The report of the inquiry into the Lamma ferry tragedy calls for congratulations but also misgivings. Congratulations because the report - 186 pages plus 82 pages of appendices - is an admirably clear summary of an inquiry which had 113 witnesses and was provided with a mass of expert evidence.
Its conclusions, other than those relating to the crew members of the vessels involved, the Lamma IV and the Sea Smooth, do not shrink from using direct language. Its comments on the Marine Department in particular pull no punches.
The misgivings arise from the fact that the conclusions relating to the coxswains of the two vessels have been redacted as the individuals have been charged. That has been done in order not to prejudice their trials, which seems reasonable in principle but raises the issue of why none of the others concerned, some of whom can be identified in the report and others who could be identified if the matter was pursued, have been prosecuted.
Are we to assume that they now cannot be prosecuted because trials would be prejudiced by what is in the report? One has to begin to wonder whether anyone in the Marine Department, Hongkong Electric or those involved in the design, building and modification of the Lamma IV will be prosecuted. Are they being enabled to hide behind departmental or corporate veils?
It would not be the first time that a few individuals have been made scapegoats so that the misdeeds of others can be, if not buried, at least not subject to criminal prosecution.
One may anyway question why the conclusions on the crew needed to be redacted given the evidence produced at the inquiry and summarised in the report. It placed most, but not all, of the blame for the collision on the Sea Smooth, whose last-minute attempt to turn to starboard (the collision-avoidance rule) was "just so late … it wasn't a practical collision-avoidance option", according to Captain Nigel Pryke, the master mariner who assisted the inquiry and made a detailed report on the navigational issues.
Responsibility for deaths in accidents do not necessarily accrue only to those immediately responsible for a collision but to those responsible for the overall safe operation of a vessel. Accidents do happen, whether the result of gross negligence, carelessness or "acts of god" beyond human control. The purpose of ship design and operation regulations is to minimise casualties when accidents occur.
In this case, the high death toll from what at first might have seemed a relatively minor collision between two small vessels close to land and in clear conditions was attributable, according to the report, to a number of factors other than navigation.
The first was that the Lamma IV sank so rapidly after the collision, and at such a steep angle, that it was difficult for passengers to escape, with or without life jackets. The reason it did so was the absence of a watertight bulkhead door, which was specified in the original design of the ship. The subsequent positioning of eight tonnes of additional lead ballast greatly reduced the vessel's ability to stay afloat after such a collision. Its damage stability was greatly reduced, for which various parties were responsible. The side-plating of the vessel's hull was also only 4.4mm thick compared with the 5mm specified.
Other factors were also responsible for adding to the death toll. One was that the seats on the upper deck of the Lamma IV were not properly secure so that passengers were catapulted as the vessels began to sink stern first and the seats became detached. A second was that, contrary to regulations, there were no lifejackets at all for children, several of whom died. While there were more than enough jackets for all passengers, they were hard to access for those on the upper deck, and all were hard to put on. Fourthly, the Lamma IV did not have four trained crew as required.
Most of the above problems should have been noted and addressed by the Marine Department, but for whatever reason they were not. That raises the question of why no prosecutions have been launched other than those of the crew. Answers are required so that culpability can be properly shared.
Apart from actions attributable to individuals, which could be subject to prosecution, the Marine Department generally was a law unto itself, waiving laws as it felt inclined. Regulations to improve safety were never implemented, presumably to please vessel operators. It is hard to resist the feeling that those two Hong Kong problems, civil service inviolability and collusion between companies and bureaucrats, have been at work.
The result was especially tragic in this case but such attitudes are too evident elsewhere in government, whether in departments appeasing the barons of the Heung Yee Kuk or racist official connivance at the gross exploitation of domestic helpers, as employers know it discourages victims from seeking implementation of laws on wages, hours and living conditions.
Chief bureaucrat Carrie Lam Cheng Yuet-ngor may be well-meaning, but she has much to do to end the assumptions of senior civil servants that they are a law unto themselves and can pick and choose which laws to implement.
Philip Bowring is a Hong Kong-based journalist and commentator