List of Annexes

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Annex A - Terms of Reference

1080-1(CMS)

8 October 2004

BOARD OF INQUIRY FIRES AND CASUALTIES – HMCS CHICOUTIMI

  1. A Board of Inquiry (BOI) composed of the members identified below shall assemble at the call of the President not later than 11 October 2004 to investigate the fires that occurred in HMCS CHICOUTIMI on 5 October 2004 and the casualties amongst her crew that occurred on or after 5 October 2004. 
    1. President – Commodore R. D. Murphy;
    2. Senior Member – Captain(N) P.T. Finn;
    3. Member – Lieutenant-Colonel W.R. Krause;
    4. Member – Commander A.R. Wamback; and
    5. Member - Chief Petty Officer 1 st Class R.K. Cooper.
  2. The following persons have been designated to advise the BOI: 
    1. Royal Navy Special Adviser – Commander Green;
    2. Legal Advisers – Commander J.B.M. Pelletier and Lieutenant-Commander T. Flavin;
    3. Medical Adviser – Commander D.R. Wilcox;
    4. Technical Advisory – Incendiary – Major J.G.G. Morinville;
    5. Technical Advisor – Commander R.J. Hovey; and
    6. Public Affairs Advisor – Lieutenant-Commander A.K.S. Wong.
  3. The BOI shall be conducted in accordance with section 45 of the National Defence Act , Chapter 21 of the Queens Regulations and Orders for the Canadian Forces, series 7002 of the Defence Administrative Orders and Directives , Canadian Forces Administrative Order 24-6 Investigation of Injuries or Death and other relevant orders and directives.
  4. The BOI shall:
    1. identify all appropriate individuals who may assist the BOI with its inquiries;
    2. obtain statements from all witnesses;
    3. obtain relevant records and documentary evidence; and
    4. where evidence is given by an expert witness based upon a technical report, attach that technical report to the record of proceedings of the BOI.
  5. The BOI shall gather all evidence relevant to the fires that occurred in HMCS CHICOUTIMI on 5 October 2004 along with the evidence relevant to the death and casualties that followed. The BOI is to gather and review any sailing orders, engineering, technical, and operational readiness documents and logs prepared for and relating to HMCS CHICOUTIMI's departure and transit for Canada. The BOI is also to obtain copies of HMCS CHICOUTIMI ship's log and any records held by her concerning the response to the fire.
  6. In respect of the fires the BOI shall make findings as to: 
    1. whether HMCS CHICOUTIMI was structurally, mechanically, technically sound and seaworthy to carry out the surfaced and dived transit to Canada;
    2. the chronology of HMCS CHICOUTIMI's movements and the prevailing environmental conditions;
    3. the date, time, and location of the fires;
    4. the probable or known point(s) of origin of the fires;
    5. the cause of the fires and all factors that contributed to the cause of the fires including, but not limited to, any operational, mechanical, construction, technical, procedural or human failures;
    6. whether the training of the crew, the doctrine applicable to the reactivation and the reactivation procedures of HMCS CHICOUTIMI contributed to the cause of the fires;
    7. the property damage to HMCS CHICOUTIMI;
    8. the nature and extent of the fires;
    9. whether the actions of any person(s) contributed to the starting or spreading of the fires;
    10. the chronology of response actions taken to fight the fires;
    11. whether responses by the crew were conducted in accordance with applicable regulations and orders;
    12. the adequacy of relevant orders and procedures;
    13. the adequacy of response actions taken to fight the fires;
    14. the adequacy of fire detection, fixed, and portable suppression equipment;
    15. the adequacy of the training and qualifications of CF members involved in the response to the fires;
    16. the adequacy of the restoration of operational capability of HMCS CHICOUTIMI;
    17. the adequacy of the doctrine, equipment, and training in respect of the restoration of operational capability of HMCS CHICOUTIMI;
    18. whether HMCS CHICOUTIMI was crewed in accordance with the Automated Establishment Report (AER) requirements;
    19. what communication capabilities were available to HMCS CHICOUTIMI after the fires and when they became available; and
    20. the flow of information (content, by what means and when) within and from HMCS CHICOUTIMI to other vessels and shore authorities during and following the fires.
  7. The BOI shall gather all evidence relevant to the death, injury and medical care of Canadian Forces personnel during and following the fires. Specifically:
    1. any autopsy report;
    2. a copy of the death certificate;
    3. any medical examiner's or coroner's report; and
    4. all CF 98 “Report of Injuries or Exposure to Toxic Material.”
  8. In respect of casualties the BOI shall make findings as to:
    1. the cause of death of Lieutenant(N) C. Saunders;
    2. whether Lieutenant(N) C. Saunders was on duty at the time of the death;
    3. whether any pre-enrolment or pre-existing medical conditions contributed to his death;
    4. whether Lieutenant(N) C. Saunders or any other person(s) were responsible for the death of Lieutenant(N) C. Saunders;
    5. whether his death was attributable to military service;
    6. the injuries to other personnel aboard HMCS CHICOUTIMI;
    7. the cause of those injuries;
    8. whether any pre-enrolment or pre-existing medical conditions contributed to the injuries;
    9. whether the injured were on duty at the time of their injuries;
    10. whether the injured or any other person(s) were responsible for the injuries;
    11. whether the injuries were attributable to military service;
    12. the matters referred to in sub-paragraphs a to e in the event of any subsequent death(s) occurring among the injured;
    13. the post-incident medical response;
    14. the adequacy of the training and qualifications of CF personnel involved in the post-incident medical response and treatment;
    15. the adequacy of the medical equipment and doctrine;
    16. the reporting of the casualties including coordination among Canadian, Irish and United Kingdom (U.K.) authorities;
    17. the chronology and adequacy of the medical evacuation from HMCS CHICOUTIMI; and
    18. any other issues of relevance to this investigation.
  9. If, after a thorough investigation and determination of the facts, the BOI finds that a member was killed or injured through the fault of some other person, it shall record whether the member, or his personal representative, has received, been offered, or claimed or intends to claim compensation from the person at fault.
  10. Recommendations shall be made regarding:
    1. measures to prevent a recurrence of such fires and casualties;
    2. any corrective action to improve survivability in an HMC submarine disable under similar circumstances;
    3. the training and qualifications of personnel involved in the response to the fires and post incident medical treatment;
    4. any corrective measures to improve responses to fires, including the response time, procedures or equipment for firefighting aboard this class of submarine;
    5. the improvement of existing fire prevention measures;
    6. any corrective measures to improve CF reactivation procedures that would prevent fire;
    7. any corrective measures with respect to doctrine, equipment, and training relating to operational capability restoration; and
    8. any other corrective measures to be taken.
  11. Should the BOI receive evidence that it reasonably believes relates to an allegation of a criminal act or a breach of the Code of Service Discipline, the BOI shall adjourn, the Convening Authority shall be notified, and the matter shall be referred to the Legal Adviser for advice.
  12. The President of the BOI shall ensure that the proceedings and activities of the BOI are conducted in such a manner as to strike the appropriate balance between the interest of the public in being informed of the BOI's progress, and the public's interest in ensuring that security, privacy, operational and international relations requirements, is achieved.  This direction is to ensure that as much information as is appropriate and reasonable is publicly available and disclosed. In accordance with QR&O 21.12(c), the President may permit the attendance of persons with a direct and substantial interest in the BOI concerning death or injury.
  13. As necessary, the BOI may liaise with other Canadian, Irish, or U.K. investigatory bodies.
  14. Where a prospective witness: 
    1. is currently the subject of a criminal (police) investigation;
    2. has been or is about to be charged with an offence under the National Defence Act or other Canadian law; or 
    3. has been arrested or detained in respect of an alleged act or omission which could constitute such an offence,
    the prospective witness shall not be compelled to give evidence before the BOI in relation to the subject matter of the police investigation, charge, arrest or detention.  Where the gathering of such evidence is deemed critical to the successful completion of the investigation, the Convening Authority shall be notified and legal advice sought prior to any action to compel such testimony, recognizing that compelling such testimony in such circumstances could have the effect of jeopardizing subsequent disciplinary proceedings.  If it appears to the BOI at any time that the evidence may justify the laying of a charge, the BOI shall cease activities, notify the Convening Authority and seek the advice of the Legal Advisor to the BOI prior to taking any further action.
  15. The BOI is designated PROTECTED B unless further evidence is presented during the BOI dictates a requirement for higher classification.
  16. The BOI shall immediately notify the Convening Authority if at any time during the investigation it believes this incident may be an indication of inherent defects with the VICTORIA Class submarine.
  17. The BOI shall commence as soon as possible and the Minutes of Proceedings
    (CF 485), in memorandum form, shall be delivered to the Convening Authority, in two copies, no later than 30 November 2004. Should it be impossible to complete the BOI by the specified date, a full written explanation shall be submitted to the Convening Authority prior to the due date indicating the reasons for the delay and the anticipated completion date.

// original by //

M.B. MacLean
Vice-Admiral
Chief of the Maritime Staff

Distribution List

Action

President of the BOI
Members of the BOI
Royal Navy Special Advisor
Legal Advisor
Medical Advisor
Technical Advisor – Incendiary
Public Affairs Advisor

Information

CDS
MARLANTHQ / Commander
MARPACHQ / Commander
CDLS (London)
CCFLHQ / Commander
MOG5HQ / Commander
HMCS CHICOUTIMI / CO

Annex B - HMCS Chicoutimi Events Timeline

The chronology of these events is based upon a compilation of data from various sources.  As not all sources are in complete agreement as to the timings, some approximation and time averaging was required. All times are Zulu.

