A Transportation Safety Board report released Aug. 14 points to inadequate training and organizational oversight as risk factors in the accident that claimed the lives of two Royal Canadian Marine Search and Rescue (RCM-SAR) members last year.
During an impromptu station-keeping exercise in the Skookumchuck Rapids on June 3, 2012, the Halfmoon Bay RCM-SAR vessel the Lewis-McPhee capsized, throwing two of the four members overboard and away from the vessel.
The other two crew members - Angela Nemeth and Beatrice Sorensen - became trapped beneath the vessel and subsequently drowned, the report stated.
Originally the Lewis-McPhee was to meet up with the Ken Moore for a planned navigation and towing exercise in Vanguard Bay. The exercise included a passage through the Skookumchuck Rapids.
According to the report, as the Lewis- McPhee arrived near the rapids ahead of schedule, the coxswain told crew members they would use the time to practise station keeping in the rapids.
Station keeping is when a coxswain finds a point on the shore and attempts to keep the vessel in line with it.
The rapids at that time (approximately 11:20 a.m.) would have been flowing at 11 knots, the report stated.
"Station keeping within the rapids in areas prone to exceptionally high current and standing waves is a high-risk exercise. Risks must be carefully analyzed when the exercise is planned, and the crew members prepared for the worst-case scenario," the report reads. "In this occurrence, the decision to conduct station-keeping exercises was made ad hoc, without an advance plan or formal consideration of the risks involved, because the vessel was ahead of time for the meeting with the Ken Moore."
After one crew member took the helm and successfully conducted the exercise, the coxswain took over and attempted to do the same, stated the report.
"He was constantly adjusting the throttle in order to maintain position when a wave from port rolled the vessel over to starboard. The coxswain had no time to react as the vessel rapidly rolled over and capsized," the report said.
The coxswain and one crew member who had been standing were thrown from the vessel, while Nemeth and Sorensen, who were seated, were pulled under.
The coxswain surfaced near the overturned boat and climbed onto its hull after transmitting a Mayday call.
The other member who had been thrown tried to hold on but was pulled away by a strong current. At that time the report stated: "The two crew members who had been seated in the vessel prior to the capsizing were nowhere in sight."
The current carried the capsized vessel for about 20 minutes before it settled in an eddy north of Sechelt Islet.
Two local work boats responded to the Mayday call and started a search for the missing members.
At about 11:50 a.m. rescuers tapped on the hull of the overturned vessel, listening for a response, but none was heard.
At that point, a self-righting device was pulled on the Lewis-McPhee but it failed to activate, and the handle came free from the cord.
At 12:25 p.m. search and rescue divers located the missing crew members tangled within the overturned boat. The cause of death was determined to be drowning.
While initial reports pointed to the failed self-righting device on the Lewis-McPhee as a possible contributor to the women's death, the Transportation Safety Board report stated, "The self-righting system is not intended to be used when personnel are trapped under the capsized vessel, as the righting action is very quick and the direction of the righting action is unpredictable."
The report pointed to a lack of training in escape from a capsized vessel as a contributor to the accident.
Crew members would have received only classroom instruction in capsize escape. The current rigid hull inflatable operator training course provides only coxswains with practical experience in the manoeuvre.
The report pointed to lack of practical training, lack of organizational oversight and lack of medical fitness standards as three of the risks that may have contributed to the accidental death of Nemeth and Sorensen.
Jim Lee, president of RCM-SAR, said the release of the report brought the tragic events of June 3, 2012 and the emotions tied to them back to the forefront for the volunteer organization.
"This was a devastating experience for all of us. In 35 years of history we've never had anything like this, so we were pretty shaken and still are, to tell you the truth," Lee said, noting he hadn't been able to fully read the report yet when Coast Reporter contacted him Wednesday afternoon. "I want to take that report in the spirit in which it's put out though, and it's a reminder of the importance of risk assessment by any search and rescue crew we do include risk assessment in our crew training throughout the province, and we emphasize it hard in our operations."
Lee said all RCM-SAR members operating around swift water have now had special training, and that shortly after the accident a rule was implemented that crews can no longer operate in anything over 11 knots.
"Our crew's safety is our absolute primary concern," he said. "When I have a good look at that report and I can contemplate what it means to us, we will institute any recommendations that the Transportation Safety Board has, for sure. We've already instituted a number."
The Transportation Safety Board's report is meant to advance transportation safety and is not meant to be a determination of fault or of civil or criminal liability.
Since the accident, a number of safety measures have been undertaken including the prohibition of training in Skookumchuck Rapids for RCM-SAR members and specification that voyages through the rapids should be limited to emergencies only. All self-righting systems on RCM-SAR vessels were also reserviced and recertified and a new training program has been initiated for members.
To read the report in its entirety, see www.bst.gc.ca/eng/rapports-reports/marine/2012/M12W0070/M12W0070.asp.