UNIVERSITY OF HONG KONG LIBRARY

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2 UNIVERSITY OF HONG KONG LIBRARY

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4 S,S. SEA WISE UNIVERSITY QUESTIONS FOR THE COURT Q.I Who were the owners of "Seawise University' 9 on January, 9th 1972? A.I The Sea wise Foundation Limited an affiliate Company of Island Navigation Corporation Limited and one of the C. Y. TUNG group of companies. Q.2 How long had "Seawise University" been under these owners? A.2 Since her purchase by Mr. C. Y. TUNG in September Q.3 Was "Seawise University" a British ship on January, 9th 1972? A.3 Yes. QA When, where and by whom was "Seawise University" built? A A By Messrs. John Brown and Company Limited; Clydebank in g.5 On January, 9th 1972 was "Seawise University" undergoing renovations at anchor in Hong Kong harbour? A.5 Yes. Q.6 If the answer to the preceeding question is "yes", what was the nature of the renovations and to what ends were they being carried out? A The vessel was being extensively refitted for re-commissioning as a passenger carrying vessel. The work of renovation was very extensive and included the creation of vertical fire-proof zones and other changes in her fabric and equipment in order to qualify her as a passenger cruiser in the category plus A Q.I A.I If the answer to question 5 is "yes" who was in charge of the renovation work? The Island Navigation Corporation Limited. Q.% Who was in command of "Seawise University" on January 9th, 1972? A& Commodore CHEN Ching-yien. Q.9 What was the approximate number of crew on board "Seawise University" when fire broke out on January 9th, 1972? A3 Approximately 250. g.10 How many workmen were on board "Seawise University" when fire broke out on January, 9th 1972? ^4.10 Approximately 294. g.ll By whom were the workmen employed? A.ll 31 were employed by Island Navigation Company and 263 by Sub-Contractors. g.12 What were their working hours? A.12 In general the working hours were 8.00 a.m. to a.m. and 1.00 p.m. to 4.30 p.m. plus overtime which cannot be specified. <2,13 Where did the workmen normally take their midday meal?,4.13 Most of the I.N. Company's ordinary workmen went ashore for lunch. Sub-Contractors* workmen normally ate in the 1st Class Restaurant on C R' Deck but there may have been minor variations from these procedures. Q.14 How many visitors, if any, were on board "Seawise University" when fire broke out on January 9th, 1972? A.14 An accurate figure cannot be given. Visitors had begun to arrive apparently from 8.00 a.m. onwards and by lunch time there were about 60 visitors on board.

5 g.15 What gangway or gangways were provided for "Seawise University" on January 9th, 1972?.4.15 Gangways were provided at shell doors on C R 9 Deck Port and Starboard leading down to a pontoon upon both sides. Q.I 6 Were there any other means of entry and exit to and from the ship on January 9th, 1972 other than by gangway? A.16 There were six shell doors open on *C Deck which had rope ladders provided by way of emergency exit and another ten doors open on C C Deck with welding barges, garbage barges etc., afloat nearby. g.17 Was any guard provided in respect of any gangway or any other points of entry and exit on January 9th, 1972? A.ll Security Guards were posted at both the *R' Deck shell door gangways and one Security Guard was posted on 'C Deck at a shell door aft on the starboard side of the vessel, Q.18 What was the state of the weather in Hong Kong harbour at the place "Seawise University" was anchored on January 9th, 1972? A.I& It was a fine, cool, dry day. g.19 What was the direction and force of the wind in Hong Kong harbour at the place "Seawise University' 9 was anchored on January 9th, 1972? A19 The wind was blowing from the north west on the port bow at about 12 knots. The ship heading north What was the condition of the sea in Hong Kong harbour at the place "Seawise University" was anchored on January 9th, 1972?,4.20 The condition of the sea was slight to moderate. Q.21 Where there fire patrols and/or fire-fighting crews provided for "Seawise University" on January 9th, 1972? A.21 Yes. Q.22 If the answer to the preceeding question is "y es " what was the nature and strength of the fire patrols and/or fire fighting crews? Was the strength adequate for a ship the size of the "Seawise University"! A.22 There were four fire patrolmen aboard on the 9th January and four professional firemen formed the nucleus of the fire fighting crew. It is not considered that the strength of these two groups was adequate in view of the size of the ship and her location, but for comment and evaluation in general see the Annex to this Report Were the fire patrols trained and instructed on the course of action to take in the detection of a fire? A.23 Most of the members of the Fire Patrol which consisted of 12 men in three shifts of four had received some instructions in the action to be taken in detection of a fire and the action to be taken thereafter. Some of them in addition had received actual fire fighting training from the Fire Services at Sek Kong but some had only very recently been recruited and would have seemed to have received only the most general instruction and training over the period of a few days from the Fire Officer on board Were the fire patrols and fire-fighting crews familiar with the positions of the fire-fighting appliances and alarms? A.24 Yes As at January 9th, 1972 had the crew members of "Seawise University" been properly instructed as to what they should do in the event of an outbreak of fire on the ship? A.25 Up to the 23rd November, officers and ratings had attended the two-day fire-fighting course at Sek Kong. No more could be taken on for instruction thereafter up until the time of the fire. Apart from this there was a Fire and Emergency Station Bill In Port which laid down duties for officers and crew including firemen and fire patrolmen up to a number of 25. Duties were not nominated and there were obvious difficulties in the way of such nominations including the fact that recruiting was going on and of those members already recruited there would be a turn-over as a result of leave of absence. The only way, therefore, for each man to discover his precise duties at a time of fire would be to muster with the otheis at the appointed fire control centre so that the senior officer on duty could tell them of it and explain their duties to them. There is no evidence that this was done. A high proportion of the newly recruited crew were hotel staff most of whom had never been to sea and who knew little about the fire fighting equipment on board and topography of this very large and complicated ship. (See Annex for comments and criticism in relation to the question of musters and drills aboard generally).