Date/Time Event
2 October 2004
02 1220 Acceptance of HMCS Chicoutimi by Canada
4 October 2004
04 0905 HMCS Chicoutimi departs Faslane Scotland HMCS Chicoutimi departs Faslane Scotland
04 1815 Sunset
5 October 2004
05 0145 HMCS Chicoutimi Position: Lat 55 35.13N Long 008 22.09W
05 0145 Weather: Wind 240@25Kts Sea State 3
05 0330 Approx time the conning tower was cycled for the Officer Of the Watch (OOW) change in watch which resulted in the first ingress of water
05 0530 HMCS Chicoutimi Position : Lat 55 33.32N Long 009 25.22W
05 0530 Weather: Wind 320@30Kts Sea State 5
05 0651 Sunrise
05 0930 HMCS Chicoutimi Position: Lat 55 29.2N Long 010 29.3W
05 1000 Approx time of reported defect in upper lid vent
05 1052 Commanding Officer (CO) orders tower run opened up for repair of defect
05 1100 Approx time personnel working in conning tower
05 1115 Approx time of Second Water Ingress
05 1130 Approx time of VP Earth
05 1200 Approx time – Damage Control Headquarters (DCHQ) closed up
05 1310 Last entry in Ships log – Slow Ahead Group Up (SAGU)
05 1315 Approx time Lieutenant(N) Saunders last observed in DCHQ
05 1315 Approx time of Sparks and electrical popping noises in Control Room
05 1315 Sometime between 05 1310 and 05 1322 fire in CO’s Cabin (1 Deck) and electrical space (2 Deck).  Aux breakers opened, main power breakers already tripped. Sometime between 05 1310 and 05 1322 fire in CO’s Cabin (1 Deck) and electrical space (2 Deck).  Aux breakers opened, main power breakers already tripped.
05 1315 Responses to Fires
  • General alarm raised
  • First aid firefighting attack on control room and electrical space
  • Upper conning tower lid opened
  • Emergency Breathing System (EBS) donned
  • SFU 90 deployed
  • Smoke boundaries established
  • Attack teams dressing
  • Two casualties in Control Room
05 1325 Report of             person in Control Room, later confirmed to be Lieutenant(N) Saunders Report of             person in Control Room, later confirmed to be Lieutenant(N) Saunders
05 1330 HMCS Chicoutimi Position : Lat 55 26.2N Long 011 14.5W
05 1330 Weather: Wind310@35Kts Sea State 6
05 1330 Approx time – CO orders auxiliary power breaker remade to clear smoke using LP Blower
05 1331 Subsequent report of fire.
05 1331 Laying off all power, no further attempts to restore power until system checks complete on 6 October 2004.
05 1335 Fire out in Electrical space
05 1345 Approx time CO orders XO to bridge with SAT Phone.  Casualty clearing team attending to CAS in CR
05 1400 Approx time – HMCS Chicoutimi attempts to establish contact with CTF 311 without success
05 1406 XO contacts MARLANT N32.  Reports fire, loss of propulsion and three casualties
05 1406 Lieutenant(N) Saunders is moved to Cox’ns Office
05 1409 CTF 311 contacted via SAT phone.  Call cut off
05 1417 CTF 311 contacted via SAT phone and appraised of situation
05 1430 SARFLT (Rescue 177) tasked for CASEVAC.  Re-tasked to standby while enroute
05 1435 Flash message sent from CTF 311 to RFA Wave Knight – Proceed to last position of HMCS Chicoutimi
05 1443 STARBOARD Engine started for smoke clearance
05 1446 CO’s Cabin fire reported out by CO, overhauled CO’s Cabin fire reported out by CO, overhauled
05 1448 Main and Aux Power Breakers assessed as dangerous by Damage Control Officer
05 1452 Duty CTF 311 Submarine Controller informed by XO of no requirement for helicopter transfer as casualties stable and weather conditions unsuitable.  Offer of additional oxygen and radios turned down.
05 1455 From CTF 311 – SAR being initiated by ARCC Kinloss to Air Ops Kinloss for SAR and communications relay.
05 1504 All personnel forward of 35 BULKHEAD evacuated to aft of 56 BULKHEAD (includes some casualties)
05 1549 SITREP to CTF 311 – Casualties stable, not life threatening
05 1554 From CTF 311 – Anglian Prince sailed From CTF 311 – Anglian Prince sailed
05 1610 RAF Kinloss SAR deployed, Submarine Parachute Assistance Group (SPAG) on stand-by
05 1620 Approx time – Lieutenant(N) Saunders moved to Junior Ranks mess
05 1625 Atmosphere in spec throughout submarine, all personnel off EBS
05 1629 SPAG deployed to Lynhan
05 1700 HMCS MONTROSE sails from Faslane Scotland
05 1700 Approx time – Lieutenant(N) Saunders moved to Wardroom
05 1705 SFU 90 repaired and recharged
05 1707 Sitrep passed from HMCS Chicoutimi to CTF 311
05 1730 CO’s Cabin and electrical space have been overhauled a second time CO’s Cabin and electrical space have been overhauled a second time
05 1742 Fire fighters stood down
05 1744 Fire sentry stood down
05 1744 CTF 311 in communication with HMCS Chicoutimi, receiving names of casualties
05 1744 Nimrod (Rescue 51) on station Nimrod (Rescue 51) on station
05 1800 HMCS Chicoutimi Position : Lat 55 26.2N Long 011 14.5W
05 1813 Sunset
05 1830 HMS Montrose now CTG 311-01 for SAR
05 1832 Rescue 177 advised by HMCS Chicoutimi that casualty evacuation is not required
05 1845 Starting Oxygen generators forward of 35 Bulkhead – 2 candles
05 1859 Both Batteries inspected and checked correct
05 1900 HMCS Chicoutimi Position : Lat 55 14.4N Long 011 11.0W
05 1910 Fire in forward oxygen generator Fire in forward oxygen generator
05 1912 Fire in Forward Oxygen Generator is out
05 1917 Lining up for smoke clearance from Weapon Storage Compartment (WSC)
05 1933 CTF 311 informed of second fire onboard
05 1957 Atmosphere in spec throughout Submarine
05 2020 All fitted internal communications systems lost except VICES, which has minimal battery life remaining.  Communication now through runners and handheld radios
05 2029 All firefighting gear stowed
05 2042 CTF 311 informed that CO reasonably content for the night.  Does not want to start any equipment due to reduced firefighting equipment.
05 2055 HMCS Chicoutimi Position : Lat 55 11.0N Long 011 13.0W
05 2210 HMCS Chicoutimi Position : Lat 55 08.8N Long 011 13.7W
05 2255 HMS Montrose ETA revised from first light to 1000.  Ship subsequently delayed by weather.
05 2300 HMCS Chicoutimi Position : Lat 55 07.0N Long 011 13.9W
6 October 2004
06 0001 HMCS Chicoutimi Position: Lat 55 05.0N Long 011 14.0W
06 0100 Handover from Rescue 51 to Rescue 52 (Nimrods)
06 0125 HMCS Chicoutimi Position : Lat 55 02.0N Long 011 15.0W
06 0325 HMCS Chicoutimi Position : Lat 54 58.0N Long 011 16.0W
06 0425 HMCS Chicoutimi Position : Lat 54 56.0N Long 011 17.0W
06 0525 HMCS Chicoutimi Position : Lat 54 54.0N Long 011 17.0W
06 0625 HMCS Chicoutimi Position : Lat 54 52.0N Long 011 17.0W
06 0653 Sunrise
06 0800 SITREP to CTF 311 – 3 casualties need boat transfer to HMS Montrose
06 0846 Physicians Assistant assesses 6 of 9 casualties out of danger.
06 1128 HMS Montrose on station, direct communications established with HMCS Chicoutimi, acting as On Scene Commander HMS Montrose on station, direct communications established with HMCS Chicoutimi, acting as On Scene Commander
06 1150 MV Carolyn Chouest departing Faslane
06 1200 HMCS Chicoutimi Position : Lat 54 47.9N Long 011 02.8W
06 1200 Weather: Wind 316@20Kts Sea State 5
06 1250 HMS Montrose has retrieved her RHIB due to rough seas.
06 1319 HMS Montrose dispatched RHIB. Two personnel transferred to HMCS Chicoutimi from HMS Montrose (1 Doctor, 1 MA)
06 1330 RFA WAVE KNIGHT on scene RFA WAVE KNIGHT on scene
06 1505 Main hydraulics have nearly collapsed at      bars
06 1522 Attempt to rig 24 volt LP battery from after battery unsuccessful
06 1539 From HMS Montrose to CTF 311 – Medical Officer has completed survey of CAS and assesses 3 CAS need to be removed from the vessel
06 1545 SARFLT (Helicopter 177) scrambled for EVAC (from Donegal Airfield).  Airborne at 1606
06 1553 Lieutenant(N) Saunders moved forward of 35 BULKHEAD with two other critical casualties
06 1600 HMCS Chicoutimi Position : Lat 54 36.9N Long 011 14.0W
06 1600 Weather: Wind 320@24Kts Sea State 5
06 1612 After Auxiliary power breaker remade after extensive checks of electrical systems and damage control preparations
06 1613 Forward DC load center energized
06 1635 HMS Montrose advises HMCS Chicoutimi of Helicopter ETA and intention of hi-line transfer
06 1705 Blew around on main ballast tanks
06 1715 Three casualties being transported to Control Room for helicopter transfer.
06 1718 SARFLT (Helicopter 177) on scene SARFLT (Helicopter 177) on scene
06 1730 Approx time – Petty Officer 2nd Class Lafleur transferred to Helicopter Approx time – Petty Officer 2nd Class Lafleur transferred to Helicopter
06 1735 Approx time – Leading Seaman MacMaster transferred to Helicopter
06 1747 Lieutenant(N) Saunders              on the bridge. Royal Navy doctor                             
06 1800 Approx time Lieutenant(N) Saunders transferred to Helicopter;            on entry,                       
06 1801 Casualty transfer complete Casualty transfer complete
06 1811 Sunset
06 1822 Anglian Prince is on scene
06 1844 SARFLT arrives in Sligo Ireland
06 1859 Lieutenant(N) Saunders admitted Sligo Hospital
06 1909 Lieutenant(N) Saunders pronounced dead in Hospital in Sligo Ireland
06 2000 Approx Time – Hydraulic pumps restored
06 2000 HMCS Chicoutimi Position : Lat 54 31.0N Long 011 11.0W
06 2000 Weather: Wind 330@29Kts Sea State 5
06 2400 HMCS Chicoutimi Position : Lat 54 25.5N Long 011 10.5W
06 2400 Weather: Wind 339@27Kts Sea State 5
7 October 2004
07 0400 HMCS Chicoutimi Position: Lat 54 23.5N Long 011 17.0W
07 0400 Weather: Wind 325@15Kts Sea State 4
07 0655 Sunrise
07 0800 HMCS Chicoutimi Position: Lat 54 20.7N Long 011 12.9W
07 0800 Weather: Wind 350@15Kts Sea State 3
07 1200 HMCS Chicoutimi Position : Lat 54 18.21N Long 011 15.17W
07 1200 Weather: Wind 000@20Kts Sea State 4
07 1251 After motor generator running
07 1446 US Navy submarine tender MV Carolyn Chouest on scene. US Navy submarine tender MV Carolyn Chouest on scene.
07 1455 Member of HMCS Chicoutimi casing party washed overboard.  Subsequently recovered by HMS Montrose RHIB
07 1509 Port HP air compressor running
07 1516 Starboard HP air compressor running
07 1600 HMCS Chicoutimi : Lat 54 15.1N Long 011 16.7W
07 1600 Weather: Wind 010@17Kts Sea State 4
07 1755 Foreplanes retracted
07 1809 Sunset
07 1850 HMCS Chicoutimi under tow by Anglian Prince HMCS Chicoutimi under tow by Anglian Prince
07 2000 HMCS Chicoutimi Position : Lat 54 11.41N Long 011 15.36W
07 2000 Weather: Wind 030@23Kts Sea State 3
07 2400 HMCS Chicoutimi Position : Lat 54 13.0N Long 011 06.0W
07 2400 Weather: Wind 013@25Kts Sea State 3
8 October 2004
08 0400 HMCS Chicoutimi Position: Lat 54 23.0NLong010 51.7W
08 0400 Wind 025@18Kts Sea State 3
08 0656 Sunrise
08 0800 HMCS Chicoutimi Position: Lat 54 36.0N Long 010 42.0W
08 0800 Wind 000@15Kts Sea State 3
08 1200 HMCS Chicoutimi Position : Lat 54 40.3N Long 010 26.9W
08 1200 Weather: Wind 030@17Kts Sea State 3
08 1406 21 people transferred to RFA Argus for rest and hot showers.  Includes six of the original casualties. 21 people transferred to RFA Argus for rest and hot showers.  Includes six of the original casualties.
08 1600 HMCS Chicoutimi Position : Lat 54 49.4N Long 010 09.6W
08 1600 Weather: Wind 050@12Kts Sea State 3
08 1807 Sunset
08 2000 HMCS Chicoutimi Position: Lat 55 03.8N Long 009 34.0W
08 2000 Weather: Wind 050@17Kts Sea State 3
08 2400 HMCS Chicoutimi Position : Lat 55 05.7N Long 009 26.9W
08 2400 Weather: Wind 030@15Kts Sea State 3
9 October 2004
09 0400 HMCS Chicoutimi Position: Lat 55 13.4N Long 009 13.5W
09 0400 Weather: Wind 055@10Kts Sea State 3
09 0658 Sunrise
09 0800 HMCS Chicoutimi Position: Lat 55 20.6N Long 008 58.2W
09 0800 Weather: Wind 070@16Kts Sea State 3
09 1200 HMCS Chicoutimi Position : Lat 55 28.7N Long 008 42.2W
09 1200 Weather: Wind 070@12Kts Sea State 2
09 1331 MV Carolyn Chouest towing HMCS Chicoutimi
09 1600 HMCS Chicoutimi Position: Lat 55 33.0N Long 008 24.0W
09 1600 Weather: Wind 090@18Kts Sea State 2
09 1805 Sunset
09 2400 HMCS Chicoutimi Position: Lat 55 25.8N Long 006 37.0W
09 2400 Weather: Wind 109@18Kts Sea State 3
10 October 2004
10 0400 HMCS Chicoutimi Position: Lat 55 13.4N Long 005 56.0W
10 0400 Weather: Wind 100@13Kts Sea State 3
10 0659 Sunrise
10 0800 HMCS Chicoutimi Position: Lat 55 21.0N Long 005 02.0W
10 0800 Weather:  Wind 055@13Kts Sea State 2
10 1200 HMCS Chicoutimi Position : Lat 55 40.6N Long 004 59.1W
10 1200 Weather: Wind 075@8Kts Sea State 2
10 1600 HMCS Chicoutimi Position : Lat 55 58.0N Long 004 47.0W
10 1600 Weather: Wind 055@7Kts Sea State 2
10 1635 Alongside Jetty 7, Faslane Scotland Alongside Jetty 7, Faslane Scotland
10 1700  Fleet HQ Whale Island standing down as Fleet Control Authority
11 October 2004
11 October 2004 Petty Officer 2nd Class Lafleur released from Sligo Hospital
14 October 2004
14 October 2004 Leading Seaman MacMaster released from Sligo Hospital
14 October 2004 Petty Officer 2nd Class Lafleur and Leading Seaman MacMaster repatriated to Canada

