A probe into search and rescue resources focused last week on the case of Burton Winters, a Makkovik teenager who froze to death on sea ice nine years ago.
Documents provided to the commission paint a detailed picture of what happened to Winters and where the system failed him.
Winters, 14, died in 2012 after his snowmobile became stuck, forcing Winters to abandon it and walk 19 kilometres in search of shelter.
The inquiry into ground search and rescue in Newfoundland and Labrador held a week-long hearing into his death to see what went wrong and make recommendations on how to improve the process for future searches.
The inquiry has left Makkovik, and is now in Nain before continuing hearings on the island. However, testimony from the province, Department of National Defence and local searchers has offered a minute-by-minute account of the days under scrutiny.
Jan. 29, 2012
Morning - Winters' stepmother and father take away his computer privileges after he was on the laptop until 4 a.m. that morning. Family says he did not appear to be upset about it and showed little emotion. Burton then attends a junior rangers event at Killman Pond.
1:30 p.m. - Burton drops off his cousin at his grandmothers' home. His cousin didn't see which direction he had taken on the yellow Tundra 300 snowmobile in black ski pants and a checkered jacket.
2 p.m. - Local hunters see a narrow track on the ice heading from Makkovik Bay out toward the "Shina," or edge of the ice.
6:30 p.m. - Burton doesn't show up at his home or grandmother's home for supper.
7:30 p.m. - Sgt. Kimball Vardy receives a call from Mike Bishop wondering if Vardy's step-daughter has seen Burton Winters, as the two were friends. She had not and he was told Burton was missing. Sgt. Vardy calls in Cpl. Stephen Howlett to help. The RCMP posts to Facebook that Burton is missing.
7:40 p.m. - Howlett runs into Burton's cousin on his way to Vardy's home. Burton's cousin says he doesn't usually go far, only to the dump or back paths around town, but never into the bay before. Mike Bishop and Rodney Jacque, Burton's father, both headed out to Killman Pond to see if he went back to the junior rangers site.
7:45 p.m. - Community constable Barry Andersen is called in. Anderson was Burton's junior rangers patrol group leader. He was called in for "hasty searches" of the area.
7:50 p.m. - Searchers spread out throughout the general area. Anderson goes out with another searcher on trails. They search 11 areas, including the entire community of Makkovik.
10:41 p.m. - Vardy contacts Sgt. Lloyd Youden to check on getting a helicopter in the morning.
11:46 p.m. - Two local hunters come to the detachment to say they had seen a narrow track on the ice heading from Makkovik Bay out toward the edge of the ice.
Jan. 30, 2012
1 a.m. - Searchers gear up with floater suits and rope and went to follow the track to see if they can tell where it was going.
1:45 a.m. - The team returns from the harbour. Two searchers, Perry Voisey and Andy Edmunds, chased the track toward open water and advised it was leading toward bad ice and was "extremely dangerous," especially for a night search.
2:30 a.m. - The search ends for the night and they plan to meet up again at 7 a.m. Vardy and Sgt. Youden have a disagreement. Vardy wants a call to go into Fire and Emergency Service (FES-NL) to have a helicopter ready for first light. Youden disagrees and says he'll call at dawn to arrange a helicopter.
7 a.m. - The group of searchers and officers meet at the RCMP detachment. Howden was tasked to be in contact with the Winters family, Andersen was tasked with being the search incident commander and deploying volunteers, and Vardy was tasked with communicating with the RCMP and FES-NL.
7:45 a.m. - Ground searchers are deployed to check shorelines and other potential places.
8:34 a.m. - Vardy speaks to RCMP pilot Wayne Winsor in the RCMP's twin otter to keep an eye out for the teenager. The aircraft was on weather hold out of Goose Bay at the time, then transporting passengers.
8:43 a.m. - Ground searchers travel from Postville to Makkovik checking Kaipokok Bay, Marks Bight and Makkovik Bay for the second time.