6 g.26 With v-list: (a) Fire-fighting appliances; (b) fire alarms; (c) fire detector systems; (d) fire sprinkler systems was "Seawise University" provided on January 9th, 1972? A.26 (a) Fire appliances etc.,: The vessel had 367 hydrants with hoses and nozzles, 184 soda acid extinguishers, 90 C.O. 2 extinguishers, 59 foam extinguishers, 37 dry-powder extinguishers, and 480 sand-buckets with sand, distributed in accommodation and machinery spaces. In the forward Fire Station in 4 R' Deck at about 270 frame there were 8 sets of breathing apparatus and 5 spare cylinders, one smoke helmet with life-line and air hose, one suit of protective clothing, together with torches, spare hoses, spare nozzles, spare extinguishers, axes, crow-bars etc. The after Fire Station on 'C' Deck at about 85 frame contained spare sets of breathing apparatus, spare chemicals etc., but it was kept locked, the key being in the forward Fire Station. (b) The vessel had a manual alarm system throughout accommodation spaces which activated alarm bells at the forward Fire Station and in the engineroom, chartroom, and officers quarters on the Bridge. It also lit up red lights on panels on the Fire Station indicating the approximate location of the fire. This was in addition to the sprinkler system described in Section (d) hereunder. This alarm system was wired to the emergency power system as well as to the ship's mains. (c) A smoke detector and alarm system was fitted covering holds, baggage spaces etc., not likely to be visited during a voyage. The sprinkler system in (d) was also a detector system. (d) A Fire Sprinkler, Detector and Alarm System was fitted to cover all accommodation spaces, public rooms, galley areas etc. On the breaking of a sprinkler head by heat, an alarm bell would ring at the Fire Station, in the wheelhouse, and in the engineroom, a yellow light would show up on a panel at the Fire Station indicating the approximate position of the fire, and the sprinkler pump would start automatically and would continue to pump until it was shut off. The alarm system was wired to the emergency power system as well as to the ship's mains. Q21 Were these appliances and systems in full working order and fully operational on January 9th, 1972? If not, to what extent were they not in such order and operational on that date? A.21 As to (a), (b) and (d) above: They were in full working order and did operate on that date. As to (c): there is no evidence to show whether or not this system came into operation. Q.28 Was "Seawise University" provided with a public address system on January 9th, 1972? If so, was such a system in full working order? A28 A temporary public address system was installed and was operating on the 9th January, It ceased to function shortly after the first announcement was made. (See comments in the Annex hereafter). Q.29 Where and at what time were signs of fire on "Seawise University" on January 9th, 1972 first observed? A.29 At approximately a.m. on the S A' Deck alleyway on the port side of the ship between the Main Square and a cross alley at 110 frame. It is considered that this may not, however, have been the first fire to start upon the vessel. Q30 By whom was the observation made and what was the nature of the observation? A3Q The observation was made by three cabin boys who smelt and saw smoke in the main alley on *A* Deck at about half way between the main stair and 110 frame. On approaching the smoke they saw small flames on a pile of rubbish in this cross-alleyway near the open shell door at 110 frame. Q.31 What action was taken following the observation? A31 The same cabin boys then ran towards the main, stair raising the alarm by shouting "fire I" where they met the special lunch-time fire patrol who proceeded at once to the site of thefibrewith extinguishers. Q32 At what other places and times was fire observed to have broken out on "Seawise University" on January 9th, 1972? A32 At about the same time there were other reports to Commodore CHEN of fires on 'B' Deck and on the Sun Deck. Later, fires were observed, (a) on the Main Stair between 4 A> and 'B* Decks; (6) in the well of the inboard port lift on 'R' Deck; (c) in a central stairway aft at about 70 frame on 'D' Deck; (d) in a smaller stairway on the port side of 6 B* Deck aft at about 48 frame; (e) on C B' Deck central stairway

