Presented tothe restrn Ausralta Section, Royal nttution of Naval Architects, 2¢* ne 2015, Perth, Australia ON A TECHNICAL INVESTIGATION INTO THE CAUSES OF AN ACCIDENT AT SEA~ THE STORY OF THE LAST AND FATAL VOYAGE OF LAMMA IV, AND A LITANY OF FAILURES IN DESIGN AND SURVEY. ‘Tony Armstrong, President, The Royal Institution of Naval Architects (Australian Division) SUMMARY: ‘This paper reports on the findings of the Comrnission of Inquiry into the circumstances relating to the collision between a fast ferry and a private launch in Hong Kong Harbour in 2012, and presents the approach taken to the technical and forensic investigations that were carried out to assist the Commission, 1, BACKGROUND TO THE EVENT October 1" 2012, was National Day in Hong Kong, a Public holiday with large commemorative fireworks display in the harbour opposite Central. The employees of Hong Kong Electric (HKE) Company, and their families and fiends, were being treated to 2 day trip to the electricity-generating plant based on Lamma Island, and then taken on two of the HKE launches for a grandstand ‘view of the fireworks. The two launches were sister ships, cach with a length of 27.2 metres, first certified in 1996 by the Marine Department to carry 224 passengers and were normally used on daily duties to carry employees to and from Lamma Island. On National Day, one of the launches, Lamma IV, was carrying 98 adult passengers and 32 children, of whom some were toddlers as young as two, The conditions for the trip to Central and the fireworks were ideal, with good visibility (10 km), and a wind of approximately 5% knots. At the same time as employees and family were being invited to board Lamma IV, 2 28-metre long fast-ferry on & regular service, Sea Smooth, was departing from Central with 95 passengers and heading for Yung Shue Wan pier, also on Lamma Island. Figurel: Tracks of Sea Smooth & Lamia I location of Yung Shue Wan pier, anchorage areas and the HKE power station ‘Maritime traffic on Hong Kong harbour is constantly monitored by a Vessel Traffic Service (VTS) consisting of 13 radar stations at various strategie sites, as well as a method to collect data from ships equipped with an Automatic Identification Systems (41S). Both of theso systems record data on a 3-second basis, including latitude and longitude, course-over-ground and speed-over-ground on a close-to-real time besis, as well as the ship ID and a VTS tracking mumber. From this information it was a relatively simple matter to accurately reconstruct the track of the two vessels involved in the drama, although Lamma TV was not required to, and did not have, an AIS system. ‘The routes and key locations are illustrated in Figure 1. Lamma IV left the HIKE port at 20:15. By this time it was dark, but with otherwise good visibility. Directly ahead was the “North West Anchorage” which contained a number of ocean-going ships at anchor and. displaying deck lights which could be assumed to have some effect on vision when a Master was heading towards them. Nevertheless, Lamma /Y was fitted with redar and thus could be expected to operate safely at her most economical speed of about 12 knots. The crew hed only Just retumed to the wheelhouse from their duties stowing ropes and checking passenger numbers when a flashing yellow light and navigation lights were noted almost dead ahead, travelling towards them at a speed estimated to be about 22 knots. The Master steered hard to starboard, es required by the Collision Regulations when meeting in a head-to-head situation, and increased RPM on the engines. ‘Meanwhile on board Sea Smooth, after travelling through the North-West anchorage, the crew had just left the ‘wheelhouse in preparation for arrival at their destination. ‘The Master was alone when he noticed a black shadow about 75 metres away and directly in front, with no obvious navigation lights. He claimed to have turned immediately to starboard and gone full astern, but it was too late, and Sea Smooth struck the side of Lamma 1V just aft of midships at an angle of about 42°, at 20:20:17 hrs. ‘Standing crew members fell over as a result of the rapid deceleration, although the Master remained in his seat. He ‘opened the port side door of the wheelhouse and saw Lamma IV, which he recognised, with lights on in the lower cabin, A crew member came into the wheelhouse and advised that they had injured passengers. At this the bilge alarm sounded in the console, indicating ‘wo flooded compartments in the port hull. The Master ‘ordered fifejackets to be donned and the Engineer went to inspect the extent of the flooding and to turn on the fire pump which could act as an emergency bilge pump. He found water in the forward three compartments on the port side. As the boat settied, water started to come in through 4 manhole in the main deck at the forward port comer of the passenger cabin, which gave access to the forepeakPresented othe Wester Australia Section, Royal nsiution of Naval Architects, 24° June 2015, Perth Ausrlla space. There was panic as passengers assumed that he craft was sinking and aggressively demanded that they be put ashore immediately. The Mastor decided that the passengers and crew were at risk, and engaged the engines and sailed to Yung Shue Wan pier at reduced