Annex D - Fire Investigator's Report

HMCS CHICOUTIMI Fire

Final Report

Fire origin and cause determination

Fire Incident – 5 October 2004

HMCS CHICOUTIMI

Background

1. A board of inquiry (BOI) was convened to investigate the fires that occurred onboard HMCS CHICOUTIMI on 5 October 2004 and the casualties amongst her crew that occurred on or after 5 October 2004.  I, Major Gaétan Morinville, was designated as a Technical Advisor to the BOI to determine the fire origin and cause of the fires.  On Sunday, 10 October 2004, I was given clear instructions and tasked to begin the fire investigation no later than Monday 11 October 2004 at 08h00.  Three apparent separate fires were to be investigated: Oxygen Generator (Weapon Stowage Compartment), Commanding Officer’s (CO) Cabin (Control Room 1 deck aft of frame 35, port side) and the electrical space (2 deck aft of frame 35, port side).  Commander R.J. Hovey was tasked to provide technical assistance and support during the investigation.

2. HMCS CHICOUTIMI was made safe and secure the night prior to my arrival onboard.  The investigation began Monday 11 October 2004 at approximately 09h15 and completed 13 October 2004 at approximately 16h00.  I was provided three Technical Advisors who possessed expertise in HMCS CHICOUTIMI’s mechanical, electrical and fire fighting systems.  Mr Ian Mitchell an electrical systems specialist, Chief Petty Officer 2nd Class J.A. Haddock a mechanical systems specialist and Chief Petty Officer 2nd Class A.S. Palmer an electrical systems specialist were the designated personnel.

3. Defence Administrative Order and Directive (DAOD) 4007-1, Fire Reporting and Investigating, and the National Fire Protection Association (NFPA) 921 “Guide for Fire and Explosion Investigations” were used as policy and technical reference respectively to assist in my investigation.

Definitions

4. For the purpose of this report the following definitions will be used:

  1. Ampacity.   The current, in amperes (A), that a conductor can carry continuously under conditions of use without exceeding its temperature rating;
  2. Arc. A high-temperature luminous electric discharge across a gap;
  3. Arc Tracking.  Arc that is produced on the surfaces of nonconductive materials if they become contaminated with salts, conductive dusts, or liquids;
  4. Arcing through Char.  Arcing associated with a matrix of charred material (e.g., charred conductor insulation) that acts as a semi conductive medium;
  5. Bead. A Rounded globule of re-solidified metal at the end of the remains of an electrical conductor that was caused by arcing and is characterized by a sharp line of demarcation between the melted and unmelted conductor surfaces;
  6. Cause.  The circumstances, conditions, or agencies that bring together a fuel, ignition source and oxidizer (such as air or oxygen) resulting in a fire or a combustion explosion;
  7. Char. Carbonaceous material that has been burned and has a blackened appearance;
  8. Combustion Products.  Heat, gases, solid particulates, and liquid aerosols produced by burning;
  9. Drop Down.  The spread of fire by the dropping or falling of burning materials;
  10. Extinguish.  To cause to cease burning;
  11. Failure.  Distortion, breakage, deterioration, or other fault in an item, component, system, assembly, or structure that results in unsatisfactory performance of the function for which it was designed;
  12. Fire. Any instance of destructive or uncontrolled burning, including explosion of combustion solids, liquids or gases;
  13. Ground Fault.  A current that flows outside the normal circuit path, such as through the equipment-grounding conductor, through conductive material other than the electrical system ground, through a person, or through a combination of these ground return paths;
  14. Material First Ignited.  The fuel that is first set on fire by the heat of ignition;
  15. Area of Origin.  The room or area where a fire began;
  16. Point of Origin.  The exact physical location where a heat source and a fuel come in contact with each other and a fire begins;
  17. Overcurrent.  Any current in excess of the rated current of equipment or ampacity of a conductor; it may result from an overload, short circuit, or ground fault;
  18. Overload.  Operation of equipment in excess of normal, full-load rating or of a conductor in excess of a rated ampacity, which, when it persists for a sufficient length of time, would cause damage or dangerous overheating;
  19. Short Circuit.  An abnormal connection of low resistance between normal circuit conductors where the resistance is normally much greater, this is an overcurrent situation but is not an overload;
  20. Smoke.  An airborne particulate product of incomplete combustion suspended in gases, vapours, or solid and liquid aerosols;
  21. Spark.  A small incandescent particle;
  22. Soot. Black particles of carbon produced by flame;
  23. Ignition Temperature.  Minimum temperature a substance should attain in order to ignite under specific test conditions;
  24. Thermoplastic.  Plastic materials that soften and melt under exposure to heat and can reach a flowable state;
  25. Thermoset Plastics.  Plastic materials that are hardened into a permanent shape in the manufacturing process and are not commonly subject to softening when heated; typically form char in a fire; and
  26. Timeline.  Graphic representation of events in the fire incident displayed in chronological order.

