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Details of the Investigation Report published in Hong Kong, 30 April 2013.

The following is from the SCMP.

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Lamma ferry inquiry report blasts Marine Department

The government department responsible for shipping and vessel safety needs an urgent overhaul, investigation of collision concludes

Simpson Cheung simpson.cheung@scmp.com

Lamma IV Report

“Serious systemic failings” in the Marine Department contributed to the Lamma ferry tragedy, the Commission of Inquiry into the disaster has found.

In its report, released yesterday, the commission pointed to a “litany of errors” at every stage of the design, construction and inspection of the Lamma IV, which contributed to the rapid sinking of the boat.

“What is required is systemic change, in particular a change in attitude to responsibility and transparency,” the commission said of the department. “In [some] areas, what is required is action, and action now.”

What is required is systemic change, in particular a change in attitude to responsibility and transparency

The commission, led by Mr Justice Michael Lunn, said it was “astonished and deeply dismayed” to learn that the department had not fully enforced a 2008 regulation stipulating that vessels should carry a number of lifejackets matching their capacity, as well as children’s lifejackets equal to five per cent of capacity.

The key factors so many lives were lost were loosely attached seats on the upper deck of the Lamma IV that came off, throwing passengers towards the stern; passengers having trouble getting to and donning lifejackets; and no children’s lifejackets.

The department has promised an internal investigation into whether any officer bears part of the responsibility for Hong Kong’s deadliest sea tragedy in 40 years.

A total of 39 passengers died when the Hongkong Electric vessel Lamma IV, taking workers and their families to see the National Day fireworks in Victoria Harbour, collided with the ferry Sea Smooth off Lamma Island.

Sections of the report dealing with the responsibilities of the two coxswains involved in the October 1 crash – both of whom have been charged with manslaughter – was redacted to avoid influencing their trials.

Secretary for Transport and Housing Professor Anthony Cheung Bing-leung said he would lead a steering committee to oversee the reform of the department. He said he would appoint a directorate-grade officer as deputy director of the department to lead the reforms.

Director of Marine Francis Liu Hon-por said the department had appointed foreign experts to review its inspection procedures and compare safety regulations with those in Singapore, Sydney and Southampton.

Chief Executive Leung Chun-ying pledged that the government would handle any case of maladministration or human error impartially, and said disciplinary hearings could start.

Liu did not answer if he would apologise or resign. Cheung said he “felt sorry”.

Ryan Tsui Chi-shing, younger brother of Tsui Chi-wai and uncle of Tsui Hoi-ying, 10, who both died in the crash, said he appreciated that the inquiry had shed light on a lot of facts. But he had doubts whether the reforms would succeed: “The director lacks the courage to even apologise, so how can I trust him to have a conscience in future?”

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This from the SCMP in Hong Kong.

This development is entirely separate to the Accident Investigation that took place earlier and which is expected to publish its report on the matter by the end of April.

The scope of that investigation was to establish the events that took place and make recommendations for actions that could assist to prevent accidents of a similar nature, and to recommend amendments to regulations based on the findings.

This latest development with Manslaughter charges to both skippers comes from the Police Investigation. They have levelled a different charge to each skipper. Perhaps surprisingly only the skippers have been charged and not any of the Officers. As Yet.

Given the tragic loss of life (almost one third of passengers perished) and avoidable nature of the accident, charges were inevitable.

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By Thomas Chan thomas.chan@scmp.com

The captains of two vessels that collided off Lamma Island on October 1 made their first appearance in court yesterday, facing a combined 78 counts of manslaughter.

Lai Sai-ming, captain of the Sea Smooth. Photo: David WongChow Chi-wai, skipper of the Lamma IV.

Chow Chi-wai, 56, captain of Hongkong Electric’s Lamma IV, and Lai Sai-ming, 55, captain of the Sea Smooth, operated by Hong Kong and Kowloon Ferry, are each charged with 39 counts of manslaughter.

Chow and Lai were represented by Gerard McCoy SC and Audrey Campbell-Moffat, respectively, in Eastern Court.