speed. ‘There was no attempt at rescue by Sea Smooth personnel, no use of the searchlight to spot flosting passengers from Lamma I¥, no lifebuoys or liferafts were deployed, and no check of the radar to even locate Lamma IV On board Lamma IV, the Master made a mobile ‘phone call to the Police (at 20:22:04) to report injured passengers, and also called the second HKE launch Lamma Il following behind, seeking help. A crew member had gone to the aft upper deck and had also made ‘a phone call to the Police (at 20:21:03) before distributing Tifebuoys to those on the aft open deck. The boat then tilted by the stern and he found himself in the see. Meanwhile, the Engineer had discovered that the Engine Room was flooding and the Master ordered lifejackets to bbe donned, The craft started to sink rapidly by the stern, followed by failure of the generator and the lights, with the emergency lights coming on after a short delay. The ‘Master noted a trim angle of about 45° and at that point ‘the seats on the upper deck started to detach from the deck and slide down into the water, taking passengers with them. He fell into the water, breaking a rib, but was able to borrow a mobile ‘phone from a passenger and to make another call whilst swimming inside the upper cabin, before reassuring passengers that help was on the way. In addition to Lamma If, some pleasure craft came to recover passengers in the water, but many were still trapped inside the cabin. The first rescue craft from the Marine Police arrived at about 20:39, followed by the Fire Services Department whose firemen broke some windows to get to the passengers swimming inside the cabins. Tho ‘Master was the last person to leave from the roof of the vessel as he looked for passengers needing rescue from the sea. The Engineer had been urging people to jump into the sea out of the main access door on the main deck. He became trapped inside the main cabin helping passengers until rescued by the firemen through a ‘window. A Government helicopter arrived and provided overhead illumination, and spotted persons swimming in the sea, Penetration dives into the hull were undertaken by divers from the Fite Services Department, starting at 22:45 and continuing through the night and the next day. ‘Twenty bodies were recovered from within the craft, and police divers recovered six bodies from the sea during the night. ‘The vessel was recovered on 3" October to a nearby shallow beach, and subsequently removed to the Government Dockyard on the 14" October 2012. 2. THE COMMISSION OF INQUIRY The Chief Executive in Council of Hong Kong sppointed ‘4 Commission of Inquiry (CON) on 22™ October 2012, to {nguire into the circumstances leading to and surrounding the collision of the two vessels, specifically to ascertain the causes of tho eccident, to make appropriate findings, and to consider and evaluate the general conditions of safety conceming passenger vessels in Hong Kong, and the adequacy or otherwise of the system of control The COI consisted of two commissioners; Hon Justice Michael Lunn and Mr. Benjamin Tan. They appointed three expert witnesses to assist them on technical issues, each with individual experience in navigation, naval architecture and electrical engineering. ‘This paper outlines the approaches taken to answer the technical issues raised by The Commission. 2.1 The Causes of the Incident ‘The tack ofthe two vessels according tothe VPS radar is illustrated in Figure 2. The data suggests that Sea Smooth must have struck Lamma 17 with a glancing blow, as it continued south for 9 sec after the collision at 20:20:17. Figure 2: Radar track. Colison at 20:20:17 However, the exact track of Sea Smooth after the collision ‘was not correctly recorded, because the system software assumes a reasonably constant speed and in order to keep track of echoes from many ships it has a predictive capability as to where the echo might be found in the next 3-second sweep of the radar. When Sea Smooth stopped suddenly, the computed radar echo trace displayed by the software continued for some time heading away from the collision. Some passengers however had given statements to the police that the Sea Smooth had penetrated into and, embedded itself inside Lamma IV, until it was deliberately reversed out using the engines. It was therefore essent to ascerain how the two craft had interacted during the collision, as it was suggested that if Sea Smooth had remained within Lama 1¥, thus “plugging the hole”, then the later eraft would not have sunk. Attough the AIS system is ebjet wo inacraracies a wo 's exact location (like any non-military GPSPresented tothe Western Australia Section, Royal Institaton of Naval Architects, 244 hne 2015, Perth, Australia system) it is considered to be accurate with regard to relative positions over @ short period of time, and therefore the AIS positioning data for Sea Smooth was compared with the radar positioning data for Lamma IV. ‘This suggested the track for the two craft as shown in Figure3. wu uno miata 2020.20 ene som ease. = : Figure 3: Track of collision using two data sources The physical damage on board both craft gave clear ‘evidence of the interactions between them, The stem bar of the port hull of Sea Smooth was the first point of ‘contact with the