Timeline of Fires

4. Timeline of events can be found at Annex B.

Casualties Information

5. During these events nine people suffered from smoke inhalation.  Unfortunately, one person died shortly after being evacuated from HMCS CHICOUTIMI.  A complete list of casualties can be found at Annex C.  This information was provided by the Maritime Forces Atlantic Fleet Support Medical Officer, LCdr R.W. Brittain.

Items removed from HMCS CHICOUTIMI

6. Forty-eight items were removed from HMCS CHICOUTIMI and transferred to a secure location onboard HMCS ST JOHN’s for possible analysis.  Additional samples were taken on 26 October 2004 and brought to Halifax.  A log of these items can be found at Annex D.

Oxygen Generator Fire Investigation

7. I first investigated the Oxygen Generator fire because it is a known occurrence onboard submarines and usually not a very serious one.  The fire occurred in a portable Oxygen Generator, located in the weapon stowage compartment, after a Mark V candle Lot No 24Y D.O.M. 10/97 was activated.  I surveyed the compartment and noticed no damage to the compartment and no physical damage to the Oxygen Generator except for some metal discoloration (See Annex A photographs 1 and 2.).

8. In order to produce oxygen a Mark V candle must be introduced into the generator and activated by a striker.  A chemical reaction begins and oxygen is produced.  According to submariners, overheating of the candle in the generator is a frequent occurrence; however, no statistics are available on the frequency of occurrence. Procedures and equipment are in place to ensure that any overheating is rapidly controlled.

Fire Fighting and Damage Control

9. On 5 October 2004 at 1910Z, a fire in a portable Oxygen Generator occurred in the WSC.  The general alarm was sounded and the overheating of the Oxygen Generator was dealt with as per procedures and was reported out at 1912Z.  All required equipment was found in the compartment: gloves, goggles, quenching trough, fire blanket, extinguisher (CO2 and Aqueous Film Forming Foam (AFFF)).  The quenched candle was found in the quenching trough filled with AFFF and covered with a fire blanket.

Probable Cause

10. The introduction of dirt, a clogged filters, a deficient candle and/or procedural error could have all lead to an overheating condition.  The specific cause could not be found during my preliminary investigation.  A qualified technician subsequently disassembled the Oxygen Generator and discovered a brown piece of paper in the location where the charcoal filter is normally located when the unit is in operation (See Annex A photographs 2A and 2B.).  This piece of paper was likely placed in the Oxygen Generator for long-term storage.  In addition, a broken sight glass was discovered (See Annex A photograph 2C.).  It can be concluded that these two factors contributed to the Oxygen Generator malfunction.  This specific Oxygen Generator  must be maintained and tested before it is used again.  Although no specific problems relating to the candle was discovered, the specific Mark V candles Lot No 24Y D.O.M. 10/97 should be examined to ensure that they were manufactured according to specifications.

CO’s Cabin Fire Investigation

11. The fire investigation occurred 6 days after the fires and consequently it was expected to see items, materials removed or moved from the fire scene.  It was also expected that a certain level of cleaning had taken place during that period in order for the crew to continue operating in acceptable living conditions.  The investigation began by a complete survey of 1 and 2 deck.  A systematic approach was used to find the area of origin, point of origin and the cause of this fire or fires.  The scene inspection began from the areas of least damage to the areas of greatest damage.

Undamaged Areas

12. The undamaged areas were visited first.  The engine room and the motor room were undamaged, but a slight smoke odour was present.  No fire damage to equipment or systems, or soot and smoke damage were detected by visual inspection.  Areas forward of frame 35 included the weapon stowage compartment, fridge flats, air turbine pump space, officers’ heads and the bunk spaces were also surveyed.  Except for a negligible smoke odour, no fire damage was noticed.

Damaged Area

13. The damaged areas were located between bulkhead 35 and 56 on 1 and 2 deck.  I began my survey on 2 deck, forward of bulkhead 56 and slowly moved forward to bulkhead 35.  Soot / smoke damage on deckheads and bulkheads was present starting at bulkhead 56, and increased as I moved forward.  The heaviest soot and smoke damage occurred in the vicinity of the electrical space.  (See Annex A photographs 3, 4, and 5.)

14. The electrical space was definitely an area where a fire occurred.  A melted laptop computer was found in a plastic bag on the compartment deck.

15. As I moved toward the centre of the electrical space, I discovered a folded aluminium desk (the Chief Engine Room Artificers (CERA)) secured with brackets and located at approximately 60 cm aft of bulkhead 35.  The desk was damaged on the top right hand side (a hole of approximately 30 cm in diameter) (See Annex A photographs 7, 8, and 9.).  Melted plastic and the remains of a burnt power cord were found on the deck.  I also noticed that a white spot in the shape of an electrical plug was present on one of the 110 volt outlets located on the bulkhead.  This indicates that an electrical appliance was plugged in at the time of the fire (See Annex A photograph 14.).  I quickly realized that the computer found in the plastic bag was on the table during the fire.  I also found the bungee cord used to secure the laptop.  I observed that limited combustible materials were in the space indicating that the fire was probably easily extinguished with a minimum amount of extinguishing agent.  However, during the time that the fire burnt a very large amount of smoke/soot was produced.  Melted metal (probably aluminium) was found at different locations in the space (See Annex A photograph 12.).  Surface burning of the deckhead, bulkhead, ventilation ducts and power cables was observed.  Melted light fixtures (thermoplastic), and several burnt marks on the deck were also observed (probably molten metal from above) (See Annex A photograph 6.).  A perforation of approximately 18 cm in diameter was observed in the deckhead approximately 1.25 meter above the desk and perfectly aligned with the hole on the desk.  At approximately 30 cm to the left (outboard) of this perforation a second hole through the deckhead of approximately 20 cm in diameter was observed.  The deckhead plate thickness is          (See Annex A photographs 10 and 11.).

16. Based only on observations, it appears that the direction of the blow through of these two holes was from 1 deck to 2 deck.  I could not find a point of origin on 2 deck.  I discarded the hypothesis that the computer was an ignition source for the electrical space fire because as it was damaged from outside to inside and also because of evidence pointing to 1 deck.  It was easy to observe that the molten metal scattered throughout the electrical space was from 1 deck.  Consequently, I was almost certain that the point of origin was on 1 deck directly above the electrical space and specifically where the two perforations were located.  Several pictures were taken of the electrical space.

17. I then proceeded to survey 1 deck forward of bulkhead 56 and aft of bulkhead 35.  Smoke/soot damage was apparent on bulkheads and deckheads.  As I moved forward, heavier and heavier smoke/soot damage was present.  Heavy smoke/soot damage was observed on the starboard forward side of the control room (sound room) and by the conning tower (See Annex A photographs 15,16,17,18, and 19.).  Some thermoplastic items, such as light fixture covers and strings, were melted but not liquefied.  I then went to the Conning tower and readily observed that the tower was used for ventilation during the fire.  The tower had smoke/soot damage throughout.  Furthermore, the upper lid did not show any smoke/soot damage and therefore this lid was opened during the fire.  At the beginning, I believed that the bottom lid was shut when the fire first ignited as the bottom lid was completely stained with smoke.  However, after observing and comparing the smoke/soot damage between the     hatch and the deckhead around the lower lid, I concluded that this lid was probably open (See Annex A photographs 5, 20, and 21.).  This was confirmed  by testimony.  The smoke/soot damage to the conning tower was caused by the evacuation of the products of combustion during the fire.

18. On the port side of the control room, I observed that a small thermoplastic doll was secured on the top of the console located aft of the CO’s cabin.  Little heat damage was observed on the doll (See Annex A photograph 16.).  Directly in front of the CO’s cabin a thermoplastic bottle was melted but had not liquefied.  From these observations and knowing that typical thermoplastic items such as the ones found have melting temperatures between 75 degrees Celsius and 160 degrees Celsius, I was able to conclude that the temperature outside the CO’s cabin during the CO’s cabin fire was not in the high range (below 200 degrees Celsius) and that the fire must have been ventilated and extinguished quickly.  In addition, if the ventilation system was crashed from the beginning of the fire and the hatches and smokes curtains were closed rapidly, available oxygen to the fire would have been limited.  Consequently, incomplete combustion would have rapidly taken place and more products of combustion would have been produced (more smoke). With limited oxygen the fire would have decreased in size.

19. It was evident that the area of origin was the CO’s cabin (See Annex A photograph 22.).  The door was opened and I could see a typical ventilation-generated pattern on the door.  I entered the cabin and noticed that the cabin’s bulkheads and deckhead were heavily damaged by fire and smoke/soot.  A clean burn pattern was noticeable on the port forward side of the cabin (front of bunk).  The false bulkhead and false deckhead between the bunk and the pressure hull had very clear burn patterns and the finishing veneer was completely consumed (See Annex A photographs 23, 24, 25, 26, 27 28, 29, 30, 31, 32, 33, and 34.).  All light fixtures on the deckhead were melted with the exception of one heavy-duty light bulb.  All thermoplastic items (light fixture, LCD screen, DVD, portable computer, headset, etc) were damaged almost beyond recognition.  The bunk mattress was lifted on its side.  Approximately one half of the mattress (forward to aft) was burnt through and one of the two sleeping bags found was almost completely consumed.  The second sleeping bag was found at the bottom (aft) of the bed virtually undamaged.  The springs of the mattress were still fully extended, indicating that the springs did not loss their tensile strength; therefore, the mattress was not exposed to temperature higher than the spring tensile strength.

