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| You are here: Home > Spotlight > Fire
on the HMCS Chicoutimi |
The HMCS Chicoutimi Board of Inquiry
On October 12, 2004, the Canadian Navy announced it would be forming
a Board of Inquiry to investigate the events that took place
on the submarine, and resulted in the death of Lt. Saunders.
Please Note : The following information was taken
from the Canadian Department of Defence Website.
For More Information on the Chicoutimi Board of Inquiry, Visit
the Official Website of the Canadian Department of Defence
Purpose of a Board of Inquiry
In general, a board of inquiry is convened by the military to inquire
into any matter connected with the government, discipline, administration,
or functions of the Canadian Forces (CF) or affecting any Canadian
Forces member.
When a member of the Canadian Forces is injured or killed, an investigation
is necessary to inform Forces authorities about key details involved in
a given situation. This includes investigating the cause of the injury
or death, whether the member was on duty at the time, whether responsibility
for the injury or death can be attributed to a given individual, and whether
the injury or death is attributable to the military service in any way.
With respect to the HMCS Chicoutimi, the Board of Inquiry will be
gathering all evidence relevant to the fires that occurred on
the submarine, in addition to any evidence that is relevant to
the death of Lt. Saunders.
Composition of the Board
The members of the Board of Inquiry are as follows:
- President – Commodore R. D. Murphy;
- Senior Member – Captain(N) P.T. Finn;
- Member – Lieutenant-Colonel W.R. Krause;
- Member – Commander A.R. Wamback; and,
- Member - Chief Petty Officer 1 st Class R.K. Cooper.
The President of the Board, Commodore Murphy, is a respected member
of the Canadian Navy. Most recently, Commodore Murphy served
as J3 Chief Staff Officer Canadian Joint Operations at US Central
Command in Tampa, Florida during Operation APOLLO (in Afghanistan).
Commodore Murphy went on to command the Canadian Naval Task Group
and the Coalition Naval Task Group (leading 20 ships from nine
nations in support of the US-led war on terrorism). Commodore
Murphy is currently the Canadian Forces, Director General Military
Human Resources Policy and Planning.
Mandate of the Board
With respect to the fires on board the HMCS Chicoutimi, the Board
of Inquiry will examine specifically:
- whether the HMCS Chicoutimi was structurally, mechanically,
and technically sound and seaworthy, sufficiently as to
carry out the surface and dive transit to Canada;
- the chronology of the HMCS Chicoutimi’s movements
and the prevailing environmental conditions;
- the date, time, and location of the fires;
- the probable or known point(s) of origin of the fires;
- the cause of the fires and all factors suspected in contributing
to the cause of the fires, including but not limited to
any operational, mechanical, construction, technical, procedural,
or human failures;
- whether the training of the crew, the doctrine applicable
to the reactivation , or the reactivation procedures of
the HMCS Chicoutimi contributed to the cause of the fires;
- the property damage to the HMCS Chicoutimi ;
- the nature and extent of the fires;
- whether the actions of any person(s) contributed to the
starting or spreading of the fires;
- the chronology of response actions taken to fight the fires;
- whether responses by the crew were conducted in accordance
with applicable regulations and orders;
- the adequacy of relevant orders and procedures;
- the adequacy of response actions taken to fight the fires;
- the adequacy of fire detection, fixed, and portable suppression
equipment;
- the adequacy of the training and qualifications of CF members
involved in the response to the fires;
- the adequacy of the restoration of operational capability
of the HMCS Chicoutimi;
- the adequacy of the doctrine, equipment, and training with
respect to the restoration of operational capability of
the vessel;
- whether the HMCS Chicoutimi was crewed in accordance with
the Automated Establishment Report (AER) requirements ;
- what communication capabilities were available to the vessel
after the fires, and when they became available; and,
- the flow of information content (by what means and when),
both within and from the submarine to other vessels and
shore authorities during and following the fires.
With respect to the death of Lt. Saunders, and the other members
of the crew that suffered directly as a result of the fires,
the Board of Inquiry will make findings as to the following:
- the cause of death of Lieutenant(N) C. Saunders;
- whether Lieutenant(N) C. Saunders was on duty at the time
of the death;
- whether any pre-enrolment or pre-existing medical conditions
contributed to his death;
- whether Lieutenant(N) C. Saunders or any other person(s)
were responsible for the his death ;
- whether his death was attributable to military service;
- the injuries to other personnel aboard the HMCS Chicoutimi;
- the cause of those injuries;
- whether any pre-enrolment or pre-existing medical conditions
contributed to the injuries;
- whether the injured were on duty at the time of their injuries;
- whether the injured or any other person(s) were responsible
for the injuries;
- whether the injuries were attributable to military service;
- the post-incident medical response;
- the adequacy of the training and qualifications of CF personnel
involved in the post-incident medical response and treatment;
- the adequacy of the medical equipment and doctrine;
- the reporting of the casualties including coordination among
Canadian, Irish, and United Kingdom (U.K.) authorities;
- the chronology and adequacy of the medical evacuation from
the HMCS Chicoutimi; and,
- any other issues of relevance to this investigation
Following its investigation, the Board of Inquiry shall make recommendations
regarding the following:
- measures to prevent a recurrence of such fires and casualties;
- any corrective action to improve survivability in an HMC
submarine disable under similar circumstances;
- the training and qualifications of personnel involved in
the response to the fires and post incident medical treatment;
- any corrective measures to improve responses to fires, including
the response time, procedures or equipment for firefighting
aboard this class of submarine;
- the improvement of existing fire prevention measures;
- any corrective measures to improve CF reactivation procedures
that would prevent fire;
- any corrective measures with respect to doctrine, equipment,
and training relating to operational capability restoration;
and,
- any other corrective measures to be taken.
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