side fender of Lamma IV, and it had cut a ‘narrow passage through the 4 mm aluminium deck plating, as shown in Figure 4, Figure 4: Path of Sea Smooth stem bar through main deck of Lamma IV, looking down on Port side Figure 5: Relative anttudes at collision From this narrow line of damage it was possible to ‘measure the relative angle of the collision (28°), and from the information evailable from the VTS on the speeds of the two craft to deduce the real heading difference of the two craft (41°). The relative positions of the two boats at the moment of collision are shown in Figure 5. ‘Sea Smooth was of fibreglass construction, with a stem bar and keelson core of 220 x 50 hardwood. The stem bar struck just forward of a sloping aluminium fender and it followed the angle of the fender as Sea Smooth moved forward into Lamma IV until it met Frame 5, (see Figure ©), where it broke off from the main structure of Sea Smooth at the point where the stem bar became the keelson, Owing to the forward motion of Sea Smooth, the hardwood keelson continued to enter the engine room of Sea Smooth creating an approximately horizontal opening, in the side plating, until it struck the aft engine room bulkhead 4 where it again broke, leaving pieces of the keelson and stem bar within the engine room. ‘Sea Smooth continued to move forward, and the keelson then punctured the side plating of the Tank Room creating ‘a roughly rectangular hole between Frames 3 & 4, below the waterline. The forward motion of Sea Smooth was arrested when the collision bulkhead of the port hull struck the side of Lamma IV and the surfaces in contact became large. The calculated time between the initial contact and coming to rest was approximately 2.0 seconds, at a deceleration of 0.6~0.8g,Presonied othe Western Australis Secon, Rayal nstution of Nawal Architects, 24° June 2018, Perth Ausra Figure 6: Damage to Lamma IV hull from the stem bar/ keelson of Sea Smooth, annotated with frame numbers “Above the main deck level, the hull plating of the port hull of Sea Smooth entered through the deckhouse side of Lanma IV wich had large rectangular windows and consequently had litte strength to withstand an impact. ‘The hull then passed over at least 12 passenger seats, although the final debris field was slightly larger. About "Ys of the width of Lamma IV at the aft port quarter was penetrated by Sea Smooth in the after ‘cabin area, the limits defined by the bending of a pillar on Frame 3, and a scrape of blue paint from the foremost point ofthe stem of | Sea Smooth on the inside of the after bulkhead of the cabin, Final positions of the two craft are shown in Fig 7. A calculation of the momentum, moments and forces suggests that the catamaran Sea Smooth rotated during the collision anticlockwise (Geen from above) as a result of collision forces acting only on the port hull, and the Lamma IV also rotated anti-clockwise as a result of being hit on the port side at the after end, and it was this rotation that eventually caused the separetion of the two craft rather than any action of either Master. It was clear that Sea Smooth had not travelled any further into Lamma IV than the after bulkhead of the eabin, becauso the side bulwark atthe after end of Lamma IV remained intact. In realty there was very litle keeping the boats together, as most ofthe structure of Sea Smooth below the main deck ‘of Lamma IV had broken off inside the hull, and above the ‘main deck there was very lite of the Lamma IV structure that remained to hold Sea Smooth in position, From this information it was possible to estimate the likely relative motions of the two craft during and immediately following the collision, as illustrated in the ‘Appendix, and to fit this to the AIS and Redar date A cairo i nem t=2.0sec Figure 7: Furthest penetration of Sea Smooth (An animation of the approach prior to collision was ‘created from the data and can be seen at: 3/0 WI Ta 1) Figure 8: Damage to Sea Smooth; port side forepeak ‘tank, cabin comer and bulwark ‘The damage to Sea Smooth essentially destroyed the forepeak on the port hull below the main deck as far as the collision bulkhead, illustrated in Figure 8. There was some damage to the shell below the waterline aft of the collision bulkhead, as well as the bulkhead itself, which admitted water to the next compartment although the craft ‘was not in danger of sinking as the starboard-side hull was. entirely intact. The damage above the main deck was essentially restricted to non-structural items such as bulwarks, although the forward comer of the deckhouse‘Presented othe Wester Australia Section, Royal nstntion of Naval Archies, 24* Jane 2015, Perth, Australia was damaged, and open to the exterior. bulichead appeared to be structurally intact. The collision ‘The information from the VIS, together with the evidence of the angle at which one craft struck the other, and the evidence of the Master of Larvma IV that he had increased engine rpm and tumed hard to starboard at the last moment, supported by statements from passengers on the aft deck, it was found that the principal cause of the collision was the tum of Sea Smooth to port in contravention of COLREGS 14(b) when in a head-o-head situation. Lamma IV did alter course quite considerably to starboard, but