7 slightly aft of 110 frame. This was observed at about the same time as the original cross alley fire and was probably connected therewith; (/) in a central stairway far forward at about 255 frame between 6 R* and C B' Decks; (g) very dense smoke was observed in the wheelhouse and on the level of the Sun Deck indicating a possible site of fire somewhere in the officers' accommodation immediately adjacent and below. These separate sites of fire eventually combined in one conflagration covering the ship from stem to stern. Q.33 By whom were the observations made and what was the nature of them? A.33 The evidence does not show who first observed these other sites of fire. Various reports were made by unidentified crewmen resulting in the observation of flames and smoke referred to above by various persons many of whom have given evidence, and who took action as a result of the reports. Q.34 What action was taken following the observations? A.34 (a) C B' Deck Fires: The Commodore sent Chief Officer ZEE to search out the seat of the fire; (&) Sun Deck Fire: The Commodore sent Staff Captain Hsu to search out the seat of the fire. Attempts were made to fight the later fires observed at sites (a), (b), (<?), (d), (e) and (/) above in A.32, as and when they were observed. Q35 Was the assistance of the Hong Kong Fire Services Department called to "Seawise University" on January 9th, 1972? A.35 Yes. Q.36 If the answer to the preceeding question is "yes" at what time was the assistance of the Hong Kong Fire Services Department called and by what means? A.36 The assistance of the Fire Services was first enlisted by a call made by V.H.F. from a Police launch under the command of Police Inspector Ho Sze-min who recorded in his log time a.m. for his first sighting of the smoke and then sent a message to the Harbour Control at a.m. Fire Services records show that the Police message was received by the Fire Control Centre at a.m. (See Annex concerning attempts to make contact with Fire Services from the vessel herself) At what time were fireboats alongside "Seawise University" and ready for action? A p.m.; the first boat to arrive being fireboat No. 2 under the command of Divisional Officer LAM Lok-bun. The Alexander Grantham and' several other fireboats arrived not long after. g.38 At what time did fire-fighting operations by the Fire Services Department commence and what was the nature of such operations? A38 At about p.m. fireboat No. 2 was playing hoses about the superstructure on the port side of the "Seawise" and at about p.m. a Fire Services detachment of fire fighters went aboard. Thereafter the fire was tackled by the use of hoses and monitors both outside and inside the vessel and Fire Services personnel also took part in the search for survivors. The bulk of the fire fighting was from outside by the directing of jets of water on the superstructure What fire resisting bulkheads and/or fire-doors were fitted to "Seawise University" and were such doors open or closed at the time fire was discovered on January 9th, 1972? A.39 There were fire-resisting bulkheads fitted in such a manner as to divide the ship into eight main vertical zones. A large number of the fire-proof doors had already been fitted but there remained some still to be completed. Very few, if any, of these fire-proof doors were closed at the time of the fire. g.40 What type and system of electric wiring was installed on "Seawise University" as at January 9th, 1972 and was the installation satisfactory?.4.40 Normal marine cables suitable for D.C. supply at 225v. Considerable re-wiring had been done aboard the vessel and most of the wiring had been tested and found to be satisfactory. <2.41 Did any of the lights on "Seawise University" go out shortly after the discovery of fire on January 9th, 1972? If so, what is the explanation for the lights going out? ^4.41 Yes. The extent to which the ship's lights went out is not certainly established. The Hotel accommodation lighting was switched off on the order of the Chief Engineer shortly after the outbreak of fire, the purpose being to prevent further fires through shorting of electric cables. Q.42 Were any open fires, burning or welding operations known to exist on "Seawise University" on the forenoon of January 9th, 1972 prior to the outbreak of fire? ^4.42 Yes. Burning and welding operations were going on during the earlier part of the morning.