20. Fire and heavy smoke/soot damage were observed between the CO’s cabin and the pressure hull.  Hydraulic lines, air lines, and power cables were also located in this void space.  The forward part of the CO’s bunk was completely destroyed.  Contents of almost all closed cabinets and lockers in the cabin were generally not damaged except for the three drawer cabinet located just beside the bunk, the drug safe (melted bottles) and where the CO’s clothes closet.  Items from the three-drawer cabinet were damaged by smoke/soot and slightly melted.  Pickaxe holes were present on all drawers of this cabinet that resulted from overhauling process.  Navigational charts were found on the cabin’s hardwood deck and in a cabinet under the bunk.  The charts were wet but they were not heavily damaged by fire.  Once cleaned, the desk did not have any fire damage. Three combination safes were in the cabin.  At that time, only one was unlocked and therefore I did not see the contents of two of the safes.  The prescription drugs safe was open two days after my investigation and I was given pictures to confirm the damage inside the safe.  I also recovered from the CO’s cabin (desk top right-hand corner) a document dated 4 October 2004 (pre sailing brief) and that was turned over to the BOI for safekeeping.

Area of Origin and Point of Origin

21. Based on observations, I determined that the CO’s cabin was the area of origin.  I concentrated my efforts removing all debris from the port side of the cabin where the bunk was most damaged (See Annex A photographs 35 and 36.).  I put most of the debris in a large garbage bag.  I noticed many pieces of melted and molten metals.  Once all debris was removed, I was able to see two holes on the deck (previously observed from electrical space) and three electrical cables of approximately 2 inches in diameter completely severed.  A forth-large cable (inboard) was damaged but not completely severed (See Annex A photographs 37, 38, 39, 40, 41, 42 and 43.).  The rupture of all individual cables occurred at approximately the same place on the cable run, namely at the junction between the cable and a bulkhead penetrator.  A red insulating material covered all the junctions.  An on-going technical investigation will identify the specific characteristics of this insulation.

22. I had the port side false bulkhead and one cabinet removed in order to locate other cables.  A total of 10 cables (8 from Main Direct Current (DC) power and 2 from alternate supplies) were found running close to the deck.  All cables had a certain amount of damage (See Annex A photographs 47, 48, 49, 50, 51, 52, 53, and 54.).  Mr Mitchell from Fleet Maintenance Facility Cape Scott, Halifax, identified the cables from a contractor’s drawing number SSK/P/167/00/0002/005.  Table 1 identifies all cables located under the bunk and cabinet.  All cables were removed for further investigation except for PD 38 and PD 36, which were too difficult to access.

Table 1

Cable Reference System Gland No Condition Remark

PD 38 (+)

Main Power

112

Damaged by heat

Not removed

PD 36 (+)

Main Power

114

Damaged by heat

Not removed

PD 37 (+)

Main Power

116

Half severed

Removed

PD 35 (+)

Main Power

118

100 % severed

Removed

PD 39 (-)

Main Power

120

100 % severed

Removed

PD 41 (-)

Main Power

122

100 % severed

Removed

PD 42 (-)

Main Power

124

Damaged by heat

Removed

PD 40 (-)

Main Power

126

Damaged by heat

Removed

PD 134

Alternate Supply

128

Damaged by heat

Removed

PD 135

Alternate Supply

130

Damaged by heat

Removed

24. From the visual and physical evidence recovered it can be determined that the point of origin of this fire was definitely under the CO’s bunk at deck level.  The clean burn patterns, the melted metals, the two holes in the deck and the three completely severed high energy cables point directly to this location.  The fire at the point of origin was extremely hot considering that       (       ) plate melted and two holes were made.  The approximate melting temperature of       (       ) is      degrees Celsius.  Furthermore,        (      ) has a melting temperature of      degrees Celsius and                  (bunk) has a melting temperature between      and      degreesCelsius.  These temperatures would have ignited all combustible materials and melted all metal with a lower melting temperature.  The temperature was definitely higher than the melting temperature of aluminium and this is the reason why melted aluminium was found throughout the electrical space on 2 deck and also on 1 deck under the CO’s bunk.  I could not find melted steel or copper pieces.  This is probably because at the extreme temperature present the material would have been completely consumed or scattered.

25. It can be assumed that the ignition temperature was extremely high and that the fire developed quickly.  However, only surface burns were found in the cabin with the exception of the port false bulkhead and the deckhead located close to the fire point of origin.  This demonstrates that the fire was rapidly brought under control (see Annex B timeline) notwithstanding that a large amount of smoke was produced during this short period of time.  Judging by the smoke damage at the time of my investigation and damage that had been partially cleaned visibility would have been almost zero from approximately 1 metre above deck on 1 and 2 deck forward of bulkhead 56 and aft of bulkhead 35 for a short period of time.

26. The forward main power breaker was found tripped when inspected.  The initial observation indicated no apparent damage.  The arc chutes were removed from positive and negative poles.  The arc chutes indicated some minor copper splash and heat damage.  The arc tips (sacrificial contacts) indicated some copper splash and heat damage but no more than normally expected between maintenance routines.  The main contacts were in good repair indicating that arcing tips performed as designed (See Annex A photographs 55, 56 and 57.).  All cables found in the forward battery switchboard are exactly the same cable runs identified previously in the CO’s cabin by Mr Mitchell.  This proves that an undesirable event occurred along the cable runs, which tripped this breaker.

27. The electrical space fire was a direct result of the fire in the CO’s cabin.  Pellets of molten metal (probably aluminium, steel and copper) would have dropped directly to the electrical space and ignited combustible materials in the space below.  This is consistent with the several burn marks found on the electrical space deck and the direction of the blow from the holes found on 1 deck.  The approximate temperature of the metal droppings would have been in the vicinity of      degrees Celsius, calculated by averaging the melting temperature of steel, aluminium and copper.

Fire Fighting and Damage Control

28. The following is based on testimony from the crew and the events timeline (see Annex B).  On 5 October 2004 at approximately 1315Z, sparks and electrical popping noises were seen and heard in the control room.  A fire in the CO’s cabin (1 deck) and in the electrical space (2 deck) ignited.  First aid fire fighting was rapidly initiated.  The general alarm was raised.  Auxiliary breakers were opened and the main power breakers tripped.  Emergency Breathing System (EBS) masks were donned by crewmembers.  The AFFF self-contained unit (SFU 90) was deployed and smoke boundaries were established.  During that time the upper conning tower lid was opened.  Attack teams dressed in full gear and prepared to respond to the fire.  Two casualties were found in the control room.

29. The crew located in the control room brought the fire in the CO’s cabin under control by using extinguishers (CO2 and AFFF) and the SFU 90.  During this attack the SFU 90 nozzle blew off from the main hose.  Consequently, the unit was completely emptied into the cabin making it unusable for a period of time.  This fire was reported out and overhauled at 1446Z.  A subsequent overhaul was performed at 1730Z.

30. The electrical space fire was brought under control and extinguished using two CO2 extinguishers by crewmembers located on two deck.  At 1335Z the fire was reported out.  The electrical space fire was overhauled one more time at 1730Z.

Cause of Fire

31. No other sources of ignition were found at the point of origin except for electrical cables and hydraulic lines.  The hydraulic lines were located approximately 1.5 m from the damaged cables.  Hydraulic lines were intact and all other cables were also undamaged with the exception of the cables close to the point of origin (charred and melted).  Also the bunk mattress was burnt from the bottom up indicating that a fire started somewhere under the mattress.  I quickly concluded that a fire could have not been ignited other than somewhere under the mattress.  The top of the bunk has three storage containers equipped with a grilled type lid.  The content of the forward storage container is not known but it is unlikely that a competent ignition source was inside this container that could cause a fire that would have travelled up and down to the deck where the severed cables are located.  Consequently, I discarded the possibly that a fire ignited by another source would have damaged these cables which would have lead to an arcing event.

32. The severed power cables were terminated in a large bead inside of the bulkhead 35 penetrators.  The clean ruptures of the connectors, the damage to the deck (2 holes) and to the surrounding area, are all evidence of a high-energy electrical arcing event.

33. An arc is a high-temperature luminous electric discharge across a gap.  This severe condition as reported in NFPA 921 will usually be accompanied with the clap of thunder and a lighting bolt.  It is well documented that when an arcing event occurs tremendous energy is released.  The amount of energy  produced by this arc rapidly increased the temperature of the surrounding area to the point that all material around these cables started melting and igniting.  At this time I cannot establish how many arcing events took place (small to large or large) and the amount of energy released.  A technical investigation has been initiated by the BOI to establish these facts.

34. In order to have an arcing event, current leakage must occur.  Damaged cable insulation or contamination could lead to an arcing event.  Physical damage to the cables could be a factor in this arcing event but I cannot verify this possibility because the fire and the arc caused too much damage to the cables.  However, judging by the condition of other cables in the vicinity and the location of all of these cables, this is unlikely.  Damage to the cables from overload conditions is also a possibility, which could lead to an arcing event.  Overloading the cables in excess of normal, full-load rating or of a conductor in excess of rated ampacity could, if it persists for sufficient length of time, cause damage or overheating which could lead to a current leakage and an arcing event.  However, breakers would protect the cables from an overloading condition.

35. When non-conductive materials become contaminated with salts, conductive dusts or liquid arcs may occur on the surfaces of the non-conductive materials.  According to NFPA 921:

it is thought that small leakage currents created through such contamination cause degradation of the base material leading to the arc discharge, charring or igniting combustible materials around the arc.  Arc tracking is a known phenomenon at high voltage.  Electrical current will flow through water or moisture only when that water or moisture contains contaminants such as dirt, dusts, salts, or mineral deposits.” 

36. Condition of the cable insulation and the timeline of events are key factors in determining the reasons why such a powerful arcing event took place.  The cause of the arcing is under investigation.