far too late, Other aspects of poor navigation ftom both Masters were noted as associated causes, because neither took sufficient action to avoid the collision, and the Sea Smooth Master did not make use of the radar, nor keep a proper lookout. ‘There was particular concern about whether Lamma IV ‘was showing any navigetion lights at the time of the collision. There was sufficient evidence from witnesses to indicate that the lights had been illuminated, notably a passenger on Sea Smooth who saw the masthead light approaching; the Master of Lamma Il; and the Master and crew of Lamma IV who had noted the lights were on. In addition the first fireman on the scene of the foundered ‘Lamma IV reported that he had tied up the police launch t0 Lamma IV by using the starboard side navigation light support structure and that the green light was still switched on, Subsequent forensic examination of the bulbs indicated that the filaments had all been at high ‘temperature when the glass was cracked or broken, as they coniained chesnical residues of titanium oxide (indicating. broken in ait) or magnesium hydroxide (broken in seawater). It was also noted that the navigation light distribution board in the wheelhouse showed all. the navigation light switches to all be in the “on” position, with the circuit breakers tripped, suggesting a large current had been present, as might be anticipated when an active DC cireult was submerged in seawater. It was accepted by the COT that Lamma I's navigation lights ‘were switched on at the time of the collision, 22 The Circumstances in which the Vessel sank ‘The COI asked for an explanation for the very rapid sinking of Lamma IV. From the very first inspection of Lamma IV, it was ‘obvious that there was no door fitted to the access opening in the otherwise watertight bulkhead forward of the steering gear compartment — the aft peak (4?) bulkhead. Close examination clearly indicated that a door had never been fitted, as there was no sign of welding for hinges or closing wedges, and furthermore the flat bar around the opening was positioned such that a watertight seal could not be made to any door in the corrugated bulkhead. ‘Nevertheless the damage stability book indicated that the AP bulkhead was intended to be watertight, and subsequent examination of all of the drawings showed that the bulkhead was marked as watertight. The Regulations also stated that any access opening in the peak bulkheads must be watertight. Without this door, and with both the Engine Room and the Tank Room open to the sea, there was no buoyancy in the aftermost 50% of the craft and the craft was doomed to sink stern first. The size of the holes in the hull and the lack of a watertight door in the bulkhead were therefore the reasons forthe rapid sinking, To examine this process in detail, an Excel macro in Visual Basic was written to model the flooding process in discrete time-stops, based on the flow of water through an orifice using the Bernouilli equation, with the assumption of asteady, inviscid, incompressible low. ‘The flow of water through an orifice, such as a hole in the side of a ship, is essentially a funtion of the head of water. The inflow velocity for a hole with rounded edges is approximately given by Y= gH)" (m/s) where H (mm) is the head of water, and the inflow rate is then given as the product ofthe velocity and the area of the hole; Q= V.Area (m/s) a Where there was no water inside the room albove the level of the inflow hole, the head of water was given by the vertical depth of water outside the ship above the centre of ‘he hole, When there was water inside the room above the level of the inflow hole, the head of water was the difference between the water level outside the ship and the ‘water level inside the room. ‘The holes inthe hull plating centred about Fr. 37% and Fr 4% had generally rounded edges associated with plating having been pushed in, and the inflow was therefore considered to be relatively smooth, and the inflow could reasonably be calculated using the above simple formula. ‘The hole (narrow angled slot) centred about Frame 6 ‘could not be considered as an orifice. Various weir-type formulations were investigated, and eventually the classic Francis weir formulation was adopted, The slot was relatively narrow and the inclusion of the width of the slot in the Francis formulation was considered to be relevant, without making the formula insolvable owing to negative values, Altemative formulations were included in the spreadsheet in order to investigate the sensitivity, but made little appreciable difference to the flow rate, particularly when allowance had to be made for debris remaining in the hole. ‘The flow of water through the opening in the AP bulkhead ‘was initially treated as if the sill was a standard weir with anappe. In this case the flow rate Q was given by: O- Cwm 2/3.(2g)*. b. H?? m’/s Q where Cn = 0.611+0.075 x (Head/Py) , and Py was the sill height.Presented tothe Wester Ausrata Section, Royal Inston of Naval Architects, 24° June 2015, Perth, Australia Where the water level inside the steering gear ‘compartment became higher than the sill height, the broad crested-weir formulation was assumed. In this case, the flow rate Q was given by: O~ Cs (a). 0. 2B). 