marchioness pt v conculsions

8/2/2019 Marchioness Pt v Conculsions

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PARTV CONCLUSIONS

18. FINDINGS

The Inquiry carried out by the inspectors has covered great detail. It includes eventsimm ediately prior to the collision. the collision itself and the search and resc ue operation.Th e inspectors also carried out detailed research into even ts and actions which took placesom e years prior to this tragic incident which have a bearing upon it .

It is inevitable in an accident such a s this, when on e of the ma in witnesses sadly loses hislife, that a certain amount of supposition must be taken into account. However, thesupposition followed is based on proven theories and the wide experience of thosecarryin g out the inquiry and investiga tion. I consider that the findings give n in this sectionof the report are a true reflection of the actual events w hich occurre d on that night.

The investigation followed every possible avenue and the inspectors findings areconsistent with good, unbiased investigatory work. Their findings clearly identify notonly the immediate cause of the casualty but a num ber of factors which were contributoryto that immediate cause.

The inspectors final finding that there was no wilful misconduct in either vesselcontributing to the collision, foundering or the loss of life is fully borne out by thepreceding sections of this report, and I make no recomm endations for any disciplinaryaction to be taken.

Th e findings of the inspectors wh o carried out the Inspectors Inquiry ar e as follows:-

18.1 T he loss of the lives of the Sk ipper and 50 passengers from the M ARCH IONESS was adirect result of her foundering, and he r foundering w as a direct result of collision with mvBOWBELLE.

18.2 Th e collision took place within a few seconds of 0146 hrs BST on 20 August 1989, ustabove Cannon Street Railway Bridge and near the middle of the river.

18.3 Theco llisionoccurred because neither vessel observed theother until too late. Th e salientpoint which stands out from the evidenc e is that no on e in either vessel w as aware of h eothers presence until very shortly before the collision. No one on the bridge ofBOWB ELLE was aware of MARCHIONESS until the coll ision occurred.

The immediate cause of the casualty was therefore fa i lu re of look-out ineach vessel.

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18.4 The principal contributory factors were that:-

visibility fr om th e whee lhouse of each vessel wa s seriously restricted;both vessels we re using the mi dd le p a r t o f t he f ai rw ay and t he cen t r e a r chesof the b ridges across t he r i ve r ;c lear ins truc t ions w ere not g iven to the forw ard look-out in B O W B E L L E .

18.5; Further probable contributory factors were:-

the s t rength of the t ide ;the phenomenon of hyd ro dynam ic in teract ion .

18.6 Further possible contributory factors were:-

insufficiently conspicuous navigation lights on eac h vessel;noise f rom the d i sco par ty on board MARCHIONESS;t i redness of MARCHIONESSS Ski ppe r .

18.7 In each vessel, the restricted visibility was caused by the position and design of thewheelhouse and stem med from inadequate consideration of the needs of the navigator, atthe design stage in BO WB ELL E and at the time of conversion in MARCHION ESS.

18.8 Despite the difficulties, it w as possible in each vessel for look-out to be maintained ifsufficient positive steps were taken. So me step s were taken but they w ere not sufficientto provide for a fully ad equate look-out in either vessel.

18.9 BOW BELLE was using the centre arches because by th e standards of the River she is alarge ship, and it was normal an d proper for her to d o so . MAR CHIONESS probably usedcentre arches initially because she was overtaking HURL INGHAM , another passengerlaunch bound dow nriver; despite the Collision Regulations, by common practice in theRiver there was no bar toher using the centre arches if the fairway was clear, as he rsk ipperevidently thought it was.

18 .10 Until shortly be fore the collision, the two vessels were heading on parallel courses which ,had they been continued, would have led to BOW BELLE overtaking M ARCHIONES Sclose but safely. Within abo ut half a m inute befo re impact, however, their courses beganto converge. The reasons for this cannot be fully established with certainty, but theconvergence w as mostprobably initiated when MA RCH IONE SS had cleared SouthwarkBridge and BOW BEL LE was passing through it. A t this stage, as BOW BELLE s bowemerged from the bridge, she made a small alteration of course to starboard in order toaccomm odate a planned alteration to port so as to line up or ransit of Cannon Street andLondon Bridges. Th e vessels where th en about 50 metres apart (BOW BELLEs bow toMAR CHIONES SS quarter) and at the sam e time MARCHIONESSS heading altered topor t; this may have been because of the first effects of interaction between th e two vesselsor possibly as an indirect result of tidal eddy, or a combination of both


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18.1 I Th is yaw to port cou ld have been rectified; but it is most probab le, taking accou nt of theslight bend in the River, that MA RCHION ESSSSkipp er saw the centre arches ofCannonStreet and London Bridges in line ahead and steadied on the new course to pass throughthem. It appears clear from the evidence that at this stage he was still unaware ofBOW BELLEs presence.