8 QA3 If the ansver to tae preceding question is "}es" what were they, where were they and what precautions were taken to safeguard such operations? A A3 On the morning of the fire there were said to be about 60 welders working aboard on funnels and various sites on C P', "M*, C A', 'B', 'R', 'C and T>' Decks., and many of them in machinery spaces principally working upon fire-proof doors and pipe-work. 19 fire-watchers were employed at vulnerable points. Q.44 What inflammable material was on board "Seawise University" on January 9th, 1972 and how and where was it stored? AM Apart from inflammable portions of the ship's own fabric, inflammable materials were stored at various points; (a) paint; (b) gas cylinders; (c) some carpeting stored in the area of the swimming pool (but said to have been damp on the morning in question). 200 recently cleaned old carpets were stored on 6 B' Deck on the port side in a doctor's room; (d) several hundred wooden deck chairs were stored on the Promenade Deck in the area of the covered promenade; (e) some mattresses and sheets of plywood were said to have been seen by one of the fire fighters on 'B' Deck in the course of the fire fighting operation. QA5 What amount of fuel oil was on board "Seawise University" on January 9th, 1972 and how was it distributed? ^4.45 3,070 tons of fuel oil were contained in the double-bottom tanks and in deep tanks in the way of the machinery spaces; there was one ton of diesel oil for the emergency generator aft on 'A' Deck in a permanent tank adjacent to the mooring winch and there was some oil in the ordinary engine room small tanks. QA6 What openings on the side of the "Seawise University" were open when fire broke out on January 9th, 1972? Why were they open? Were they or any of them subsequently closed? ^4.46 There were some 32 shell doors open in all and of these 16 were upon *C 5 Deck. Reasons were given for this unusual situation but the Court is not satisfied that it was necessary to have had so many doors open. (See comments in narrative and note in 'Evaluation' of events in the Annex to this Report). Only one of these doors was subsequently partially closed. QA7 What precautions were taken to control smoking by persons aboard "Seawise University"! AA1 'No Smoking' notices were posted at various places on the ship; Security Guards kept a check upon places where 'No Smoking* was supposed to be enforced and occasionally warned persons whom they found smoking there, one workman being actually discharged because of disobedience to this rule. About 400 sandbuckets were distributed at various places and workers were advised to use these for putting out cigarettes. There were also daily announcements on the Public Address System concerning the dangers of smoking. Q.48 At a certain stage of the fire fighting operations on January 9th, 1972 was it found necessary to stop putting water into "Seawise University" on account of the list? AAS Yes If the answer to the preceding question is "y es " 3 at what time was this and what was the angle of the list at that time?,4.49 At 3.28 p.m. at which time the vessel was listing between 12 to 15 to starboard. X50 Was any water subsequently directed on to "Seawise University"! If so, at what time, by what authority and for what reason? A50 At about 5.30 p.m., the list appearing to have slightly decreased, the playing of water from the monitors on the fireboats was resumed sporadically when opportunity afforded, at perceived sites of fire and in order to cool the hull and superstructure and this went on until about 8.00 p.m. Operations continued during the following two days on such parts of the vessel as were visible Did "Seawise University" eventually capsize or founder after fire broke out on January 9th, 1972? If so, when and what was the probable cause of the capsizing or foundering? A.51 Yes. At 12 noon on the 10th January the "Seawise University" capsized due to complete loss of stability as a result of the inflow of water through open shell doors Did the fire as it was at its peak commence with one outbreak or was there more than one outbreak, and if so were the outbreaks or any of them associated? A.52 The evidence suggests that there were at least three independent outbreaks of fire at roughly the same time: one on *A* or 4 B' Deck between frames 48 and 70 aft. One at 'A' Deck in the cross alley at frame 110 on the port side and one probably in the officers' accommodation at the fore-end of the Boat Deck. Later fires observed in the lift shaft on *R* Deck and on the Main Stair at 210 frame and at the forward central stairway at 255 frame might have been separate fires but there is no evidence to prove this conclusively and they may have been associated with the earlier fire on the upper levels.

9 Q.53 What was the cause or probable cause of the outbreak or outbreaks of fire on "Seawise University" observed on January 9th, 1972? A.53 While it cannot be categorically stated that the outbreaks referred to above could not have been accidental, the Court is of the view, having regard to the number and location of the outbreaks and the time of their occurence, that the probable cause of these outbreaks was, in each case, a deliberate act or deliberate acts on the part of a person or persons unknown. Q.54 At what time was "Seawise University" evacuated on January 9th, 1972? A.54 Evacuation of persons aboard commenced shortly after the outbreak of the fires. The vessel was finally evacuated at 3.27 p.m. on the 9th January Did any human injury or loss of human life result from the casualty on "Seawise Universitv" on January 9th, 1972? ^4.55 There was no loss of life and the only serious injuries occurring to anyone aboard the vessel as a result of the fire emergency were fractures of leg and ribs sustained by Mr. PING, a Company official, in making his escape through a porthole when he fell from the porthole onto a launch below. In addition there were numerous rope burns and minor injuries such as cuts to hands At what notice could "Seawise University" have been able to have her main propulsion machinery capable of effectively propelling her? A.56 There was evidence that two propellers could have been in operation within a period of six hours At what notice could the anchors have been weighed? A57 Immediately, so long as electric power aboard the vessel was available Was controlled beaching a feasible proposition after the outbreak of fire? A58 No. (See Note on Beaching in 'Evaluation' in the Annex to this Report). Q.59 If the answer to the preceding question is "yes", would beaching have permitted the fire fighting operations to continue? If so, would there have been any likelihood of fire being brought under control? A.59 Does not arise Was any advice tendered to the owners of "Seawise University" for providing against fire on the ship? A.6Q Yes If the answer to the preceding question is "yes", by whom was such advice tendered? A.61 By officers of the Marine Department in consultation with officers of the Fire Services Department Did any Government department have any statutory responsibilities in respect of "Seawise University"*! A.62 While the Director of Marine has various responsibilities in relation to the control of shipping and while powers are given to the Directors of the Fire Services and Labour Departments to control and abate industrial and fire hazards, the legislative position in relation to hazards arising from work being carried out aboard ships at anchor in the harbour is somewhat obscure and unsatisfactory. It is doubtful that any Government Department had unequivocal statutory powers to control the working methods employed in the operations going on aboard the "Seawise" at the date of the casualty. Within the context of the events leading to the casualty the Court is therefore of the opinion that this question should be answered in the negative. (This matter is discussed in the Annex) If the answer to the preceding question is "yes", what was the nature of such responsibilities and were they discharged? Does not arise in view of the answer to the previous question.