8:50 a.m. - Vardy contacts Sgt. Youden about the 444 Squadron in Goose Bay and their availability.
9:02 a.m. - Sgt. Youden lets Vardy know that the Universal helicopter was tasked to help with the search but on weather hold.
9:12 a.m. - The JRCC receive a call from Paul Peddle with FES-NL. They request assistance.
9:18 a.m. - The JRCC decide that because there's no serviceable Hercules planes and both were out for maintenance, they didn't want to send the Cormorant helicopter from Gander. They task the 444 Squadron from Goose Bay to help.
9:20 a.m. - The 444 Squadron finds their Griffon helicopter has a leak. The other is out for maintenance. They are unserviceable until at least 2 p.m.
9:33 a.m. - The JRCC tells FES-NL that based on weather and aircraft status, they cannot offer support and FES-NL should call back in the future in case weather and aircraft situations improve.
10 a.m. - A helicopter from Woodward Oil in Postville heads to Makkovik to assist after a break in the weather.
10:05 a.m. - Vardy calls Sgt. Youden and says the Woodward helicopter is able to fly and asked about the Universal helicopter. Universal Helicopters is notified and they give an ETA of 12 p.m.
10:34 a.m. - Vardy is called by a Universal Helicopters pilot, who advises he is en route and would be there for noon.
10:40 a.m. - Woodward helicopter is on scene and searches around Makkovik toward the ocean.
12 p.m. - The Universal helicopter arrives.
Time unknown - Woodward helicopter flies over the open water when the pilot says they need to land due to a serious mechanical issue. The pilot lands on Strawberry Head and the helicopter shuts down. Andersen is notified of potential tracks sighted by Perry Voisey, who is making his way along the ice edge.
Andersen went to the ice edge and was walking with Perry Dyson when Dyson called out. Dyson had gone into a hole to his armpits. Andersen crawled back and hauled Dyson out.
12:20 p.m. - Andersen confirms the snowmobile track heading into open water off Strawberry Head. The open water was 60 feet wide and five kilometres in length. The team concluded that given Winters was on a 300 cc Tundra snowmobile, it was highly unlikely he made it across.
12:25 p.m. - Anderson requests a camera to photograph the tracks before snow covered them.
12:30 p.m. - Cpl. Howlett takes the second helicopter over with a camera for photographs.
1 p.m. - The group photographs the tracks and heads back to Makkovik to get a boat to search the open water for debris; nothing is found.
2:10 p.m. - Vardy updates Youden about the tracks into the open water.
4:40 p.m. - Searchers checking shorelines and the open water are called back to Makkovik due to dangerous ice conditions. Vardy calls Cst. Babstock and requests an underwater camera be sent up the next morning in the Pilatus RCMP plane.
5:03 p.m. - Search is called off for the night.
Jan. 31, 2012
8 a.m. - Searchers and RCMP meet at the detachment. While waiting for the underwater camera, the searchers are deployed to again eliminate other areas on land.
12 p.m. - Search teams return to Makkovik; no sign of Burton.
1 p.m. - Teams are sent to the open water to drill holes with augers for the camera to look for the snowmobile.
3:45 p.m. - RCMP Air Services arrives. Vardy and Andersen take the camera to the scene while Howlett and other searchers board the Pilatus for a flyover of the area to look for debris.
3:54 p.m. - Howlett sees the snowmobile approximately 2.5 kilometres past the track that was heading toward open water. It was in an upright position with the gas can appearing to have been physically placed behind it. Ice was dangerous around the machine and it was 400 yards offshore. Vardy phones FES-NL to request air services for a second time.
4:15 p.m. - Search teams head toward the land adjacent to the snowmobile.
4:47 p.m. - Peddle with FES-NL calls JRCC asking for help.