Findings

37. The following are findings:

Oxygen Generator Fire

  1. An overheating condition developed in the portable Oxygen Generator;
  2. The oxygen Generator candle was extinguished rapidly;
  3. Proper equipment was in place in the compartment;
  4. Candle was from: Lot No 24Y D.O.M. 10/97;
  5. No apparent damage was observed in the WSC from this fire;
  6. A brown piece of paper was found in the location where the charcoal filter is normally located when the unit is in operation;
  7. The Oxygen Generator sight glass was discovered broken; and
  8. It is highly probable that the overheating condition was caused by a malfunction of the generator due to the brown piece of paper found in the location where the charcoal filter is normally located when the unit is in operation. 

CO’s Cabin Fire

  1. A high energy electrical arc caused the fire on HMCS CHICOUTIMI; (sequence of event not known);
  2. The point of origin was at the three completely severed high energy cables;
  3. The fire started in the CO’s cabin under the bunk located aft of bulkhead 35 on the port side of the cabin where the three cables are located;
  4. Fire in the electrical space was a consequence of the fire in the CO’cabin;
  5. Fire at the point of origin developed rapidly but was quickly controlled;
  6. A large amount of black smoke/soot was produced in a very short period of time;
  7. The CO’s cabin sustained severe fire damage;
  8. The fire was contained in the CO’s cabin and the electrical space;
  9. Smoke/soot damage was heavy on 1 deck and 2 deck forward of bulkhead 56 and aft of bulkhead 35;
  10. Materials fire propagation characteristic (cables, insulation materials, bulkhead finishing, duct insulation, etc) appears to be good;
  11. Smoke developed index of materials (cables, insulation materials, bulkhead finishing, red electrical moulded insulation) is suspect;
  12. The conning tower upper lid was definitely open during the fire;
  13. The CO’s cabin door was open during the fire;
  14. Visibility would have been almost zero from approximately 1 metre above deck on 1 and 2 deck forward of bulkhead 56 and aft of bulkhead 35;
  15. Smoke curtains worked perfectly;
  16. Self-contained AFFF unit SFU 90 nozzle blew off from the main hose during fire fighting;
  17. Eight crewmembers suffered smoke inhalation; and
  18. One crewmember died from the result of smoke inhalation.

Recommendations

38. I strongly recommend that the technical investigation initiated by the BOI determine the following:

  1. The events that lead to this catastrophic arcing;
  2. The smoke developed index, fire propagation index and toxicity of the material recovered from the fire scene and/or similar materials; and
  3. The temperature gradient and smoke movement to establish the ambient condition during the fire.

39. It is recommended that the SFU 90 be inspected and tested prior to future use.  Planned maintenance for this fire fighting equipment must be reviewed.

40. Finally, it is recommended that:

  1. The Oxygen Generator that sustained the overheating condition be sent for maintenance and tested before putting it back into service;
  2. The crewmembers must be made aware that every Oxygen Generators must be tested prior to using these units onboard to ensure proper and secured operation; and
  3. The specific Mark V candles of lot No 24Y D.O.M. 10/97 should be also investigated to ensure this lot meets the required specifications.

Date: 01 December 2004

Prepared by:  Major Gaétan Morinville, Lead Fire Investigator

Signature: OSB by Major Gaétan Morinville

Position:  Canadian Forces Fire Marshal 4; Head of Fire Protection Engineering.

Photograph 1: Mark V candle Lot used

Photograph 1: Mark V candle Lot used

Photograph 2:  Portable Oxygen Generator and equipment. Located WSC

Photograph 2:  Portable Oxygen Generator and equipment. Located WSC

Photograph 2A  Oxygen Generator disassembled

Photograph 2A  Oxygen Generator disassembled

Photograph 2B Paper found between ceramic plates

Photograph 2B Paper found between ceramic plates

Photograph 2C Broken Sight Glass

Photograph 2C Broken Sight Glass

Photograph 3:  View of Electrical Space

Photograph 3:  View of Electrical Space

Photograph 4: Looking outside electrical space Port side forward bulkhead 35.

Photograph 4: Looking outside electrical space Port side forward bulkhead 35.

Photograph 5:     Hatch, 2 deck.  Not open during fire

Photograph 5:     Hatch, 2 deck.  Not open during fire

Photograph 6:  Electrical Space Desk.  Notice burnt spots on deck

Photograph 6:  Electrical Space Desk.  Notice burnt spots on deck

Photograph 7:  Electrical Space.  CERA’s desk

Photograph 7:  Electrical Space.  CERA’s desk

Photograph 8: Electrical Space. CERA’s desk

Photograph 8: Electrical Space. CERA’s desk

Photograph 9: Electrical Space

Photograph 9: Electrical Space

Photograph 10:  Electrical Space Inboard Hole

Photograph 10:  Electrical Space Inboard Hole

Photograph 11: Electrical Space Outboard Deck Hole

Photograph 11: Electrical Space Outboard Deck Hole

Photograph 12:  Electrical Room.  Metal drops from above.

Photograph 12: Electrical Room.  Metal drops from above.

Photograph 13:  Outside Electrical Room Passageway.

Photograph 13: Outside Electrical Room Passageway.

Photograph 14: Electrical Outlet used by computer

Photograph 14: Electrical Outlet used by computer

Photograph 15: Control Room. Port side forward.

Photograph 15: Control Room. Port side forward.

Photograph 16 Outside CO’s cabin. Port side. Thermoplastic doll

Photograph 16 Outside CO’s cabin. Port side. Thermoplastic doll

Photograph 17:  Control Room.  Looking at Sound Room

Photograph 17: Control Room. Looking at Sound Room

Photograph 18: Starboard side Control Room Forward.  Looking at Sound Room

Photograph 18: Starboard side Control Room Forward.  Looking at Sound Room

Photograph 19: Control Room. Looking Aft

Photograph 19: Control Room. Looking Aft

Photograph 20: Looking up Conning Tower. Combustion Products ventilated through tower.

Photograph 20: Looking up Conning Tower. Combustion Products ventilated through tower.

Photograph 21: Conning Tower Upper Lid.  No apparent smoke/soot damage

Photograph 21: Conning Tower Upper Lid.  No apparent smoke/soot damage

Photograph 22: CO’s Cabin.  Standing up at entrance door

Photograph 22: CO’s Cabin.  Standing up at entrance door

Photograph 23: CO’s Cabin.  Forward end of Bunk

Photograph 23: CO’s Cabin.  Forward end of Bunk

Photograph 24: CO’s Bunk

Photograph 24: CO’s Bunk

Photograph 25: CO’s Cabin. Forward end of Bunk

Photograph 25: CO’s Cabin. Forward end of Bunk

Photograph 26: CO’s Cabin. Looking behind door. Door was hooked during fire.

Photograph 26: CO’s Cabin. Looking behind door. Door was hooked during fire.

Photograph 27: CO’s cabin. Looking at the back of door

Photograph 27: CO’s cabin. Looking at the back of door

Photograph 28: CO’s Cabin. Locker located right hand side when you enter the cabin.

Photograph 28: CO’s Cabin. Locker located right hand side when you enter the cabin.

Photograph 29: CO’s Cabin. Prescription Drugs safe. Located above desk

Photograph 29: CO’s Cabin. Prescription Drugs safe. Located above desk

Photograph 30: CO’s Cabin. Forward end of Bunk and desk and 3 drawers cabinet

Photograph 30: CO’s Cabin. Forward end of Bunk and desk and 3 drawers cabinet

Photograph 31 CO’s Cabin. 3 Drawers cabinet beside bunk.

Photograph 31 CO’s Cabin. 3 Drawers cabinet beside bunk.

Photograph 32: CO’s Cabin. Looking through false bulkhead. (Port side)

Photograph 32: CO’s Cabin. Looking through false bulkhead. (Port side)

Photograph 33: CO’s Bunk once mattress removed (looking forward)

Photograph 33: CO’s Bunk once mattress removed (looking forward)

Photograph 34: CO’s Bunk. Looking Aft

Photograph 34: CO’s Bunk. Looking Aft

Photograph 35: CO’s Bunk Forward Storage Compartment

Photograph 35: CO’s Bunk Forward Storage Compartment

Photograph 36: First look at severed power cables

Photograph 36: First look at severed power cables

Photograph 37: CO’s Cabin. Under bunk. Looking at damaged cables.

Photograph 37: CO’s Cabin. Under bunk. Looking at damaged cables.

Photograph 38: CO’s Cabin. Location of severed cables.

Photograph 38: CO’s Cabin. Location of severed cables.

Photograph 39: CO’s Cabin. Outboard and inboard holes

Photograph 39: CO’s Cabin. Outboard and inboard holes

Photograph 40: CO’s Cabin. Inboard Hole

Photograph 40: CO’s Cabin. Inboard Hole

Photograph 41: CO’s Cabin. Outboard hole

Photograph 41: CO’s Cabin. Outboard hole

Photograph 42: One of the three severed Cable connector.

Photograph 42: One of the three severed Cable connector.