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12 LIST OF WITNESSES 1. Mr. T. Alexander Simpson 2. Mr. CHOU Chia-cheng 3. Mr. Philip Rizza 4. Mr. Norman Stevenson 5. Mr. John Dunbar 6. Commodore CHEN Ching-yien 7. Mr. WONG Chung-wing 8. Mr. PAU Wen-shang 9. Mr. SZE Chong-ping 10. Mr. William John Moir 11. Mr. LEE Kwok-kwong 12. Mr. WONG Pao-lung 13. Mr. Jim POON 14. Mr. LIN Hung-sun 15. Mr. TSIM Fook-shing 16. Mr. MAN Kwok-shui 17. Mr. POON Yat-lai 18. Mr. MOK Chi-kong 19. Mr, WONG Chi-kim 20. Mr. Ko Ngan-wan 21. Mr. KWONG Ving-kuen 22. Mr. Liu hen 23. Mr. ZEE Su-tang 24. Captain Hsu Pang-tsuey 25. Mr. CHAU sang 26. Mr. Ng din 27. Mr. Lui fai 28. Mr. CHANG Hui-chiu 29. Mr. CHENG huan 30. Mr. YEUNG Wai-hung 31. Mr. Cffl Chien-kwo 32. Mr. WONG Yuet-yan 33. Mr. TUAN Nu-ming 34. Mr. WONG Chi-yuen 35. Mr. CHEN Kuang-kwan 36. Mr. John Winther Jensen Senior Principal Surveyor of Lloyds Register of Shipping. Project Engineer of Island Navigation Corporation Limited. Senior Principal Surveyor of Lloyds. Senior Ship Surveyor of Lloyds. Senior Ship Surveyor of Lloyds. Commodore commanding s.s. Seawise University. Chief Engineer of s.s. Seamse University. Marine Superintendent of Island Navigation Corporation Limited. Carpenter working on s.s. Seamse University (transcript of evidence admitted by agreement). Investment Manager (eye-witness of fire). Supervisor of Far East Sea Training School (eye-witness of fire). Fire-fighting Officer of s.s. Seawise University. Room Division Manager of s.s. Seamse University. Cabin boy on s.s. Seawise University. Cabin boy on s.s. Seawise University. Carpenter working on s.s. Seawise University. Carpenter working on s.s. Seawise University. Carpenter working on s.s. Seawise University. Cabin boy on s.s. Seawise University. Fireman on s.s. Seawise University. Deck Cadet on s.s, Seawise University. Chief Officer on s.s. Seawise University. Chief Officer on s.s. Seawise University. Staff Captain of s.s. Seawise University. Fireman on s.s. Seawise University. Fireman on s.s. Seawise University. Foreman fireman on s.s. Seawise University. Fourth Engineer on s.s. Seawise University. Deck Engineer on s.s. Seawise University. Fire Patrolman on s.s. Seawise University. Sailor as fire patrolman on s.s. Seawise University. Fire Patrolman on s.s. Seawise University. Public Relations Officer on s.s. Seawise University. Fire Patrolman on s.s. Seawise University. Sailor on s.s. Seawise University. Representative of Manners Engineering Limited. 10

13 37. Mr. Po Sik-kuen 38. Mr. LEE Yung-hua 39. Mr. CHU Hai-chau 40. Mr. CHOW Ting-mo 41. Mr. CHAN Lung-cheung 42. Mr. TSE Shu-kwong 43. Mr. Liu Fuk-yue 44. Mr. YUNG Pak-lam 45. Mr. CHEN Wen-liang 46. Mr. SHEN Ti-sien 47. Mr. No Kwok-leung 48. Mr. LEUNG Woon-ngo 49. Mr. LAM Charn-woon 50. Mr. CHEUNG Shui-lau 51. Mr. CHOW Lin-chang 52. Mr. LEUNG Shui-hung 53. Mr. NG Ka-chuen 54. Professor SUNG howe 55. Mr. Yu Kwok-ming 56. Mr. Ho Hon-keung 57. Mr. CHEUNG King-sun 58. Captain FUNG Hon-lam 59. Mr. HSIA Yuen-sheng 60. Mr. Ho Shi-ming 61. Mr. Robert Houreau 62. Mr. CHEUK Man-ki 63. Mr. POON Man-fat 64. Mr. LEE Kun-kwong 65. Mr. WONG Kin-cheung 66. Mr. TUNG Wing-cheong 67. Mr. Abraham Razack 68. Mr. Leonard Worrallo 69. Mr. LEUNG Chun-ming 70. Mr. LAM Lok-bun 71. Mr. CHANfong 72. Mr. Jo Tai-chang 73. Mr. DOONG Hwa Electrician on s.s. Seawise University. Photo Supervisor on s.s. Seawise University. Cabin Supervisor on s.s. Seawise University. Sailor on s.s. Seawise University. Junior Engineer on s.s. Seawise University. Junior Port Engineer of Island Navigation Corporation Limited. Deck Cadet on s.s. Seawise University. Staff Chief Engineer on s.s. Seawise University. Port Engineer of Island Navigation Corporation Limited. Port Engineer of Island Navigation Corporation Limited. Security Guard, junior inspector on duty on s.s. Seawise University. Radio Technician working on s.s. Seawise University. Security Guard on duty on s.s. Seawise University. Security Guard on duty on s.s. Seawise University. Second Engineer on s.s. Seawise University. Port Engineer of Island Navigation Corporation Limited. Senior Supervisor of Security Guards on s.s. Seawise University. Decoration consultant of Island Navigation Corporation Limited. Engine-room apprentice on s.s. Seawise University. Electrician working on s.s. Seawise University. Bar head-waiter on s.s. Seawise University. In charge of crew