5:10 p.m. - JRCC decides to send the Goose Bay Griffon helicopter if they can go in the next hour or so and if not, they will send the Aurora that was on a nearby mission. The officer in command doesn't want to send the Cormorant without a Hercules in the region for potential other emergencies.
5:13 p.m. - Goose Bay team finds an oil line leak and says they will be ready to go by 6 p.m.
5:22 p.m. - JRCC will now be coming from Goose Bay when maintenance is done.
5:33 p.m. - Griffon is tasked to help with the search.
6:05 p.m. - Search teams try to find any sign once again, but have to turn back as the terrain is too rough for a nighttime search.
6:29 p.m. - Vardy works with Capt. Christian MacDonald of JRCC to give him information about the area and location of snowmobile. Vardy is told the Griffon team would only be able to work until 1 a.m. and wouldn't be available again for 12 hours.
7:28 p.m. - JRCC calls the Griffon helicopter team and it has not departed yet.
7:30 p.m. - The search teams return to the office.
7:38 p.m. - Griffon helicopter team departs Goose Bay.
8:12 p.m. - Vardy asks the Griffon team to spend the night in Makkovik to continue searching at first light. JRCC says there is only one crew and they will be on rest until 1 p.m. after they finish their night search. JRCC suggests FES-NL arrange a helicopter for first light.
8:23 p.m. - JRCC phones FES-NL and tells them to have someone lined up for first light to continue the search after the night crew is done. Vardy thanks JRCC.
9:00 p.m. - The Griffon helicopter from the JRCC arrives on scene in Makkovik from Goose Bay and begins searching.
10:18 p.m. - JRCC phones the Air Force, saying says the Aurora is serviceable and was tasked to the Strait of Bell Isle. JRCC asks if it can be rerouted to look for any heat signatures of Burton.
10:30 p.m. - JRCC officer in command agrees and the Aurora is tasked.
11:16 p.m. - The Aurora helicopter is en route from St. Anthony to conduct a heat search.
11:30 p.m. - The Aurora is on scene and starts searching.
Feb. 1, 2012
1:15 a.m. - The Griffon crew returns to Makkovik and tells Vardy they picked up a track walking from the snowmobile south toward the closest point of land. It went for about 50 metres, then disappeared. The Aurora completes its search without finding anything.
8 a.m. - RCMP officers and searchers meet at the RCMP detachment.
8:50 a.m. - Search team is deployed to Strawberry Head.
10:15 a.m. - The Universal helicopter arrives on scene. Andersen, Randy Edmunds and Errol Andersen go up in the helicopter to look for any signs.
10:22 a.m. - The volunteer search team rappels over an ice cliff to look for signs of Burton. The helicopter crew flies over the snowmobile and Andersen photographs the machine.
11:06 a.m. - The helicopter group finds tracks leaving the area of the snowmobile heading south past Cape Strawberry and across Wild Bight to Wild Bight Point. A search team is sent to the area.
11:10 a.m. - Andersen tells Vardy they found tracks again that travel south to Foxy Rocks.
11:20 a.m. - An additional search team is deployed to the Foxy Rocks area.
11:23 a.m. - Andersen sees a person very close to the ice edge who isn't moving. The ice conditions were not good so the pilot stated he could lightly press down to retrieve him.
Andersen, Edmunds and Errol load Burton's body into the helicopter. The boy had his rod over his face and no gloves found at the time. They set him down and covered him with a coat.
11:37 a.m. - All searchers recalled to Makkovik.
12 p.m. - Burton is brought to the Makkovik clinic.
12:15 p.m. - Andersen and Howlett are told Burton cannot be pronounced dead until his body is warmed up. Howlett, Andersen and other volunteer searchers perform CPR on him while a medevac crew is en route.
2:35 p.m. - Medevac aircraft arrive from Goose Bay and take over CPR from Andersen. Vardy also performed CPR on Burton until his body was warm enough to pronounce dead.
3 p.m. - The doctor from Goose Bay pronounces Winters dead.