Table of Contents
Archived Content
This page has been archived for reference, research or recordkeeping purposes. It has not been altered or updated after the date of archiving.
Archived pages are not subject to the Government of Canada Web Standards. As per the Communications Policy of the Government of Canada, you can request alternate formats by contacting the webmaster.
- Executive Summary
- Table of Figures
- List of Abbreviations
- Summary of Events
- Part I - Conduct of the Investigation
- Chronology of Investigative Activities
- Attendance of persons with a direct and substantial interest in death and casualties
- Information to the Public
- Receipt of Evidence from the Crew of HMCS Chicoutimi
- Identification of Witnesses
- Cooperation - Royal Navy and the United Kingdom Ministry of Defence
- Cooperation with BAE
- Information Sharing Protocols
- Collection of Evidence
- Statistics
- Part II - Findings
- Mechanical and Technical Status of HMCS Chicoutimi
- Movements of HMCS Chicoutimi
- Date, Time and Location of Fires
- Origin of Fires
- Cause of Fires
- Crew Training and Reactivation Procedures
- Property Damage to HMCS Chicoutimi
- Nature and Extent of the Fires
- Actions Contributing to Fire
- Firefighting Chronology
- Crew Response
- Adequacy of Orders and Procedures
- Adequacy of Response Actions to Fires
- Adequacy of Fire Detection, Fixed and Portable Suppression Equipment
- Adequacy of Training and Qualifications with Respect to Fire Response
- Adequacy of the Restoration of Operational Capability
- Doctrine, Equipment and Training with Respect to Restoration
- Crewing of HMCS Chicoutimi
- Post-Fire Communications Capability
- Communications Flow
- Cause of Death
- Duty Status of Lieutenant(N) Saunders
- Pre-existing Medical Conditions
- Responsibility for Death
- Connection to Military Service - Death
- Injuries to Crew Members
- Cause of Injuries
- Pre-existing Medical Conditions of Crew
- Duty Status of Crew
- Responsibility for Injuries
- Connection to Military Service - Injuries
- Subsequent Deaths
- Post-Incident Medical Response
- Training and Qualifications - Post-Incident
- Adequacy of Medical Equipment and Doctrine
- Reporting of Casualties
- Chronology and Adequacy of Medical Evacuation
- Part III - Recommendations
- List of Annexes
