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July 19, 2002
Louis Pilakapsis
death voyage was preventable
Cargo boat was never
inspected by Transport Canada, never certified for cargo, report says
JIM
BELL
When Louis Pilakapsi stood
in the wheelhouse of the Avataq at 5 a.m. on Aug. 25, 2000, steering out of
the Port of Churchill with 15.8 metric tons of cargo bound for Arviat, his dangerously
overloaded lobster boat was already a death-trap.
But evidence contained
in a 15-page investigation report by the Transportation Safety Board of Canada
released July 12 shows Pilakapsi and his three crewmen either
didnt know or didnt care.
Neither did Transport Canada
officials, who until then had never inspected the many small vessels that perform
informal, unregulated commercial cargo services in the Arctic.
As a result, its
unlikely that the 63-year-old captain and his three crew members were aware
of the enormous risk posed by the tons of cargo stowed upon their vessels
afterdeck, the report finds.
The board launched the
investigation five days after the Avataq foundered and sank at about 1:30 a.m.
on Aug. 26. Pilakapsi, along with Larry Ussak, 45, Sandy Sateana, 28, and David
Kadjuk, 25, all of Rankin Inlet, perished in the chilly waters of Hudson Bay
just 10 nautical miles from Arviat.
The board found that when
the Avataq departed from Churchill, the aft end of the 12-metre vessel sat so
low, its afterdeck rode below the water-line.
"The deck was actually
under water. The actual deck of the vessel was underwater," said Ken Potter,
the safety board investigator who wrote the report.
On that day, the Avataq
carried 12,096 kilograms of building materials, and 3,727 kilograms of propane
tanks.
The building materials
were made up mostly of heavy steel space-frames for use in the construction
of social housing units that Sanaajiit Construction was building for the Nunavut
Housing Corporation.
Umingmak Supplies had ordered
the material for Sanaajiit, and contracted Pilakapsi to carry it from a warehouse
in Churchill run by Northern Transportation Company Ltd.
Although NTCL conducts
a regulated commercial barge service along the Kivalliq coast, its unclear
why the company was not contracted to carry the goods.
Pilakapsis boat was
originally designed to carry lobster traps, not cargo.
"This is an east-coast
lobster boat. It has a wide-open aft deck area thats designed for holding
lobster traps," Potter said.
After the cargo was stowed
on board, Potter said, the Avataqs freeboard, or the amount of clearance
between the top of the railing and the waterline, was estimated to be only 40
centimetres, or about 16 inches.
That problem was compounded
by the fact that the boats scuppers or drainage holes had
been stopped up with barrel plugs to prevent the low-lying ship from taking
on water. This meant that any water taken on deck had no way to drain back out.
So when 30-knot winds blowing
from the northwest predicted the day before by Environment Canada
whipped up the sea just as the Avataq neared Arviat, Pilakapsi and his crew
of three didnt stand a chance.
As the wind-driven waves
rose, water easily poured onto the Avataqs low afterdeck, pushing it deeper
into the water, and as the water on the deck slid back and forth, the boat became
dangerously unstable.
The technical term for
this phenomenon is "free surface effect," Potter said.
"When you have a pan
full of water and try to walk across the room, youve seen how it sloshes
back and forth? Its very awkward. The shifting affects the centre of gravity.
"Water built up on
the deck aft, and, as you have that mass of water sliding back and forth, it
does two things: it puts the vessel deeper in the water and lowers it down,
but then it creates an instability where the vessel wants to roll over,"
Potter said.
And that, he said, is likely
what happened to the Avataq after becoming destabilized, it heeled over,
filled up with water, and sank.
But thats not all.
Potters report found that there was no system of regulating and inspecting
small, informal commercial cargo carriers in the Kivalliq region.
For years, small boat owners,
many of them unilingual Inuit, have been making a few bucks in the summer shipping
cargo for customers in the Kivalliq region but no one bothered to find
out if these carriers know how to operate safely.
"When the vessels
are inspected by Transport Canada, they are assigned whats called a load
line, and thats a line thats physically painted on hull of vessel,
showing the safe amount of load that it can take," Potter said.
"But that depends
upon the vessel being inspected by Transport Canada in the first place."
Potter also found that
searchers in Arviat, and Nunavut Emergency Services staff in Iqaluit unnecessarily
delayed the start of an air search.
At 1:30 a.m., Aug. 26,
hunter radio operators in Arviat learned that the Avataq was sinking. But Arviat
searchers didnt tell Nunavut Emergency Services about it until 2:55 a.m.
because they decided instead to travel down the coast on ATVs to see
if they could spot the boat.
In turn, Nunavut Emergency
Services didnt inform the Rescue Co-ordination Centre in Trenton, Ont.,
until 5:19 a.m.
Under an agreement reached
after the 1994 sinking of the Qaosoq in Frobisher Bay, NES should have informed
the Trenton rescue centre immediately.
A coroner found that Pilakapsi
and Ussak, who were wearing Mustang PFD flotation suits, died of hypothermia,
not drowning.
Based on the estimated
survival time for victims wearing such suits, the two men may have survived
in the 8 C water for at least five hours.
But because of the delay,
a military Hercules that was in the air over the Foxe Basin at the time didnt
arrive at the scene until 8:10 a.m.
The first search plane,
a privately owned Cessna from Rankin Inlet, took off at 6:00 a.m.
At 7:08 p.m., a British
Royal Air Force helicopter crew found Pilakapsis body floating among the
debris left by his sunken boat. They found a clothes hanger stuck in the back
of his flotation suit a sign that the boat sank quickly and that Pilakapsi
and his crew didnt put on the suits until the very end.
Larry Ussaks body
was found at about 7:00 p.m. on Aug. 26, with his survival suit only partially
zipped up another sign that the men acted in extreme haste. The bodies
of the other two crew members were never recovered.
Transport Canada is now
attempting to identify all Arctic vessels that carry cargo so that they can
be inspected, Potter said.
Soon after the sinking
of Avataq, Transport Canada detained a similar vessel in Churchill, but the
Kivalliq Inuit Association complained about the move, saying boat owners hadnt
been informed about Transport Canadas rules.
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