The Coast Guard may choose not to reinstate the Rescue Diving Pilot Project in any form and to take no further action with respect to rescue diving generally.

The termination of the Rescue Diving Pilot Project has eliminated a service which can not be easily provided by the remaining rescue dive service providers. Although an exhaustive review of rescue dive service providers in British Columbia was not completed, it appears that rescue dive services are now only available from the RCC, from the RCMP "E" Division Dive Team and, to a limited extent, by volunteer dive groups in other areas including the Terrace SAR Water Rescue team (part of PEP). As stated earlier in this report, municipal police and fire departments in the lower mainland do not provide dive services of any kind.

Even considering the existence of the other rescue dive service providers, by eliminating the Rescue Diving Pilot Project there has been a reduction in rescue dive capacity in the lower mainland and other areas within response area of the Sea Island hovercrafts. This reduction in rescue dive capacity is the result of factors including:

increase in response times resulting from the lack of a dive team operating on a 24/7 basis;
increase in response time due to the physical location of rescue divers (for example, SAR Techs are dispatched by from Comox and RCMP divers are dispatched from various locations); and
reduction in availability of rescue divers specifically trained in live extraction from automobiles and capsized vessels.

As previously mentioned SAR Tech divers tasked by the RCC are available on a 30-minute response basis from 0800 to 1600 hours seven days a week during summer hours. During non-summer hours they are available during the same hours, Monday to Friday. At all other times SAR Tech divers are available on an on-call basis with an expected response time of up to 120 minutes. RCMP "E" Division dive teams, situated in six regions in the province, are able to perform rescue dives on an on-call basis. The RCMP does not have a full-time dive team but rather calls out divers as needed. Again, the RCMP considers its divers to be recovery rather than rescue divers, although they will assist in a rescue operation when possible.

Further, with the elimination of the Rescue Diving Pilot Project on Sea Island it appears that response times to rescue dive incidents in the lower mainland will now increase. This is noteworthy considering that there is a greater need for rescue dive services in the lower mainland than in other areas as a result of greater volumes of marine and automobile traffic in and around local bodies of water. SAR Tech divers are tasked out of Comox on Vancouver Island and RCMP "E" Division divers from various locations. Rescue divers from Sea Island were able to respond more quickly to rescue in the lower mainland and surrounding areas than divers from those agencies.

22.3 Co-operative Arrangement

The Coast Guard could consider working in a lead capacity with other emergency response service providers, including local police and fire departments, to develop a system in which rescue dive services are provided on combined-efforts basis. The Reviewer appreciates that jurisdiction issues would make such a co-operative arrangement difficult but such difficulty should not preclude making efforts in this regard.

One of the significant issues raised in numerous discussions with Coast Guard management including discussions with George Horel and Jon Churchill was staffing. These individuals felt that, given current staffing levels at the Sea Island and Kitsilano Coast Guard bases, the Coast Guard could not provide 24/7 rescue dive services while at the same time complying with HRDC diver safety standards. In particular the inability of rescue divers to comply with the requirement for a back-up dive team in the case of potential entrapment was at issue.

Jon Churchill pointed out that the Coast Guard has a pool of approximately thirty personnel that could possibly be trained as rescue divers while local fire departments can draw from a pool of over one thousand firepersons. This raises the obvious argument that the personnel required for rescue dive services could more easily be provided by local fire departments or the police.

Provision of rescue dive services by local fire departments, the RCMP or city police was discussed with representatives of those agencies. It is apparent that the Vancouver Fire Department, Vancouver Police, Richmond Fire Department and the RCMP "E" Division Dive Team are not currently planning to include rescue diving as part of their mandate. Not surprisingly an important issue for both the fire and police departments is funding. Another related issue, especially for municipal fire and police departments is that by creating a rescue diving team they may be creating an obligation to provide emergency services outside of their jurisdiction. Again, in light of the Calgary Fire Department model, whereby that agency's team is paid for responding outside of their jurisdiction, the jurisdiction issue does not seem insurmountable.

As mentioned earlier in this report, police or fire departments provide rescue dive services in the United States and the United Kingdom.

