Revealed: Shocking catalogue of failures that led to deaths of 39 in Lamma ferry crash

Marine Department was lax on provision of lifejackets and did not notice doomed Lamma IV was lacking a watertight door, says disaster report

PUBLISHED : Wednesday, 01 May, 2013, 12:00am
UPDATED : Friday, 03 May, 2013, 6:21pm

The Marine Department failed to uphold the law, document its decisions or conduct proper inspections, yesterday's report into the Lamma ferry tragedy says.

The Commission of Inquiry said the department never fully implemented a 2008 requirement that the number of lifejackets carried should be equivalent to a vessel's capacity, and that the number of children's lifejackets should be equivalent to 5 per cent of capacity.

Its report also said the department's inspectors missed several chances to spot that the doomed Lamma IV did not have the watertight bulkhead door stipulated in its design.

A marine official told the inquiry there was a "policy" within the department not to apply the law to vessels already operating, but that the reasons for the decision were never documented.

"It appears that the 'policy' was disseminated by word of mouth only among Marine Department officers," the report said. "Without such records … discerning what those matters and reasons were is left to the frailties of human memory."

The lack of records jeopardised transparency and exposed officers to the danger of corruption, it said.

If problems arose, officers were "left hoping that some senior officer would come forward on their behalf and stand by the undocumented 'policy'".

The commission heard the Lamma IV could have remained afloat after its collision with the Sea Smooth had it been fitted with a watertight door as shown in its design drawings

The commission found the Marine Department inspector assumed the door would be watertight and did not check with shipbuilder Cheoy Lee. Other officers failed to notice the absence of the watertight door in later inspections of the finished vessel.

One of the reasons the accident claimed so many lives, the commission found, was that seating on the upper deck became detached from the floor.

It said the Marine Department was partly responsible because it had not gathered adequate information to determine whether seats were properly secured. An officer ignored the problem, despite noticing that the seating was secured only with self-tapping screws.

The department was also criticised for failing to document the reasons why it ordered the boat's owner, Hongkong Electric, to increase the number of crew on the Lamma IV from two to four in 2008.

The company did not increase the size of the crew and instead regarded an individual passenger on any particular voyage as the fourth crew member.

The report described the company's failure to add an extra crew member as "regrettable".

Hongkong Electric managing director Wan Chi-tin insisted the company complied with the regulations and had nine staff on board the boat as well as the three crew on the night of the tragedy.

The commission recommended that the government appoint an independent, qualified professional to take charge of future marine accident inquiries.

It also recommended that all ferries and launches permitted to carry more than 12 passengers be equipped with a very high frequency radio.

Vessels permitted to carry more than 100 passengers should also be fitted with an automatic identification system and collision-avoidance radar, it said.

Hongkong and Kowloon Ferry, the operator of Sea Smooth, said it was studying the report and would comply with policies.


Findings And Recommendations

Why were so many lives lost?

Seats on the upper deck broke off, causing both them and passengers to be thrown down

Passengers had difficulty retrieving and donning lifejackets

There were no child lifejackets


The Marine Department's failings:

It did not document what factors it considered or give its reasons for not strictly following rules on lifejackets during inspections

It did not give in writing its reasons for requiring Hongkong Electric to increase the number of crew members on Lamma IV to four



Checks on the watertight subdivisions on all vessels permitted to carry more than 100 passengers which were certified before 2007

Coxswains and seamen required to keep lookout undergo a basic medical check and eyesight test once every five years

Crew should demonstrate to passengers how to don a lifejacket