1? ms 8 where Cwa = 0.65/{1+(Head Py)”. ‘The overall situation is clearly a dynamic one, because the ‘Vessel trims as the water enters, and the height of sea water above any opening changes as the vessel trim changes. For the purposes of estimating the tim and draughts of the craft in discrete time intervals, it was assumed that the “buoyancy” of the craft remained constant, andthe incoming water was treated 23 if it were an additional weight in each compartment, for which the ‘exact centre of gravity needed to be calculated. ‘The problem was further complicated because the weight of incoming water changed the trim of the craft, which in tum changed the relative angles of the free-surface water within the vessel, which in tur changed the longitudinal location of the centre of gravity (LCG) of the water within ‘the ship. For this reason all draughts were referenced to a common location of Frame 0. All water levels were assumed to remain horizontal, Further complications had to be addressed, such as excluding the volumes of the fuel oil tank, the fresh water tank and the main engines because these geometric shapes could not be flooded. Their excluded volumes changed with the height of the water inside the compartment and the ship trim. Various data tables were obtained using Hydromax software, and were included as look-up Tables within the spreadsheet, including: — Trimmed hydrostatic data (for the whole boat, ‘over a large range of displacements up to the ‘main dock). = Trimmed volume data of the large items inside the Tank Room and Engine Room (as noted above), — Trimmed intemal volume data (as Bonjean ‘eurves) for each of the engine room, the tank oom and the steering gear compartment, including centres of gravity, and — Data relating to the geometry of the craft, including the heights and locations of the various ‘openings in the hull and the sill to the Aft Peak bulkhead opening. [AL any progressive time during the sinking process, the ‘low rate through hull openings at Fr.3%, Fr.4¥% and Fr.6 and the opening in the AP bulkhead could be calculated from the trim of the vessel and the geometric locations of the various holes relative tothe external sea level Assuming a discrete time interval (such as 0.5 second), the ainount of water entering the vessel during that period ‘could be calculated, as well as the amount flowing into the steering gear compartment. Taking the weight of this additional amount of water as well as its centre of gravity allowed the effect on the trim of the vessel to. be calculated using the hydrostatics in the data tables, with refinements for the volume of the intemal structure, tanks and outfit, The next time interval was then repeated until the vessel stabilised or sank. Some of the fibreglass hull plating from Sea Smooth had fragmented within the hull of Lamma IV in the region of the narrow angled slot (Frame 6), and this debris would. have obstructed the free inflow of water. Therefore a factor (termed a choke factor) was introduced into the calculation for each hole, resulting in a reduction in the fiow rate. Varying the choke factor permitted a sensitivity study to be cartied out on the effect of the flow rate, ‘The result of the calculation of the vessel trim is illustrated in Figure 9 for a vessel with an open access in the AP bulkhead. The margin line was immersed at the transom after sbout 90 seconds from the initial collision. ‘The caloulation was also repeated for the vessel assuming ithad been fited with a watertight AP bulkhead. ‘eimag e] ‘pee Figure 9: Calculated elapsed time vs. trim Once the deck edge at the transom had immersed, there was virtually no buoyancy remaining at the after part of the vessel, and the rotation of the hull was thereafter assumed t0 occur with a rotation centre approximately at the waterline and with the weight of the submerged hull causing the hull to continue rotating under the action of gravity, with some additional damping owing to entrained water. Hoemer [1965] gives a formula for the drag of a rovating cylinder as Drag ='4Cy pb ix? ae @ where Cp is @ drag coefficient (0.7), p is the specific gravity of water, 6 is the diameter of the cylinder, ois the speed of rocation and x is the longitudinal location of the clerments of the cylinder. ‘The rotational acceleration was then calculated from gravity, less the damping correctionPresented tothe Westen Australia Section, Rey Instiion of Naval Architect, 24° June 2015, Pert, Austral derived from the rotational drag and the hull mass using ‘Newton's 2™ law. ‘The rotational speed os the transom immersed was calculated and used as a starting point for the rotational phase, and thereafter calculated at discrete time intervals. ‘This “gave a total time to achieve 62° tim of approximately 118 seconds, as ilustrated in Figure 10, at which time the transom of the eraft met the mud on the seabed as illustrated in Figure 11. ‘The transverse GM was positive at all stages ofthe sinking process, ase Figure 10: Total trim angle vs. elapsed time ‘The vessel remained in this attitude for approximately two hours, during which time rescue of passengers and crew was effected by rescuers smashing the windows just above the sea surface. As the tide changed, so the attitude of the boat changed, until it had