To this Reviewer a reasonable compromise would be to create a system in which Coast Guard divers at the Sea Island base remain involved in the provision of rescue dive services, even if this means not providing rescue dive capacity on a 24/7 basis. This compromise could be realized by using divers in the following suggested ways:

Coast Guard divers at Sea Island could, as they have with DND Divers, train rescue divers for other agencies including, for example, local fire and police departments.
Once sufficient rescue dive capacity was reached by other agencies, Coast Guard divers could respond either as the primary responders with divers from other agencies acting as back up or in a secondary role.
In any case Coast Guard vessels could be used to transport rescue divers from other agencies to rescue dive incidents.

Continuing the existence of the Rescue Diving Team at Sea Island, even in a more limited capacity, would ensure that the accumulated expertise of the members of that team is preserved.

The subject of co-operation between the Coast Guard, Richmond Fire Department and the RCMP has come up in recent discussions between representatives of the Sea Island Coast Guard base Richmond Fire Department and the Vancouver Airport Authority. In particular those agencies have discussed that possibility of a co-operative fire-fighting training facility located at Sea Island. The advantages of this facility would increased fire fighting response capability in case of a fire on an aircraft and reduced training expenses (personnel, including flight attendants are currently trained off-site). Although not directly related to the issue of rescue dive services the fact that the creation of a co-operative training facility has been discussed between those groups is of interest. It is conceivable that such a facility could expand its mandate to include training of rescue divers.

22.4 Create a Permanent Rescue Dive Project

A further option is that the Coast Guard resurrect the Rescue Diving Pilot Project as a national program implemented on a regional basis. Prior to establishing rescue diving at Sea Island as a national program two key conditions must be met.

First, if the Coast Guard decides to establish rescue diving as a national program a defined national policy with respect to the provision of this service must be created. A defined policy is necessary to ensure that there is certainty in the collective minds of other emergency service providers and within the Coast Guard ranks whether and how rescue diving will be provided. Further, the need for a national policy is imperative in light of this Reviewer's findings that the lack of a national policy created a great difficulty in maintaining support for rescue diving within Coast Guard.

Second, in light of internal reports prepared for the Coast Guard on the Rescue Diving Pilot Project, the dive program could not be instituted on the same basis, with the same procedures and staffing levels as existed during the Pilot Project stage. If the rescue diving is to become part of the Coast Guard mandate the recommendations as set out in the reports of Jeff Nemrava and Drew Edey must be instituted. It was clear from those reports that the problems inherent in the Rescue Diving Pilot Project were not insurmountable.

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Conclusions

23. Response to the Terms of Reference

In response to this report's terms of reference, it should be noted that the Reviewer has not specifically been asked to make a recommendation with respect to the continuation of rescue diving at the CCG Station Sea Island in Vancouver. Rather, the process and the basis of the decision to cancel the Rescue Diving Pilot Project are the subjects of this report and those elements were deficient in a number of respects.

Specific deficiencies, which it is hoped will be clear from the text of the report, include a lack of adequate or sincere public consultation regarding the future of the Rescue Dive Pilot Project, a lack of appropriate consideration to key factors in the continuation of the pilot project including the need for rescue dive services and finally, a disturbing absence of effort to notify the public and other emergency response service providers of the decision to suspend and terminate the pilot project.

However, in the circumstances, and having regard for the information that was available, the Reviewer agrees that the decision to suspend and ultimately cancel the Rescue Diving Pilot Project made by Management Board and subsequently implemented by the decision of the Regional Director Pacific Region was correct, even if made within a rather faulty framework.

It should be noted that in general documentation recording details of the decision-making process is inadequate or entirely lacking. This made it necessary for the Reviewer to speculate, to a certain degree, as to the real basis for the decision. That is, the Reviewer was required to conclude whether the factors referred to in this report formed the primary basis for the decision to cancel the pilot project or instead whether the decision was based on some predetermined negative inclination towards rescue diving.

With respect to the basis of the decision, the Reviewer finds that most of the relevant factors were considered, to varying degrees, by Coast Guard management before the decision to terminate was made on February 16, 2001. Relevant factors which appear not to have been included in the decision making process include the need for dive services, Coast Guard morale and public confidence in the ability of the Coast Guard to provide rescue services.