The pair are accused of unlawfully killing 39 people by gross negligence. The victims died on October 1, 2 and 5.

Some died at the scene and some in hospital.

Court documents say Chow owed a duty of care to his passengers and Lai to other vessels and their passengers. They were allegedly in breach of that duty of care by failing to keep a proper lookout, and to take any effective measures or steps to avoid the collision.

The gross negligence caused by the breach of duty was allegedly a substantial cause of the death of the victims.

Principal Magistrate Bina Chainrai adjourned the case to May 9 upon the request of Director of Public Prosecutions Kevin Zervos. Zervos said the prosecution needed four weeks to prepare documents, and on the next occasion it would ask for a return-day hearing.

Chow and Lai were released on HK$20,000 cash bail each. The court also ordered them to surrender all their travel documents.

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From SCMP, Hong Kong.

Sea Smooth turn “absolutely the cause” of ferry disaster: expert

A covered body lies on a rescue boat, after two vessels collided in Hong Kong

Maritime official says the vessels would have missed each other narrowly if not for the move

Ada Lee ada.lee@scmp.com

A wrong turn by the vessel Sea Smooth was the “actual cause” of its fatal collision with the Lamma IV on October 1 last year in which 39 people died, an expert told the commission of inquiry yesterday.

British maritime expert Captain Nigel Pryke returned to the commission to answer questions, after giving testimony in December. As he did then, he identified the Sea Smooth’s left turn, moments before the collision, as the key mistake. “The actual cause of the collision was the Sea Smooth’s alteration of course to port at 20:19 and a half minutes,” Pryke said. “That was absolutely the cause.” The two vessels would have narrowly missed each other if the left turn had not been made, Pryke said.

He spoke while being questioned by Charles Sussex SC, who represents Hong Kong and Kowloon Ferry and the Sea Smooth’s crew. Sussex quoted regulations that say one method for crewmembers to determine whether a head-on collision was looming was to look at the other ship’s navigation lights. But Pryke said they should not rely on the lights alone.

“The whole point of the rule of the road is to keep vessels apart. It’s not about arguing with each other which rule applies,” he said. “In almost every case, you would alter course to starboard [to the captain’s right]. It’s in a navigator’s DNA that he alters to starboard.”

Pryke said the Sea Smooth, as a high-speed vessel, should have been the “first one to alter course” when it foresaw a collision.

“At that stage, in fairness to the Lamma IV, because of the relative speeds of the vessels, [the captain of the Lamma IV] would have had to have been very, very slick to have avoided it,” he said.

The Sea Smooth left the scene soon after the crash, and 39 people died.

The inquiry also heard yesterday that Hong Kong and Kowloon Ferry’s guidelines telling ferry coxswains how to react, after a collision with another vessel, could be “confusing”.

In one section the guidelines tell the helmsman to “steer away from the [ship’s original] course”, giving no further explanation. But in another section the guidelines say they may have to stay at the site and help the other vessel.

Nelson Ng Siu-yuen, the company’s general manager, said coxswains should be able to judge for themselves whether to remain at the scene of a collision depending on the situation.

He told the inquiry the ferry company did not require coxswains to get their eyesight and health regularly checked. Sea Smooth captain Lai Sai-ming had his eyes tested in 1997 when he got his Marine Department licence, which is valid until 2023. Lai was involved in three minor accidents from 2008 to 2010.

The lack of regular check-ups was widespread in the industry, and the department did not require them, Ng said, adding that the two parties were discussing the issue.

See a Video Simulation of the Crash.  Follow this link

Lamma IV - Sea Smooth Collision Animation

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For Video. Follow this link

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From SCMP.

See video simulation prepared by naval architect Dr Neville Anthony Armstrong, the expert appointed by the Comission of Enquiry into the sinking of the Lamma IV, illustrating the impact and angle of the collision of the two ferries on 1st October 2012.

Lamma IV - Sea Smooth Collision Animation

Follow this link to watch the animation on YouTube.