rotated to approximately 120°. [SITUATION AT 420 SECONDS AFTER COLLISION ‘VESSEL STABLE, NOT FLOODING FURTHER Figure 11: In contact with the sea bed 2.3. Why so many lives were lost ‘AS Lamma IV assumed a severe stern trim, all of the fastenings connecting the seats to the upper deck failed, with the exception of one seat (which probably did not have a passenger upon it), Several bodies were eventually recovered from undemeath the tangled seats. From the evidence remaining on board after recovery, there were many different types of fasteners and screws used to “secure” the seats, including in at least one case a couple of aluminium “pop” rivets. There was also plenty of evidence to indicate that securing loose seats to the deck hhad been an on-going problem. ‘The upper deck was manufactured from sandwich fibreglass construction, having two layers of fibreglass ‘mat, separated by a non-structural core of PVC foam. The 25mm screws holding the seats down were mainly ‘embedded in the PVC foam, and only secured by the upper 2.1mm thick glass mat, a depth which was clearly inadequate to secure the seats with the load of a passenger at abnormal trim angles, with only one thread making ‘contact with the deck material. Figure 12 illustrates the arrangement, using screws recovered from the deck, together with a photograph illustrating previously attempted repairs tothe deck mounting using “pop” rivets. Ro Figure 12: Seat fastening arrangements to upper deck ‘The seats also created a problem when it came to donning, lifejeckets, which were of a type having long tapes for ‘wrapping around the body and tying off. These long ‘apes, about two metres in length, became wrapped around the open legs ofthe seats and were a severe impediment to donning them, especially given the rapid sinking and the failing seats on the upper deck. Some bodies were found ‘entangled in the wreckage by the lifejacket tapes. ‘Adult lifejackets were stowed under every seat, as shown in Figure 13, but most were wrapped in plastic shopping ‘bags to provide # barrier against cockroaches, and which had to be ripped open, causing more delay to putting them ‘on, Furthermore there were no liféjackets on the aft openPresented othe Western Australia Seton, Royal Inston of Naval Architects, 26° hae 2015, Perth Autre deck, where many’ passengers had gone, and many went back into the upper cabin to get their lfejackets and were then trapped inside owing to the speed of sinking and the immersion of the aftfacing door. In addition there were no children’s Lifejackets on-board, and adult lifejackets cannot be fitted to children, Because this trip was a “family” outing there were many (32) children on board. Figure 13: Lifejackets under seats in plastic bags 2.4 Adequacy of the system of Control of Safety Investigations by the COI revealed several issues relevant tothe accident ‘The operational licence for Lamma IV had been changed for some unknown reason by HK Marine Department (Mardep) some years previously, increasing the crew numbers from three to four. However, the company had continued to operate with three, and to designate an employee travelling on board as the nominal fourth crew member. On the day of the accident there was no such nominated person. This circumvention of the licence conditions was not known to Mardep. Perhaps a fourth crew could have assisted in keeping a better look-out. Lamma IV had been inspected many times by Mardep surveyors on an annual besis. Although required to carry children’s lifejackets (up to 5% of the total passenger numbers), and noting that the Mardep surveyors had annually signed these off as being sighted, nevertheless the COI found that children’s lifejackets had never been fitted on-board, and was in direct contravention of the ‘current (2007) regulations. “The Marine Safety Regulations in foree at the time of construction were quite clear, but in 1995 Mardep was in the process of moving from their established “Instructions, for Survey of Launches and Ferries (1983)" to a new Code of Practice, and which came into effect six months before the keel was laid on Lamma IV, Nevertheless there was ‘no agreement amongst the various surveyors interviewed during the COL as to which regulations were being applied at that time; perhaps both of them. In any case, both sets of Instructions required peak bulkheads at both ends and that any access opening in a watertight bulkhead was to have an efficient watertight closing appliance. Also all riew launches designed to carry more than 100 passengers had to comply with the watertight —subdivisi requirements in the Regulations. To confuse the issue further, Mardep had sent an informal letter 10 various designers at that time that stipulated that for the purposes of damage stability investigations, a one-compartment standard of sub-division should be assumed. In accordance with this letter, the damage stability was investigated for each individual flooded compartment, which was acknowledged by Mardep (and stamped as seen”). ‘The calculations indicated an adequate stability capability, however, both the designer and Mardep failed to satisfy the requirements of the Regulations because no investigation was carried out into the immersion of the ‘margin line, and furthermore the requirement