18.12 On their now converging courses, the vessels cam e so close that in MARCHIONESScontrol wa s lost due to interaction and the vessel sh eared strongly to port across the tidewhich set her on to BOW BEL LEs bow. There was probably an initial relatively lightimpact on her port quarter, and she pivoted so that she came roughly broadside on to thepath of the larger ship. In this position a second, heavy, impact was inevitable, whichrolled the launch ove r on to and beyond her beam ends. As a result she flood ed rapidlyoverall and sank , probably within about a minute of impact.

18.13 Th e alarm was raised imm ediately by the H URL INGH AM and a Se arch and R escueoperation w as begun at once, and was carried out with comm endab le efficiency und er thedirection of Tham es Division of the Metropolitan Police. 80people survived , he majoritybeing picked up by the HU RLIN GHA M and by Police launches.

18.14 When MARCHIONESS was first noticed by the look-out in BOWBELLE he made noreport, for his instructions were to report vessels only if he considered that haza rd existedand at that stage, even thou gh the vessels were already close, their cou rses had not begunto converge and therefore no hazard was evident. When he did recognise danger andshouted a w arning he was not heard, because of the noise of the disc o party in progresson board MARCHIONESS.

18.15 It isprobable that MAR CHIO NES S had been seen from BO WB ELLE at a relatively earlystage but not recognised for wh at she was, perhap s becaus e of the proliferation of otherlights. It is unlikely that this is relevant to the collision as she was probab ly only visiblefrom the focsle and the look-out on duty there, in accordance with his instructionsreferred to in the preced ing paragraph, would on ly have reported her if he had consideredthat hazard existed. It is possible that BO W BE LL E was seen at a distance but not noticed,also because of the backgro und of other lights; and not seen when c lose at hand becauseher navigation lights were insufficiently visible, due to their placing and he r construction.However, she would have been visible to a careful and searching look. There is nosuggestion that either vessel was not show ing the lights as required.

18.16 Proper information w as broadcast by BO WB ELLE about her passage dow nriver, andbroadcasts w ere also made by W oolwich Radio; a total of five broadcasts in all, thoughonly two of them w ere made while MAR CHIO NES S was on passage. It is possible thatthe messages were not heard by MA RCH IONE SS because of the noise made by the discoparty.

18.17 It is possible that M ARC HION ESSS Skipp er was less alert than usual because he hadalready undertaken one disco cruise that night. His concentration may also have beenaffected by the noise of the disco.

18.18 Both vessels were properly certificated, in soun d condition, and m anned in accordancewith the appropriate requ irements. In both vessels the bridge or wheelhouse was properlymanned.

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18. I9 Both vessels were proce eding at a speed which was consistent with th e requirements ofthe Collision Regulations and PL A Bye-laws.

18.20There was no wilful misconduct in either vessel contributing to the collision, thefoundering or the loss of life. In as much as personal fault wa s responsible for h e accident,that fault lies jointly with those in direct charge of the two vessels at the time and withthose responsible for both the perpetration and the ac ceptance of their faulty design. It isneither practicable no r desirable to identify every individual concerned a s the faults goback over a period of 25 years.


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19. RECOMMENDATIONS

Based on the Inquiry into the accident and the find ing s of the in spectors, the follow ingrecommendations are made which, if impleme nted, will p revent recurrence of s uch a naccident and gen erally im prov e the safety of life at sea.

Almo st immediately after the accident, steps were taken to require launch skippers toreport the number of passengers on board at th e time of sailing and to make a safetyannouncem ent describing em ergency procedures; and the Dep artment and PLA increasedrespectively their inspections of passenger launches and their patrols of the River.

This action was later followed by the publication of six recomm endations which wereforthcoming from the Interim Report issued in Septem ber 1989.Those recomm endationshave been somewhat revised to take account of the completed investigation and areincluded in this section in their revised form and marked with a #.

A numb er of the recomm endations are also considered to be most urgent, in the contextof the accident; these are marked with an *.Finally, some m atters considered in the course of the investigation call for attention andhave therefore led to recomm endations even though, upon examination, they did notprove to bear upon the accident. It follows that the list below must not be read in isolationas an indication of causative factors.

The name in brackets which follows each recommend ation is the organisation to whomthat recomm endation is addressed.

# * 1. In all vessels of more than 40 metres in length with wheelhou se aft navigating inthe River Thames above the Thames Barrier, a look-out should be stationedforward at all times. He should be instructed to report all sightings and should havecomm unication with the wheelhouse, preferably by telephone or if no telepho ne isfitted by UHF/RT. (The Department and PLA)# * 2. All vessels of mo re than 40metres in length navigating in the River Thames aboveCherry Garden Pier by night, should carry a light suspended over the bow or,alternatively, a light on each side illuminating the bow but shielded so as not toimpair visibility. This should be in addition to the lights at present required. (The

Department and PLA)# * 3. Those in charge of Tham es passenger launches should be strongly reminded of thevital need to look frequently astern and to k eep con tinuou s radio watch on VHFChannel 14. Routine traffic messages broadcast by TNS Woolwich should bemonitored w hile the launch is alongside, prior to departure. (PLA and LaunchOperators A ssociation)# * 4. The existing guide-lines on navigational bridge visibility for sea-going shipsshould be enforced if necessary by Regulations. While in the long term the aim

should be to develop requirements which ap ply internationally, action in respect