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From the SCMP.

f04_06749528

Lack of watertight door sank Lamma IV, inquiry told
Naval architect also tells hearing there wasn’t enough time for crew to evacuate passengers

The Lamma IV would still be afloat with two gashes created by the Sea Smooth if there was a watertight door between its compartments, the commission of inquiry into the October 1 ferry collision heard.

Naval architect Dr Anthony Armstrong also came to the conclusion, based on computer projections, that the deck at the stern of the Lamma IV started to go below the water 96 seconds after its collision, and that it took eight seconds for the vessel to tilt from seven degrees to 70 degrees, with the stern hitting the seabed, and settling into the mud. In total it only took around 118 seconds from the collision, for the Lamma IV to rest at 70 degrees.

“[There is] certainly not enough time in which the crew would have been able to organise evacuation from the ship,” the commission-appointed expert witness said.

The bow of Sea Smooth had created two gashes on Lamma IV’s hull during the collision – one in its engine room and the other in the tank room.

Armstrong found that the stern of Lamma IV would almost be submerged, but that the vessel would remain afloat if just those two compartments were flooded.

Lamma IV - Hull Damage

The second gash was made by the large kinetic energy generated by the high speed of the Sea Smooth, Armstrong said.

But a large opening on the bulkhead between the tank room and its adjacent steering gear compartment led to the flooding of the third compartment, which contributed to the sinking of the vessel, Armstrong’s calculations showed.

According to the original drawings of the ship when it was built, a watertight door was meant to be fitted at the opening. But shipbuilder Cheoy Lee had earlier argued that it was just a mistake made by an outsourced designer.

Further calculations by Armstrong showed that even when the ship was newly built in 1996, Lamma IV would have sunk if the watertight door was not installed, regardless of the installation of a 8.25-tonne ballast at the stern two years later.

The Australian expert also said whether or not Sea Smooth had reversed after the collision would make no difference to the flow of water into the hull of Lamma IV because the bow of the Sea Smooth had been broken and left inside Lamma IV.

Some Lamma IV passengers who testified earlier said they felt the engine restarting and thought the other vessel was backing out.

But Armstrong said if that was the case, it must have happened within 10 seconds as Lamma IV was sinking quickly. He said the engine sound could have come from the flooding of Lamma IV’s engine. He believed the collision bulkhead at the bow of the Sea Smooth stopped it from penetrating further into Lamma IV.

The hearing continues today.

Meanwhile, the seven crew members of the two vessels were expected to have their bail extended for another month when they report to police today, pending a prosecution decision by the Department of Justice, a police officer said.

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Recap.

The Lamma IV, a 24 metre boat owned by Hongkong Electric carrying about 124 staff and their family members, with a crew of 3, travelling to watch Fireworks in Victoria Harbour, collided with the ferry Sea Smooth, in waters off Lamma Island at about 8.23pm on October 1, 2012. More than 100 passengers on the boat fell into the water, and at least 39 are confirmed dead. This is the deadliest boat accident in Hong Kong in 40 years. The Fireworks were scheduled to start at 9.00pm, and attracted around 150 spectator vessels. It was reported the Sea Smooth was travelling around 24 knots and the Lamma IV around 14 knots. Visibility was good. It appears the Sea Smooth Port Bow made contact with the Lamma IV Hull in the area of the Stern Port Quarter, where the Engine room compartment is located. It was reported that the impact caused a hole of 9 sq. metres. The Lamma IV engine compartment became inundated with in rushing sea water, causing the stern to rapidly sink to a depth of 15 metres trapping people inside. Eyewitness reports state the Lamma IV was barely visible as a dark shape after the crash. It’s reported the Sea Smooth stayed for around 5 minutes before leaving the scene. Eyewitness reports state the Lamma IV, sank with it’s Bow sticking out of the water within 5 minutes of the collision.

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The following drawing was published in the SCMP. It illustrates the differences between the two vessels that collided, and shows how the Lamma IV,  was very vulnerable to a large breach of the Hull in the Engine Room section, or next aft section, which they have called the Sterntube compartment.