that any ‘opening had to have a minimum length of 0.12 (Z being the ship length) was ignored. The Aft Peak space was less ‘than 0.12 and therefore if this spece was damaged, the calculations should have included the Tank Room and over-ridden the “one-compartment standard”. The initial drawings for Lama IV taken from the Mardep archive indicate a watertight bulkhead fitted at Frame %, as illustrated by Figure 14, which matches the requirements of the regulations, Plan approval at Mardep without doubt assumed that the AP bulkhead at Fr.i4 was watertight, because all the drawings stamped by Mardep, including the damage stability book, clearly indicate this. & Figure 14: Original guidance drawing of Bhd. Ys However, at late stage of drawing approval, the designer submitted a revised detailed plan for the aft peak bulkhead, as shown in Figure 15. This had been changed to indicate an access opening in the bulkhead, which elsewhere on the same plan was indicated to be watertight, and continued to be shown as watertight on all other relevant plans. It should be noted that the Regulations state that all access openings in watertight bulkheads are to have an efficient watertight closing appliance, so this change to the drawing did not suggest that there would be no door, and it rang no alarm bells within Mardep.Presented to the Wester Australia Section, Royal Instinsion of Naval Arcecs, 24 Jure 2013, Perth, Australia | i rm tie TTT TEA i EPS EL Figure 15: Revised drawing of Bhd. % ‘What the shipyard was trying to do in asking the designer to remove the door is not at all clear. The cost of a door ‘was minimal, 60 it could not be the cost, and furthermore they could have saved far more money by making the ‘whole bulkhead non-watertight. It was indicated by the shipyard during the COI that the aft peak bulkhead required by the regulations was in their opinion the same as the aft engine room bulkhead, and consequently the bulkhead at Fr.% was not required to be watertight. ‘This ‘caused considerable discussion in the COI about what was the fimction of an Aft Peak, but the result was that Fr. ‘was decided to be the AP bulkhead, despite repeated attempts to justify the alternative suggestion by the shipyard. The shipyard also maintained that the many references on various drawings to the bulkhead at Fr.i4 being watertight were simply “a mistake”. Figure 16: The access opening in Bhai, looking aft Because the shipyard was busy at the time, the hull of Lamma IV was manufactured in Chine to the approved drawings. There was no drawing of a watertight door, and the hull was made with an opening in Fr./4, and no door was over fitted, as shown in Figure 16, Subsequent survey by Mardep officers failed to notice the opening or to ‘understand the significance of the Inck of a door. A door vwas not shown on any drawing given to the surveyors, and they did not interact with the plan approval officers. 2.5 The role of ballast on the sinking Twice during the life of Lamma IV, 1998 and 2005, ballast ‘was added (or changed) to improve the trim of the craft and reduce the fuel consumption, An inclining experiment and a new stability book were approved by Mardep on each occasion, but both of these late revisions continued to indicate a one-compartment standard of sub- division, and an assumption was made that the vessel had been correctly built and surveyed previously. The Mardep surveyors who checked the ballast (witich was fitted on cither side of Fr.'4) and who witnessed the inclining, failed to notice that the watertight bulkhead had a large opening in it, with no door, despite the damage stability book clearly indicating a watertight bulkinead. In fact the transverse damage stability was adequate with an opening in this bulkhead, but neither the shipyard nor Mardep ever investigated the immersion of the margin line, as required by the Regulations. Had they done so, they would have found that the margin line immersion ‘was satisfactory in 1995 when the vessel was constructed, ‘but after the ballast was added in 1999 the margin line was immersed for the condition when the Tank Room was flooded and the AP bulkhead was not watertight, as summarised in Table 1. Furthermore, asthe steering gear compartment was less than 0.1Z, then any damage to the AAP would include the Tank Room, and the margin line hhad become immersed in this condition after the ballast ‘was added in 1998, ~ | Depth to margin line fel Condition | Dau sor Wah Wt daw | [-Ne Wir door ‘With Ballast [1968 With W/T door | No WIT door 1.007 | Satisfactory | Raiked Balint [2005 | 1 With WIT door Flooded, at various datesPresented tothe Wester Australia Secon, Royal Instn of Naval Architects, 24" Jane 2018, Perth, Australia Lama IV at the time of the accident suffered & loss of ‘watertight integrity to the Engine Room and the Tank room. Would a watertight door have made a difference to its survival in reality? Table 2 illustrates thet the door would have made a big difference, as with a door the ‘margin line would not have been immersed, but without the door it sank. T Depth to Condition | Date margin line Agwonirucid [1995 Wie 7978 | Satistaciary FAL —__| _] i Wi Baiiaa | ION, 1 Wir WT door Margin line [— FATE] immecsad. Ne Wit doar Fall Haired Ballast 172005 With WT door