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of United Kingdom ships should not await international agreeme nt: provided thatthe requirements are set out clearly so that they can be taken into account at thedesign stage, they should not penalise domestic owner s. (The Departmen t)

* 5 . Regulation s should be introduced requiring minimum standards of visibility fromthe steering position of passenger launches. (The Department)

6 . Th e Report submitted by the consultant "The MA RCH ION ESS Inquiry - RelevantHuman Factors" will be submitted.to Marine Directorate of the Department ofTransport, and its recommendations should be examined; a submission to theInternational M aritime Organization should be considered when the examina tionis complete. (The Department)

7. Trials should be carried out to test various possibilities for im proving ste m ligh ts.(The Department)* 8. M eans should be adopted to ensure that in small passenger vessels the sou nd level

in the wheelhouse doe s not exceed 75 dBA , even when a di sc o party is in progress.Wh ere a noise limiting device is necessary, it should be a su rveyable item, and theneed for i t to be kept in operation at all times should be most strongly impressedupon Skippers. (The Department, PLA, Launch Operators Association and PortHealth Authority)* 9. In vessels on board which disco parties are held, provision sho uld be mad e for alldisco sound to be cut o u t when safety announcements are to be made. (TheDepartment, PLA. Launch Operators Association and Port Health Authority)

* IO . Navigational broadcasts made by Port Authority radio stations should be precede dby an alerting tone. (The Department, PLA and British Ports Federation)

1 1 . The investigation no w in progress of VHF reception in the Thames should beactively pursued with the aim o fen suri ng that reception is satisfactory in all v esselsregularly using the upper tidal reaches. (PL A, Launch Operators Asso ciation andCompany of Waterman and L ightem en)* 12. In addition to their minimum operational crew, passenger launches should berequired to carry persons trained in emergency pro cedures, the number required tobe linked to the number of passengers actually carried at the given time. Theseadditional persons could be bar or catering staff. (Th e Departm ent)

13. All launc hes on the tidal Tham es when carrying passengers should be com man dedby a man who is, at least, fully qualified as a W aterman. (The Department and PLA )14. Minimum medical standards for Tham es Watermen should be drawn up, especiallywith respect to sight and hearing. (The Depa rtment and PLA )

15. For small passenger vessels elsewhere, the Boatman's Licence should be givenstatutory status and made the minimum requirement for the Skipper, and itssyllabus should be revised. (The Department)

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16.

17.

# * 18.

* 19.

20.

21.

* 22.

23.

24 .

25.

26.

# 27.

Consideration should be given to extending the London Pilotage area to include al lparts of the River used by sea-going sh ips. Exem ption Certifica tes should only begranted under strict conditions. (The De partment and P LA )

Th e development by the Department of Regu lations to cover permissible hours ofwork shou ld be pursued an d should cover person s operating river craft as well assea-farers. Pending the development of requirements, passenger launch operatorsshouldensure hat crewsdonot undertake twosuc cessivecru iseson the same night.(The Departm ent, PLA and Launch O perators Association)

Vessels in the Thames should keep as fa r as possible to the starb oard side of thefairway, even when the fairway is thought to be clear. Rule 9 of the CollisionRegulations should be strictly enforced in the R iver. (PLA)

A signalling system to control traffic through Tham es bridges shou ld be developedand brought into operation as soon as possible. (The Department and PLA)A full review should be carried out of the requirements for Class V vessels relatingto stability and construction. Particular attention should be paid to ensuringadequate escape arrangements. (The D epartment)Provision should be made for military helicopters engaged in rescue operations tobe able to comm unicate directly with Police. (T he Department and MOD)Military helicopters designated fo r SAR work shou ld carry infra-red heat-seekingequipment. (The D epartment and MOD)Revision of the Port of London Emergency Plan POLACAP, which is now inprogress, sho uld ensure that its application tocraft in the upper tidal reaches is mad eclear. (PLA )A further review of life-saving appliance requirements for Clas s V vessels shouldbe made before the draft regulations are submitted for consultation. (The Department)South Coast Shipping Ltd should appoint a specific senior person ashore to haveresponsibility for technical and safety aspects of the operation of their ships, asrecommended in M erchant Shipping Notice M. 1188. (South Coast Shipping Ltd)

The D epartment of Transport should make eve ry effort within their power to ensurethat compatibility with good operational practice is the first consideration in thedesign of ship s and th e provision of their equipm ent; and should use their influenceto foster this approach throughout the maritime community, both in the UnitedKingdom and at IMO. (The Department)These recommendations should be transmitted to Port Authorities in th e UnitedKingdom generally for their consideration, as a nu mber of those which at presentare directed towards the River Tha me s may a lso be relevant to oth er areas. (TheDepartmen t and British Ports Federation)

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