The drawing of the Lamma IV shows Five Bulkheads built into the vessel, each of which would either be a sealed bulkhead with no penetration, or have a watertight door to gain access from one section to the next, such as was likely the case between the Engine Room and the Sterntube section.

In some of the news reports, there has been speculation that watertight doors may have been left open allowing more than one compartment to flood.  The investigation will answer that question. If the Sterntube section did as seems likely flood, then there may be additional reasons for that to happen, including additional cracks or openings in the Hull that allowed seawater into that section.

Some survivors have been quoted in the news papers to say that they felt they only had a minute or two after the collision before the Lamma IV aft passenger section was inundated with sea water, and the stern started to slip below the water.

Based on assumptions of the dimensions of the Lamma IV engine room together with the anticipated water flow with a large opening below the water line, I believe it would only have taken around 1 to 2 minutes for the engine room compartment to be filled with more than 80 to 100 tons of sea water.

It is staggering to realise that an opening of less than one square foot, a metre below the sea surface could allow sea water to rush into the vessel at a rate of around 1,000 gallons per minute. Bear in mind that reports mention the opening in the Lamma IV Hull caused by the impact was around 9 square metres.

If there was one watertight door open between the engine room and the sterntubes compartment then at most it would have taken less than six minutes for the compartment to fill with sea water.

These are ‘broad brush’ estimates based on published tables of ‘Estimated Water Flow Rates’, taking into account the size of opening and fall distance. They are also conservative estimates.

With both compartments filled with well over 100 Tons of seawater, and the buoyancy of the aft section removed, the vessel’s stern would rapidly sink, and the vessel upturn into the Bow Up condition as seen in so many photographs.

Anyone trapped in the passenger compartment in the aft section would now be under several metres of water, in a vessel that is vertical, with loose items freefalling down on top of them. A very perilous situation.

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To give some support and context to the above assumptions, there follows below an eyewitness report of the aftermath of the collision as recounted by Chris Head, who was seated on the upper open deck of the Sea Smooth. This was published in the SCMP.

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Teacher and Lamma resident Chris Head, 48, who was sitting outside at the back of the upper deck of the Sea Smooth, relived the moment of impact and the harrowing minutes afterwards when he thought his 12-year-old son was aboard the stricken vessel the ferry had hit.

“Visibility was fine, it wasn’t crystal clear, there was that haze, but you could see quite clearly. The water was calm,” he said.

“I just heard this enormous whack. I thought we had hit the biggest wave of all time. The force of the collision toppled me out of my seat, I ended up on my hands and knees on the deck. My first reaction was that of shock, just simply ‘wow! what happened?’ I didn’t know if we had hit a rock, a reef, a lighthouse or what.

“Then, because I was at the back of the ferry, I could see the other boat and realised what could have happened. All I could see was this very dark, silhouetted vessel limping away, it was leaning over to one side. It didn’t seem to me like a ferry, it was so dark, there were no lights on it. I thought it was a fishing boat.

“I couldn’t hear any shouts for help or screams, nothing, the boat was just so dark.

“Initially we were trying to put on our life jackets, so we were more concerned with that. But after a few minutes, probably about five, I could see the end of the boat – I couldn’t tell whether it was the bow or the stern – sticking vertically out of the water and I thought ‘Shit! This is real’.

Unquote

Lastly take a look at the following photographs taken of the Lamma IV as she was lifted onto a Barge to remove her for further investigation.

The massive tear in the Hull caused by the impact can clearly be seen in the Blue Hull. It is also possible the massive impact on the Hull caused other cracks to open further aft.

These are quite chilling photographs as after looking at these it is not hard to imagine just how quickly the stern section would have filled with sea water and sank.

There is an eyewitness report from ‘gac’ on the Lamma Forumn, who saw the Lamma IV as she was lifted onto the barge. He describes the tear in the Lamma IV to be like in an L shape, with a vertical tear from the top of the Hull down to the chine (foot of the side) linking with a horizontal tear along the chine, as illustrated below. In addition there appears for be an opening at the rear bulkhead of the engine room, likely caused by the force of the impact on the Hull shell plate at the time of impact.

