Louis Pilakapsi’s death voyage was preventable

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 didn’t know or didn’t 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, it’s 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 vessel’s 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, it’s unclear why the company was not contracted to carry the goods.

Pilakapsi’s 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 that’s designed for holding lobster traps,” Potter said.

After the cargo was stowed on board, Potter said, the Avataq’s 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 boat’s 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 didn’t stand a chance.

As the wind-driven waves rose, water easily poured onto the Avataq’s 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, you’ve seen how it sloshes back and forth? It’s 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 that’s not all. Potter’s 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 what’s called a load line, and that’s a line that’s 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 didn’t 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 didn’t 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 didn’t 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 Pilakapsi’s 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 didn’t put on the suits until the very end.

Larry Ussak’s 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 hadn’t been informed about Transport Canada’s rules.