Photograph 43: CO’s Cabin. View of two Alternate Supply cables

Photograph 43: CO’s Cabin. View of two Alternate Supply cables

Photograph 44: CO’s Cabin. Cables not removed from HMCS CHICOUTIMI

Photograph 44: CO’s Cabin. Cables not removed from HMCS CHICOUTIMI

Photograph 45: Cross view of alternate supply cable

Photograph 45: Cross view of alternate supply cable

Photograph 46: Cross view of Main Power System Cable

Photograph 46: Cross view of Main Power System Cable

Photograph 47: Main Power Cable PD 35 Gland 118

Photograph 47: Main Power Cable PD 35 Gland 118

Photograph 48: Main Power Cable PD 41 Gland 122

Photograph 48: Main Power Cable PD 41 Gland 122

Photograph 49: Main Power Cable PD 39 Gland 120

Photograph 49: Main Power Cable PD 39 Gland 120

Photograph 50: Alternate Supply Cable PD 134 Gland 128

Photograph 50: Alternate Supply Cable PD 134 Gland 128

Photograph 51: Alternate Supply Cable PD 135 Gland 130

Photograph 51: Alternate Supply Cable PD 135 Gland 130

Photograph 52: Main Power Cable PD 42 Gland 124

Photograph 52: Main Power Cable PD 42 Gland 124

Photograph 53: Main Power Cable PD 40 Gland 126

Photograph 53: Main Power Cable PD 40 Gland 126

Photograph 54: Main Power Cable PD 37 Gland 116

Photograph 54: Main Power Cable PD 37 Gland 116

Photograph 55: Tip

Photograph 55: Tip

Photograph 56: Breaker

Photograph 56: Breaker

Photograph 57: Arc chute

Photograph 57: Arc chute

Annex B – TIMELINE

Events preceded with “Approx” denote an estimated time based upon review of Testimony and Exhibits by members of the Board of Inquiry

DATE/TIME (Z) EVENT

5 October 2004

05 1315Z

Approx time of sparks and electrical popping noises in Control Room

05 1315Z

Sometime between 05 1310Z and 05 1322Z fire in CO’s cabin (1 deck) and electrical space (2 deck).  Aux breakers opened, main power breakers already tripped.

05 1315Z

Responses to Fires

  • General alarm raised
  • First aid fire fighting attack on control room and electrical space
  • Upper conning tower lid opened
  • Emergency Breathing System (EBS) donned
  • SFU 90 deployed
  • Smoke boundaries established
  • Attack teams dressing
  • Two casualties in Control Room

05 1325Z

Report of             person in Control Room, later confirmed to be Lieutenant(N) Saunders

05 1330Z

HMCS CHICOUTIMI Position and Weather: Lat 55 26.2N Long 011 14.5W Wind310@35Kts Sea State 6

05 1330Z

Approx time – CO orders auxiliary power breaker remade to clear smoke using LP Blower

05 1331Z

Subsequent report of fire.

05 1331Z

Laying off all power, no further attempts to restore power until system checks complete on 6 Oct 04.

05 1335Z

Fire out in Electrical space

05 1443Z

STBD Engine started for smoke clearance

05 1446Z

CO’s cabin fire reported out by CO, overhauled

05 1448Z

Main and Aux Power Breakers assessed as dangerous by Damage Control Officer

05 1504Z

All personnel forward of 35 BKHD evacuated to aft of 56 BKHD (includes some casualties)

05 1625Z

Atmosphere in spec throughout submarine, all personnel off EBS

05 1657Z

Sunset

05 1705Z

SFU 90 repaired and recharged

05 1730Z

CO's cabin and electrical space have been overhauled a second time

05 1742Z

Fire fighters stood down

05 1744Z

Fire sentry stood down

05 1845Z

Starting Oxygen Generators forward of 35 Bulkhead - 2 candles

05 1910Z

Fire in forward Oxygen Generator

05 1912Z

Fire in Forward Oxygen Generator is out

05 1917Z

Lining up for smoke clearance from Weapon Storage Compartment (WSC)

05 1957Z

Atmosphere in spec throughout submarine

05 2029Z

All firefighting gear stowed

Annex C – Casualty Information

Casualty Information
Rank Surname First Name SN Age Height* Weight* Nature / Injury Condition / Status

 

      

     

    

  

    

    

Smoke Inhalation

Taken to hospital post-incident - left after a few hours.                           .

   >

      

     

    

  

    

    

Smoke Inhalation

Taken to hospital post-incident - left after a few hours.                                       .

PO2

Lafleur

Denis

    

  

    

    

Smoke Inhalation

Admitted to Sligo Hospital 6 to 11 Oct 04.  Initially respiratory symptoms,                                                   .

LS

MacMaster

Robert

    

  

    

    

Smoke Inhalation

Admitted to Sligo Hospital 6 to 13 Oct 04.  Respiratory symptoms                .

  

      

     

    

  

    

    

Smoke Inhalation

Taken to hospital post-incident - left after a few hours.                      .

  

      

     

    

  

    

    

Smoke Inhalation

Taken to hospital post-incident - left after a few hours.                                        .

  

      

     

    

  

    

    

Smoke Inhalation

Taken to hospital post-incident - left after a few hours.                                       .

  

      

     

    

  

    

    

Smoke Inhalation

Taken to hospital post-incident,                                       .

LT(N)

Saunders

Chris

    

  

    

    

Smoke Inhalation

Fatality.

Annex D – List of items removed from HMCS CHICOUTIMI

Items Removed from HMCS CHICOUTIMI for possible evaluation and testing

Serial Description Location Remark

Items gathered between
11 October to 13 October 2004 by Major Morinville

1 Draeger Tubes Jr Mess
2 Draeger Tubes 2 Deck outside Jr Mess
3 Draeger Tubes Motor Room
4 Draeger Tubes Control Room
5 Filter ATU #2 Upper Sample removed 16 Oct 04 for analysis
6 Filter ATU #1 Lower
7 Filter ATU #2 Lower Sample removed 16 Oct 04 for analysis
8 Filter ATU # 1 Upper
9 Filter After Battery vent Sample removed 16 Oct 04 for analysis
10 Filter Fan Space door upper Sample removed 16 Oct 04 for analysis
11 Filter Fan Space door lower
12 Filter Search Periscope
13 Mattress CO’s Cabin
14 Briefcase CO’s Cabin 16 Oct 04 CO’s Personal items removed from briefcase by Cdr Hovey
15 Spare Sleeping Bag CO’s Cabin
16 Sleeping Bag CO’s Cabin
17 Forward outboard bulkhead door CO’s Cabin
18 Forward Bunk Locker Cover CO’s Cabin
19 Curtain CO’s Cabin
20 Molten Metal CO’s Cabin
21 Light Fixture Cover CO’s Cabin
22 Insulation Under bunk CO’s cabin
23 Brackets Under bunk CO’s cabin
24 Molten Metal From Deck, Under bunk CO’s cabin
25 Fearnought Suit Used for Firefighting during fire
26 NCD Jacket LS MacMaster Control Room
27 NCD Jacket Control Room Removed wrong jacket.  Item returned to HMCS CHICOUTIMI
28 Cable PD 35 Gland 118 Under bunk CO’s cabin
29 Cable PD 41 Gland 122 Under bunk CO’s cabin
30 Cable PD 39 Gland 120 Under bunk CO’s cabin
31 Draeger Tubes 2 Deck Across Wardroom
32 Cable PD 134 Gland 128 Under bunk CO’s cabin
33 Cable PD 135 Gland 130 Under bunk CO’s cabin
34 Vent Trunking Insulation Electrical Space
35 Deckhead Insulation Electrical Space
36 NCD Jacket PO2 Lafleur Control Room
37 Sample Bulkhead veneer CO’s cabin
38 Cable PD 40 Gland 126 CO’s cabin
39 Cable PD 42 Gland 124 CO’s cabin
40 Cable PD 37 Gland 116 CO’s cabin
41 Arc Chute (+V) Forward Main Power Breaker
42 Arc Chute (-V) Forward Main Power Breaker
43 Light Fixture Cover Sound Room
44 Light Bulb CO’s cabin
45 Draeger Tubes 2 Deck Wardroom

Items gathered on 16 October 2004 by Cdr Hovey

27 Filter Starboard Engine
28 Filter Starboard Engine
29 Filter Starboard Engine

Items gathered on 26 October 2004 by Major Morinville

49 Debris CO’s Cabin by holes
50 Debris CO’s Cabin inboard hole
51 Metals CO’s Cabin under bunk
52 Metal bracket CO’s Cabin under bunk
53 Debris Electrical Space 2 Deck
54 Metals Found on CERA’s table Electrical space 2 Deck

Annex E - Fire Investigation Test Plan

Fire Investigation Test Plan

1080-1 (CHI BOI)
12 December 2004

BOI President

TEST PLAN

HMCS CHICOUTIMI BOARD OF INQUIRY - Fire INCIDENT 05 OCTOBER 2004

References:

  1. 2711 (NETE MH) IT2252-S/31 - HMCS CHICOUTIMI Board of Inquiry on Fire Incident 05-OCT-2004, Technical Advisory Team Investigation Survey and Test Plan Recommendations, dated 11 November 2004
  2. 2711 (NETE MH) IT2252-S/31 – HMCS CHICOUTIMI Board of Inquiry on Fire Incident 05-Oct-2004, Fire Investigation Test Plan, dated 09 December 2004

The enclosed Test Plan includes a series of tests for establishing additional understanding of the characteristics of the short circuit arc onboard HMCS CHICOUTIMI, as well as thermal characteristics of material involved in the resulting fire.  It is recommended that the Test Plan be included with the BOI report for consideration by the convening authority.