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So in summary the Lamma IV sank so quickly due to the massive breach of her hull. Her fate was sealed the instant the two vessels collided. As soon as the Hull had been ripped open to the extent it was, then rapid flooding and sinking was the only outcome.

Given the force of the impact, any vessel of the same specification and construction as the Lamma IV would surely have had the same outcome.

The tragedy is that the collision took place in the first place, and the Investigation will seek to provide answers to how could that happen, as well as to “Why the Lamma IV sank so quickly”.

The last two Photos are courtesy of contributors of the My Lamma Forumn.

Lastly I’d like to pay my respects to all those affected by this tragic accident with such a sickening loss of life.

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Recap.

The Lamma IV, a 24 metre boat owned by Hongkong Electric carrying about 124 staff and their family members, with a crew of 3, travelling to watch Fireworks in Victoria Harbour, collided with the ferry Sea Smooth, in waters off Lamma Island at about 8.23pm on October 1, 2012. More than 100 passengers on the boat fell into the water, and at least 39 are confirmed dead. This is the deadliest boat accident in Hong Kong in 40 years. The Fireworks were scheduled to start at 9.00pm, and attracted around 150 spectator vessels. It was reported the Sea Smooth was travelling around 24 knots and the Lamma IV around 14 knots. Visibility was good. It appears the Sea Smooth Port Bow made contact with the Lamma IV Hull in the area of the Stern Port Quarter, where the Engine room compartment is located. It was reported that the impact caused a hole of 9 sq. metres. The Lamma IV engine compartment became inundated with in rushing sea water, causing the stern to rapidly sink to a depth of 15 metres trapping people inside. Eyewitness reports state the Lamma IV was barely visible as a dark shape after the crash. It’s reported the Sea Smooth stayed for around 5 minutes before leaving the scene.

Good Visibility on Night of Accident

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The scene that greeted rescue crews arriving at the sinking ferry off Lamma Island on Monday night was the stuff of nightmares.

“It was chaos,” a senior fire officer said yesterday. “The survivors were aged from young to old and most of them were not wearing lifejackets.”

The unstable state of the stricken ferry, poor visibility and obstructions also hampered efforts by divers as they searched under the water, he said.

Unstable Ferry, Darkness, Murky Waters & Confusion.

On land, things were scarcely better for ambulance officers, who were hampered in their efforts to get survivors to hospital by a manpower shortage.

The 24-metre Lamma IV sank vertically to a depth of 15 metres with only its bow above the surface.

Survivors pulled out of the water were put on passing vessels, fireboats and police launches before being taken to five hospitals for treatment.

Fire Services Department divers entered the sunken boat to search for victims.

“In the vessel, visibility was very poor and our divers had to search by hand,” the fire officer said. “There was a lot of debris including furniture that caused obstruction. We had to remove it piece by piece before searching each room.”

The two-deck sunken vessel was unstable and divers worked in the knowledge that it could sink further. At about 3am a barge was called in to secure the vessel.

The bodies of 26 victims were found on the upper and lower decks of the Lamma IV before the search was completed at noon.

With visibility of about a metre, divers yesterday were continuing their search for missing persons on the seabed.

Chan Shi-ki, chairman of the Fire Services Department Ambulancemen’s Union, said there was a shortage of ambulances and officers during the rescue and some ambulances were drafted in from as far away as the New Territories.

“It was very chaotic. Many ambulances had to work cross-district,” he said. “But this is very risky. Seriously injured patients might die from loss of blood if ambulances cannot arrive within 12 minutes.”

Chan said some ambulances called in from Ma On Shan did not arrive as they were diverted to handle cases in Kowloon.

Because of a manpower shortage, some patients were handled by firemen and St John Ambulance volunteers.

“From an ambulance man’s point of view, it is best for patients to be handled by us,” Chan said. “If there are enough officers, we do not need help from St John Ambulance.”

Officers on the midday shift worked from 11am to 11pm and had no time for dinner, he said.

Ambulance Service

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