quarters on s.s. Seawise University. Project Electrical Engineer of Island Navigation Corporation Limited. Police Inspector commanding Police Launch No. 10, Programme Officer on s.s. Seawise University. Police sergeant commanding Police Launch No. 5. * D.P.C attached to Police Launch No. 10. P.C attached to radio control room, Marine Police Headquarters. Fire Officer attached to fire control room of Fire Services Department. Senior Fireman attached to fire control room of Fire Services Department. Employee of Butterfield and Swire (H.K.) Limited. Assistant Chief Fire Officer, Hong Kong Island. Marine Assistant of Marine Department. Divisional Officer of the Fire Services Department. Assistant Divisional Officer, Fire Services Department. Acting Divisional Officer, Fire Services Department. Assistant Station Officer commanding fire-boat "Alexander Grantham". 11

14 74. Mr. Harold Leonard EJse-aorth 75. Mr. Herbert Thomas John Hutchins 76. Mr. Alfred Evelyn Harry Wood 77. Mr. Malcolm James Alexander 78. Mr. Derek Hall 79. Mr. Alan John Stockman Lack 80. Mr. Morris Leonard Labistour 81. Mr. Neville James Matthew 82. Mr. Johannes Garrit Pasteuning 83. Mr. TAM Shun-kwong 84. Mr. Stewart Reid Bridgeford 85. Mr. John LEE 86. Mr. CHOW Sun-ming 87. Mr. Kenneth Milburn 88. Mr. CHEUNG To-yun 89. Mr. Kenneth Alfred Billington 90. Mr. LIANG Ming-shing 91. Captain Yu Tse-chiang 92. Mr. WANG Chao-sing Senior Divisional Officer of Fire Services Department. Chief Fire Officer, Hong Kong Island. Director of Fire Services. Deputy Director of Marine Department Surveyor of Ships Marine Department. Principal Marine Officer. Marine Officer Marine Department. Senior Surveyor of Ships. Principal Surveyor of Bureau Veritas. Field Service Manager of Otis Lifts Limited. Marine Officer Marine Department. Manager of Passenger Department of Island Navigation Corporation Limited. Broadcasting Station Attendant on s.s. Seawise University. Former Director of Marine Department. Welder (statement admitted). Consultant Engineer to s.s. Seawise University (two statements admitted). Senior Executive Manager of Island Navigation Limited. Corporation Personnel Manager of Island Navigation Corporation Limited. Deck Cadet (statement admitted). 12

15 ANNEX TO THE REPORT In the matter of a Formal Investigation made by a Marine Court held at the Legislative Council Chamber on the 8th, 10th-28th (inclusive) (Mondays to Fridays only) of February, 1972, and in Room 150 on the 29th February to 30th March, 1972 (inclusive) (Mondays to Fridays only) and also on 4th April, 1972 in the Colony of Hong Kong before Mr. Justice A. M. McMullin assisted by Mr. John Robson, M.B.E., B.Sc., F.R.I.N.A., C.Eng. and Captain John d'oyly Green, RNR (Retired) to enquire into the casualty of the s.s. Seawise University which occurred on the 9th January, The Director of Marine was represented by Mr. H. J. Somerville, Crown Counsel; Mr. N. R. Macdougall, Senior Crown Counsel represented the interests of Government Departments on a 'watching brief 5 basis; Mr. R. F. Stone, Q.C., appeared on behalf of the owners of the "Seawise University" and was instructed by Messrs. Deacons, Solicitors and Notaries, Hong Kong and Messrs. Ince and Company, Lime Street, London. Mr. Stone was assisted by Mr. Charles Ching. 3. The "Seawise University" (formerly the "Queen Elizabeth") was a steel passenger vessel of 82,998 tons gross with registered dimensions as follows: Length feet, Breadth feet and Depth 74.5 feet. She was built in 1940 by John Brown and Company Limited, Clydeband, Scotland for the Cunard Steamship Company Limited and was acquired by the present owners, Seawise Foundation Limited, in September 1970 after she had been under American ownership in Miami, Florida for two years as a tourist attraction. 4. She was propelled by four sets of single reduction geared steam turbines developing a total of 200,000 horse-power, the steam being supplied by twelve boilers. There were six machinery compartments, two for the turbines and four for the boilers. The machinery was also supplied by John Brown and Company Limited. 5. The vessel had thirteen decks named, commencing at the top, Sports Deck, Sun Deck, Boat Deck, Promenade or T J Deck, Main Deck or *M? Deck, *A* Deck, <B' Deck, Restaurant or <R* Deck, 'C Deck, T>' Deck, C E' Deck, T' Deck and *G' Deck. 