foal | Satan "No WIT door FAIL Table 2: Margin line situation, with engine room and tank room flooded, as ship condition on I" October 2012 3, CONTROL OF MARITIME SAFETY ‘The COL was very critical of the obvious failure of some aspects of control of maritime safety in 1995, but was also very critical of the current system whereby changes 10 lation in 2007 concerning the number of children’s lifejackets to be carried on board had been completely jgnored by Mardep, with no written instructions or departmental communication on the subject except by: word of mouth, and consequently no enforcement of safety standards. This was not only dangerous but could have invited corruption. The COT consequently strongly recommended immediate action to determine the state of safety of the whole of the Hong Kong local fleet, particularly those crait licensed to carry more than 100 passengers, and to overhaul the whole regime of maritime safety. It was noted that there was no defined overall safery philosophy, with no high-level objectives and no real ownership of safety issues, rather the approach was to continue to use a motley collection of guidance rules and instructions that had been gathered together over the years. Also highlighted were the continuous failure by Mardep to notice the lack of a watertight door in the access opening in the Aft Peak bulkhead, as clearly: required by the Regulations, especially as this error has been continued throughout the life of the ship, including the first plan approval, initial certification, all ofthe annual surveys, re- certification in 1998 when ballast was introduced and the second re-certification when the ballast was moved. A list of proposed immediate improvements to the safety regulations were suggested, including operational safety 10 management of ships (training and watch-keeping) and watertight subdivision standards. Guidance rules and standards covering drawing approval and surveys were also desperately in need of overhaul, together with improvements to lifejacket standards, The Safety Management standards of HKE were also criticised. The crew numbers bad been less than those required by the licence to operate, and the Master was not trained in the use of Radar, with the only manual for the radar written in English which the Master could not read. 3.1 Postscript to the COL Lloyds Register of Shipping was commissioned by Mardep to introduced wholesale changes to the way that Mardep treated plan approval & survey. ‘The whole fleet of ferries and launches in Hong Kong certified to carry more than 100 passengers was checked for lifesaving appliances and for watertight subdivision. Court prosecutions were instigated against the two Masters for failure to navigate safely and for 39 counts of manslaughter. 4. CONCLUSION ‘The cause of the Collision was found to be an inadequate standard of navigation from both Masters, + Lamma IV sank very quickly mainly because of a missing watertight door in the aft peak bulkhead, as well as the extent of damage, The door was required by Regulations but mumerous surveys had failed to notice the ‘omission. All design plans and documentation, including damage stability calculations, indicated a watertight door in the aft peak bulkhead, but a disconnect between the plan approval and survey functions was a major cause of the loss of the vessel. Design calculations for a ship when damaged must include not only transverse stability but also calculation of the immersion of the margin line at the ends. ‘Xo children’s lifejackets had ever been on-board Lamma IV, in direct contravention of the survey requirements, and the design of the adult fifejackers ‘themselves proved to be unsuitable. Sea Smooth was never at risk of sinking, despite the loss of watertight integrity of the forward three compartments on the port side. Being a catamaran, it was supported by the starboard hull, which remained intact 5. DEDICATION In memory of the 39 innocent passengers who were lost. 6, REFERENCES Hoemer SF: “Fluid Dynamic Drag’, Hoerner Fluid Dynamics, Bakersfield, USA, 1965 (first published 1957)Presented to the Western Ausirata Section, Roya Instition of Naval Architects, 24° June 2013, Pert, Australia APPENDICES: ‘Schematic Flow Chart of Excel Macro for calculation of inflow rate in discrete time steps for one hole. j a ea > Cecil whee al Stor What Frs | -waterine is below or above inlet ~ ~ ‘hole, and choose appropriate . a | ator hb [From ted at tle eae : |__nitte_ 4 > Gee How ve niaee we | JN THIS EXAMPLE THE INTERNAL arene s secon Te = mT Heae | caren 3 . Knowing vole rede tgkoom and ship tim, calcul |. am SBetnte netmapr wrote ‘omoaton tron [> Calculta wheter rieral ‘water ie blow or above let fle, end choose approenate ‘lw form aon > From Head at hole clot inlet rate Q > Ghee iow volume mies ‘perod (in Nits EXAMPLE THE INTERNAL WATERLINE 18 ABOVE THE IMETHOLE DO caf sere olen Knwng wume inside ardreom and ship tam, cleat | | ‘ LCG of watr ini ed crught of rier water sure sing karpolton fuer. SSMIULTANEOUSLY & SMULARLY [CALCULATE ALL FOUR OPENINGS « (See) =a Ete REPEAT u‘Presented tothe Western Australia Section, Royal nstinion of Naval Architects, 2#* ne 2015, Peri, Australia DURING SKETCHES SHOWING THE RELATIVE POSITIONS OF THE TWO CRAFT THE COLLISION. 2