Although reviews had been done at two-year and four-year intervals during the currency of the Rescue Diving Pilot Project, these were not intended to cover the important issue of the need for rescue dive services. The Nemrava Report was not requested until November 3, 2000 and was required to be completed within a very short time so that the issue could come before the November 23/24, 2000 Management Board meeting. Admirably, Mr. Nemrava completed his task in the time allotted. However, this left very little additional time for consideration of all of relevant issues by Coast Guard management and, in particular, for review and determination of those issues not left with Mr. Nemrava. In the result, the question of the need for rescue diving services was left to Jon Churchill as acting Director of Marine Programs for the Region and may not have received the consideration it deserved.

That being said the decision to terminate the Rescue Diving Pilot Project without considering the affect of that decision or other available options is not fully supportable. Such other options, which were discussed in the section immediately above, could well have been preferable to the public, at least the public in the Greater Vancouver and Lower Georgia Strait areas, and to the divers and other rescue personnel at Sea Island and elsewhere.

To this Reviewer the attitude of senior Coast Guard Management towards rescue diving will probably not be changed unless the Minister directs them to establish a policy, create a national program and generally support the rescue diving concept both philosophically and financially.

RESPECTFULLY SUBMITTED

Peter G. Bernard, Q.C.
Vancouver, B.C.
June 17, 2001

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Appendix C-1

Terms of Reference

Review of the DFO Decision to Terminate the Canadian Coast Guard (CCG) Rescue Diving Pilot Project at the Sea Island Base

Scope

To review the basis of a decision made by the department of Fisheries & Oceans on February 16, 2001 to terminate the Canadian Coat Guard Rescue Diving Pilot Project at Sea Island Base, Richmond, B.C. (the "Decision")

Specifically, the reviewer shall identify the information available to the Canadian Coast Guard at the time of the Decision and comment on steps taken by the Coast Guard before making the Decision.

The report will be made public by the Minister of Fisheries & Oceans.

Analysis

The reviewer has permission to investigate as he/she deems pertinent, but as a minimum will include a file review of Coast Guard materials located at the Coast Guard Pacific Region Headquarters, Sea Island Base, and Coast Guard National Headquarters.

The reviewer may also take into consideration what is being done in other jurisdictions nationally and/or internationally. This will be done by means of literature searches and/or phone interviews as may be required. Further, the review of all relevant documentation may be supplemental as appropriate, by interviews with relevant CCG personnel or others involved in, and/or affected by, the Decision.

Any individual, may decline to be interviewed. Subject to any legislative requirement, the reviewer shall, however, adopt whatever measures he or she considers appropriate and necessary to secure relevant information from any CCG personnel while protecting the anonymity of any Coast Guard personnel wishing to provide information or opinions in confidence. The reviewer shall not assign blame or fault to any individual or make any recommendations or determination as to disciplinary action to be taken, or determination as to civil or criminal liability.

Deliverable

A written report delivered to the Minister, Fisheries and Oceans reviewing and analyzing the basis of the Decision.

The reviewer shall submit all documents obtained or created during the review to the Minister for retention and ATIP administration. For this purpose, the term "documents" includes any correspondence, memorandum, book, plan, map, drawing, diagram, pictorial or graphic work, photograph, film, microform, sound recording, videotape, machine readable record, and any other documentary material, regardless of physical form or characteristics, and any copy thereof.

Reviewer

The review will be undertaken by an independent, credible, outside expert with experience in the marine safety environment.

The reviewer may, with the written prior authorization of the project contracting authority, engage an assistant, or assistants as required.

The Reviewer and any assistant(s) shall not, without the prior written consent of the Department, disclose or use any information obtained during the review except where required by law. The Reviewer will undertake not to make any public statements on the review before the Minister has considered the report and determined the appropriate action to be taken.

Time for Completion

60 days from the date of appointment.

Project Authority

For financial administration purposes the project contracting authority will be the Director, Safety & Environmental Response Systems - Canadian Coast Guard, Marine Programs.

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Search and Rescue

Search and Rescue

Review of the Decision of the Department of Fisheries and Oceans to Terminate the Canadian Coast Guard Rescue Diving Pilot Project June 17, 2001

The international mandate for rescue

Requirements for a national program

Human Resources issues

Risk and safety regulation

Loss of experience and equipment

Success of program

Coast Guard morale

Public confidence

Rescue Diving in other jurisdictions

Terms of Reference

Scope

Analysis

Deliverable

Reviewer

Time for Completion

Project Authority

Review of the Decision of the Department of Fisheries and Oceans to Terminate the Canadian Coast Guard Rescue Diving Pilot Project
June 17, 2001