'A' Deck was the upper most continuous deck extending from stem to stern, C R' Deck the "bulkhead deck". *E' /F' and 4 G' Decks were partial decks at the ends of the vessel only. There were public rooms and cabins on all decks from the Sun Deck down to 'D 5 Deck and there was a gymnasium on *E* Deck aft. Below the accommodation there were holds, baggage rooms, storerooms etc., at the ends of the vessel, and deep tanks for oil fuel at the sides of the ship in the way of the machinery spaces. There was a doublebottom for fuel oil, water ballast and fresh water extending from the fore-peak bulkhead to the after-peak bulkhead. The vessel was transversely framed and the frames, numbered from aft, ran from 0 to 360. There were fifteen main transverse water-tight bulkheads extending to the underside of *R* Deck dividing the ship into the holds, baggage spaces, stores, machinery spaces etc., mentioned above. Water-tight doors were fitted in the bulkheads dividing the compartments of the machinery spaces and in addition there were twenty-one water-tight doors in the bulkheads dividing up the passenger accommodation on 6 C Deck. All of these doors were open at the time of the fire. 6. Above 'R' Deck, the ship was divided into 8 Main Vertical Zones by fireproof bulkheads, each being generally in line with a watertight bulkhead below. Where the fireproof bulkhead was not in line, the joining deck was insulated to preserve the integrity of the zone. The main and auxiliary stairways were contained in fireproof enclosures, and the wood treads and risers of the stairs were protected by steel and insulation. There were to be 251 fireproof doors in the bulkheads and stairway enclosures, and of these 175 were actually fitted and the rest were in the process of being fitted. Very few, if any, of the doors were closed at the time of the fire. Any ventilation ducts passing through fireproof bulkheads had dampers fitted, but these were all open. 7. There were four main stairways on the ship. (a) The forward main stairway at about 255 frame extended from 'R' Deck to Sun Deck and went round a liftshaft (b) The midships main stairway at about 210 frame was a double stairway going from 'R' Deck to T' Deck. The lobbies served by this stairway were the main Entrance Squares and extended virtually from side to side of the ship on S R', *B' and 'A' Decks. There were four liftshafts at the after-end of the square within the fireproof enclosure, three of these lifts travelling to the Sun Deck and one to the Sports Deck, The Main (1st Class) Restaurant opened off the after-end of the Main Square on *R* Deck. (c) The after main stairway was at about 105 frame and extended from 'B' Deck to *P* Deck. It was between two liftshafts, one of which went from 6 B' Deck to *P' Deck and the other from *B* Deck to Sun Deck. (d) The fourth and aftermost main stairway was at about 65 frame and extended from *E* Deck to *P Deck. This stairway encircled two liftshafts. 13

16 8. In addition to these main stair\va>s there were many minor stairways also in fireproof enclosures, and of these the one at about 48 frame on the portside was the scene of one of the fires which were fought by members of the ship's crew. 9. There was an open-air swimming pool on T* Deck aft, and a swimming pool and thermal baths on C C Deck amidships. In addition to three large restaurants there were lounges, smoking rooms, drawing rooms, shops, offices, bars, libraries and enclosed promenades, as well as a theatre and a cinema. 10. This description of the ship and the recital of the layout give only a hint of its vastness and intricate arrangement, facts of the greatest significance in any assessment of the risks of harm to men and materials, the measures taken to avoid or combat those risks, and the difficulty of organising and controlling the many different, and sometimes opposing, interests of those on board. Also the position of this ship was wholly different from that of a ship in commission, so that Commodore CHEN, who as Master was charged with, and accepted, the conduct of affairs, found himself in a post quite different from that of a Master on his own Bridge at sea. The "Seawise" Project 11. The idea of a floating university was first mooted in a speech by the Secretary-General of the United Nations, the underlying purpose being to provide an environment in which students of many races might mingle in conditions which, it was hoped, would be especially conducive to the promotion of mutual dependence and co-operation. 