R.J. Hovey
Cdr
BOI Technical Advisor

Enclosure:  1

HMCS CHICOUTIMI FIRE INVESTIGATION TEST PLAN

Investigation Requirement

1.   The test requirements are to attempt to establish the following:

  1. Location of Insulation Compromise;
  2. Insulation Failure Mode;
  3. Type of Conductor;
  4. Arcing Duration;
  5. Combustion By-products and other thermal characteristics.
Category

2. The individual components of the Test Plan are categorised as follows:

  1. Category 1 (Causal) – the information gathered would assist in the determining the probable cause of the incident;
  2. Category 2 (Thermal Characteristics and Force Health Protection) – the information gathered would assist in determining the thermal characteristics of selected material from the scene of the fire. This information will also complement efforts by DCOS Force Health Protection in the CF Health Services Group (OPI: Dr. Steve Tsekrekos), in determining the effects of the fire on human health. 
Test Name – Information Type
(Fire Investigation Requirement)
Appl Para. (Ref. A) Description Objective Procedure
1. Cable Examination Category 1 (Requirement #1a) 16.c. & 17.a. Visual examination of CHI damaged cables. To detect evidence of arcing. Visual examination of damaged surfaces.
16.d. & 17.a. Dielectric resistance measurement of CHI cable insulation. To show condition of any undamaged cable insulation. Routine laboratory method using high voltage insulation resistance tester. MIL-STD-202G Test Methods 301 & 302
2. Penetrator Examination – Category 1 (Requirement #1a) 16.e. & 17.a. In-situ radiography of CHI penetrators for cables PD35 to 42 (Fwd and Aft of Blhd 35). To detect evidence of arcing, to determine condition of internal components of penetrators and possibly identify installation variations. Standard industrial radiography using gamma rays. See QinetiQ Report when issued.
17.a. Visual examination of CHI penetrators. Complimentary to and confirmation of the results of Test 2.a. Disassemble retrieved penetrators and conduct visual examination of all surfaces.
17.a. Dielectric resistance measurement of CHI penetrator insulation. To determine condition of the penetrator insulation. Routine laboratory method using high voltage insulation resistance tester. MIL-STD-202G Test Methods 301 & 302
3.  Connector Examination – Category 1 (Requirement #1a) 16.e. & 17.a. In situ radiography of CHI connector assemblies for cables PD35 to 42 (Fwd and Aft Blhd 35). To detect evidence of arcing, to determine condition of connectors and possibly identify installation variations Standard industrial radiography using gamma rays
17.a. Visual examination of CHI connectors To determine condition of the connectors. Visual examination of all surfaces
17.a. Insulation resistance and electrical resistance measurement of CHI retrieved connector assemblies. To show quality of connection, to reveal installation variations and to determine ranges of resistance. Data will be used as part of 3.e. Dielectric resistance measurements - Routine laboratory method using high voltage insulation resistance tester. MIL-STD-202G Test Methods 301 & 302 Electrical resistance measurements – Routine laboratory method using micro-ohmmeter. MIL-STD-202G Test Methods 303A & 307
(Requirement #1b) 17.b. In-situ thermal imaging of connectors on HMCS WINDSOR. To show range of temperatures for connectors under given load conditions, and to show connector installation and resistance variations. Data will be used as part of 3.e. Using high-resolution infrared camera and thermocouples to determine the temperature profile of the connectors during a basin or sea trial.
17.b. Modelling of thermal behaviour of connector system. To predict the thermal profile of the connector system under different load conditions and to provide an indication of connector installation performance. To provide data for use in Test 7. Build a validated numeric model using commercially available software
4.  Conductor Presence Identification – Category 1 (Requirement #1c) 16.a. & 17.d. Elemental traces analysis on collected CHI debris samples. To identify foreign conductor material or contaminants. DRDC-DL standard laboratory methods using Inductively coupled plasma-atomic emission spectroscopy (ICP-AES)
16.a. & 17.d. Elemental traces analysis on external & internal surfaces of CHI cable, penetrator and connector insulation. To determine presence of seawater. DRDC –DL standard laboratory methods using conductivity meter pH paper Titration using silver nitrate ICP-AES (see DRDC Interim Report, dated 22 November 2004)
5.  Deck Plate Analysis – Category 1 (Requirement #1d) 16.f. & 17.a. CHI in-situ residual DC magnetic field mapping on CO’s Cabin deck and on Bulkhead 35 To attempt to determine peak discharge current levels at the time of the arcing event. Results will be used in Test 3c and Test 8. See NETE Guidelines titled HMCS CHICOUTIMI Bulkhead 35 Magnetic and Radiographic Measurements Guidelines, dated 22 November 2004 See QinetiQ Report when issued.
16.f. & 17.a. Elemental analysis of CHI deck plate material. To establish deck plate composition. Results will be used to establish arcing event energy level and duration. Standard laboratory methods using scanning electron microscope.
16.f. & 17.a. Characteriza-tion of CHI deck plate material. To establish deck material’s melting temperature and melting energy. Results will be used to establish arcing event energy level and duration. Standard metallurgical techniques.
6.  Main Power Breaker Performance – Category 1   (Requirement #1d) 16.g. & 17.a. Characteriza-tion of CHI Fwd Battery Main DC Power Breaker. To establish duration of arcing incident. Laboratory evaluation of the response characteristics at different short circuit current levels.
16.g. & 17.a. Characteriza-tion of CHI Aft Battery Main DC Power Breaker. To establish duration of arcing incident. Laboratory evaluation of the response characteristics at different short circuit current levels.
7.  Connector System Performance – Category 1   (Requirement #1b) 17.a. a) Material characteriza-tion of CHI connector insulation before and after accelerated degradation (fatigue). To establish the effects of degradation on the properties of the connectors’ dielectric insulation (including watertight integrity of the insulated assembly. Results will be used in Test 8.b. Routine laboratory method using high voltage insulation resistance tester. MIL-STD-202G Test Methods 301 & 302 Tests before accelerated degradation of insulated assembly may indicate lack of watertight integrity. If so, this may preclude requirement for accelerated degradation test (7c).
17.a. b)Characteriza-tion of electrical performances of CHI connector before and after accelerated degradation (fatigue). To establish the effects of degradation on the properties of the connectors’ electrical performance. Results will be used in Test 8.b. Routine laboratory method using micro-ohmmeter. MIL-STD-202G Test Methods 303A & 307
17.a. c)Accelerated degradation (fatigue) test on connector system assembly To establish the effects of degradation on the properties of the connector system assemblies. Results will be used in Test 8.b. Test procedure based on standard CSA C57-98 Electric Power Connectors for use in Overhead Line Conductors in order to induce insulation failure in cable assemblies.
Re-creation of Arcing – Category 1   (Requirement #1b) 17.a. Laboratory demonstration of arcing event on collected connector system samples. To attempt to corroborate the arcing event against the collected testimony Experimental set-up simulating operating conditions. Insulation failure will be induced to observe arcing phenomena using infrared and high-speed cameras.
17.a. Laboratory demonstration of arcing incident on accelerated-degraded undamaged connector system samples. To attempt to determine if the arcing event was due to material degradation or improper installation. Using the degraded cable assemblies obtained from Test 7c, an arcing source will be applied to observe arcing phenomena using infrared and high-speed cameras.  Should test 7a have indicated water ingress then this test may not be required.
Chemical Analysis – Category 2   (Requirement #1e) 17.d. Chemical analysis of CHI evidence. To determine combustion products content and concentrations DRDC-DL standard laboratory methods using Inductively coupled plasma-atomic emission spectroscopy (ICP-AES) Pyrolysis gas chromatography/
mass spectrometry Scanning electron microscopy x-ray energy spectrometry
10.  Material Specification – Category 2 (Requirement #1e) 17.e. Analysis of applicable safety documenta-tion of material in the CO’s Cabin vicinity. To determine the flammability characteristics, smoke generation indices and combustion by-products concentrations of the materials in the vicinity of the CO’s Cabin. Materials will be identified by review of the Victoria Class Technical Data Package. Where possible material specifications, MSDSs etc will be sourced and required data tabulated. UK MOD resources will be required to provide assistance.
Destructive Testing – Category 2   (Requirement #1e) 17.f. Destructive testing of CHI collected samples To determine flammability characteristics, smoke generation indices and combustion by-products concentrations of the materials in the vicinity of the CO’s Cabin that could not be identified in Test 11. Appropriate test procedures will be identified by reviewing; Underwriters Laboratory Standards; National Fire Protection Association Standards; MIL Specifications; and Naval Engineering Standards

Annex F - Location of Crew when Fire Erupts

Location of Crew when Fire Erupts

Location of Crew when Fire Erupts

Location of Crew when Fire Erupts

Location of Crew when Fire Erupts

Annex G - Sea State Table

Sea State Table

Pierson - Moskowitz Sea Spectrum
Values are worst case forecasts for open water in vicinity of referenced point

Wind Speed (Kts) Sea State Significant Wave (Ft) Significant Range of Periods (Sec) Average Period (Sec) Average Length of Waves (FT)

3

0

<.5

<.5 - 1

0.5

1.5

4

0

<.5

.5 - 1

1

2

5

1

0.5

1 - 2.5

1.5

9.5

7

1

1

1 - 3.5

2

13

8

1

1

1 - 4

2

16

9

2

1.5

1.5 - 4

2.5

20

10

2

2

1.5 - 5

3

26

11

2.5

2.5

1.5 - 5.5

3

33

13

2.5

3

2 - 6

3.5

39.5

14

3

3.5

2 - 6.5

3.5

46

15

3

4

2 - 7

4

52.5

16

3.5

4.5

2.5 - 7

4

59

17

3.5

5

2.5 - 7.5

4.5

65.5

18

4

6

2.5 - 8.5

5

79

19

4

7

3 - 9

5

92

20

4

7.5

3 - 9.5

5.5

99

21

5

8

3 - 10

5.5

105

22

5

9

3.5 - 10.5

6

118

23

5

10

3.5 - 11

6

131.5

25

5

12

4 - 12

7

157.5

27

6

14

4 - 13

7.5

184

29

6

16

4.5 - 13.5

8

210

31

6

18

4.5 - 14.5

8.5

236.5

33

6

20

5 - 15.5

9

262.5

37

7

25

5.5 - 17

10

328.5

40

7

30

6 - 19

11

394

43

7

35

6.5 - 21

12

460

46

7

40

7 - 22

12.5

525.5

49

8

45

7.5 - 23

13

591

52

8

50

7.5 - 24

14

655

54

8

55

8 - 25.5

14.5

722.5

57

8

60

8.5 - 26.5

15

788

61

9

70

9 - 28.5

16.5

920

65

9

80

10 - 30.5

17.5

1099

69

9

90

10.5 - 32.5

18.5

1182

73

9

100

11 - 34.5

19.5

1313.5