2012 Lamma Island Death Reports
Part 4: Exposing the Marine Department’s faulty ship inspections.
Originally published: 08/12/2021 12:55 p.m. Stand News
The Lamma disaster, which caused 39 deaths, did not convene a coroner’s inquest, but the police pointed out in the death investigation report that the in-depth investigation of the Marine Department was not completed until after the independent investigation was completed and recommended that a coroner’s inquest be held so that Marine Department officials could testify in a public hearing. The police said the “in-depth investigation” relates to the Marine Department’s ship inspection arrangements, including whether the staff have formal training, whether there are clear guidelines for ship inspection, etc., related to maritime safety. However, the relevant information and witnesses have not been given the chance to give further evidence in court to clarify the issue, so as to prevent the recurrence of another maritime disaster.
According to the 2,000-page death investigation report, the police took statements from 25 current or former Marine Department surveyors in 2014. Nineteen of them had approved the plans of Lamma IV or surveyed the ship at least 39 times from 1994 to 2012, and most of them visited the ship itself. The police said they all did not notice the watertight door on the plan was missing.
The passageway between Cabin E (fuel tank room) and F (steering room) of Lamma IV had never been fitted with a watertight door from the time the vessel was built to the time of the incident. A number of officers of the Marine Department had conducted on-site inspections of the vessel and found no problem. (Screenshot from the Independent Investigation Report)
Police: Investigation yielded negligence from the Marine Department, showing no formal training or guidelines for ship inspection.
The 2013 independent investigation of the maritime disaster revealed that many officers of the Marine Department criticized the negligence of the ship inspection, failure to find contradictions in the plans of Lamma IV, omission of watertight doors, miscalculation of sink resistance data, installation of unstable seats, and absence of children’s life jackets
After the completion of the independent investigation, the police started to interview the officers involved in the Marine Department, which revealed the systemic problems again. At least six of them said they received no formal training after joining the department, some of them said there were no internal guidelines on how to inspect a ship, and at least 12 of them said there were no guidelines on how to inspect a ship with a blueprint.
According to the statements, the inspectors generally relied on visual inspection. For example, they would visually assess the depth of the paint on the hull of the vessel and whether or not it has become deformed and rusted in order to determine whether any problems or changes had arisen since the last inspection. Only after a failed visual inspection would they actually utilise the ship’s blueprints or conduct actual safety tests. Since the inspectors did not bring along any plans or blueprints to inspect the vessel, at least three of them stated that if they did not see any signs of change from the last inspection, they wouldn’t realise there was a missing watertight door.
Of the three interviewees, one was a ship inspector surnamed Luk, who stated that he had no formal training and that there were no written guidelines for ship surveys. Compared with the report of the independent Commission of Inquiry chaired by Judge Michael Lun in 2014, a person with the matching surname and the matching dates of the three inspections is the witness, Luk Hon-ying, the ship inspector. Checking the government telephone directory shows that he is now a senior ship inspector. The reporter called Luk Hon-ying to make enquiries, but he refused to make any comments and told the reporter to check with the Marine Department.
Police suggestion to open a coroner’s court; Summoning Marine Department staff to give testimonies.
In the death investigation report, the police confirmed that two Marine Department officers had seen the plans and sinking data calculations submitted by Cheoy Lee Shipyard, but did not check them with each other, and that 18 other Marine Department officers had inspected the ship after the construction of Lamma IV and did not find the discrepancy between the plans and sink resistance data.
The police submitted a report to the coroner in 2015, recommending that a coroner’s court be convened. One of the arguments was that the in-depth investigation against the Marine Department was completed only after the conclusion of the independent investigation, and that the department, as the supervisory department related to the maritime disaster, had never been summoned to testify in a public hearing.
The 2,200 page long police death investigation report obtained from the Coroner’s Court by the families of the Lamma IV victims.
Marine Department: Has demanded new inspections to bring plans to inspect the ship, to provide systematic training to staff.
Szeto Ka, a chartered ship surveyor with over 30 years of marine experience, explains why the missing watertight door was never discovered by inspections: According to the photos taken of Lamma IV, there were no screws on the bottom plate of the passage between the fuel tank room and the steering gear room, and there were no signs of alteration, so it would be difficult to find the so-called missing watertight door. Szeto added, “Human error is certain, but how do we remedy human error? The Marine Department has done a lot of things to improve. Firstly, it has stipulated that ships can be inspected only after reading the plans.”
The Marine Department replied to Stand News that the Transport and Housing Bureau reformed the operation of the Marine Department after the maritime disaster, including explicitly requiring ship inspectors to bring plans to ensure consistency between the hull and plans, and providing more systematic training and guidance.
Thirteen Marine Department officials involved in the disaster faced disciplinary proceedings, but the government has refused to disclose results.
As early as 2014, the Transport and Housing Bureau completed an internal investigation into the Marine Department, which identified 13 Marine Department officials involved in misconduct and referred them to the Civil Service Bureau for follow-up on disciplinary proceedings.
In April this year, the Civil Service Bureau refused to comply with the “Code on Access to Information” to share information on the outcome of disciplinary proceedings with Stand News. The Office of the Ombudsman agreed with the government’s approach, saying that the disclosure of information was unfair to the officials involved.
Ms. Leung, a family member of the deceased in the Lamma disaster, said that the 39 deaths revealed a lot of things, but everything that was revealed was only known to the police, the Department of Justice, the Coroner’s Court, or within the Transport and Housing Bureau, and was not fully disclosed or heard.
Ms. Leung finally stated that, “Is this fair to the 39 who died in that disaster? How can they say they have provided the public with the entire truth?”
The wreck of the Lamma IV still is impounded at Government Dockyard at Stonecutters Island (as of the article being released at December 2021)
Next: Part 5
The last 118 seconds of the Lamma IV: Loss and goodbyes.