12. Mr. C. Y. TUNG is a Hong Kong businessman controlling a group of associated companies which includes the Island Navigation Corporation Limited, a Company operating about 4 million tons of cargo and passenger ships trading all over the world, and owning a repair and maintenance yard at Lai Chi Kok. He believed that such a scheme was practicable and decided to embark on it on the grandest possible scale. He decided that the "Queen Elizabeth'" was the ship he wanted, but he was unsuccessful in his first effort to acquire her, and she became a tourist attraction in Miami, Florida. He was able to buy her in September 1970, but by then she was in a very neglected and run-down state, no appreciable maintenance work having been done on her in the meantime, Mr. TUNG set up "Seawise Foundation Limited" to operate the ship as "Seawise University". The Foundation is an affiliate company of the Island Navigation Corporation Limited and the "Seawise University" the Foundation's sole asset, was to be fitted out and operated by the Corporation as agents of the Foundation. We will refer to the Corporation hereafter as I.N.C. or the I.N. Company. 13. It was decided that the work of reclamation and conversion would be done in Hong Kong by his own repair organisation, so that the only work that had to be done in Florida was the minimum work needed for a single voyage to Hong Kong. A team consisting principally of I.N.C. engineers and workers was flown to Florida and set about this work. Six of her twelve boilers were re-activated and other work was done to her hull and machinery, and the necessary Classification and Safety Certificates were obtained to allow her to sail as a Cargo ship. (See (a) to (e) at Appendix A.I). 14. On the 10th February, 1971 she sailed from Port Everglades under the flag of the Bahamas and bearing her new name, itself an ingenious tribute to the ship's triumphant past, her new career and her owner's contribution to them both. For convenience she will be referred to hereafter simply as the "Seawise". Voyage Port Everglades/Hong Kong 15. The ship sailed under the command of Commodore HSUAN and she carried a number of technical advisers engaged for this preliminary run by the I.N. Company. These included a former Master from her Cunard days, Commodore Marr, and a Mr. Billington, an engineer who had been a deck engineer employed by Cunard on the vessel's last voyage to Southampton on the 21st October, There was also a retired Captain of the New York Fire Brigade, a Mr. George Vollmer, who was to advise on fire control and to train members of the crew in matters pertaining to the prevention and fighting of fires at sea. 16. The early part of the voyage was inauspicious. In the first few days number 4 boiler went out of cornmission and there was an air race fire in number 4 boiler-room which necessitated her being towed to Aruba. There she remained for three months during which time repairs were effected and other renovations progressed. Meanwhile the Lloyds surveyors, who were also advising on the project at large, had prepared a memorendum describing in detail the work which must be done to bring the ship up to the standards of safety required by international convention for a vessel of her age if she was to be certified fit for the carriage of passengers. (See Appendix A.2). 17. On her arrival in Hong Kong she was given a tumultuous and triumphal welcome as she came slowly up the East Lamma Channel. A flotilla of small craft had gone out to meet her, and among them were vessels of the Marine and Fire Services Departments which escorted her to her allotted berth. Because it was the typhoon 14

17 season, this was an anchor berth to the north of Kau Yi Chau Island. Later the vessel moved to the south west corner of the western quarantine anchorage. There she was moored with two anchors forward (centre anchor six shackles in the water and starboard anchor four shackles in the water) and with two wires from the stern to a buoy (starboard wire seven inches circumference and port wire eight inches). This berth was approximately half a nautical mile from the oil installations on the eastern side of Tsing Yi Island; one mile from Kwai Chung container berth and two miles north of Green Island explosives depot. It was also the closest berth to the Island Navigation Company's dockyard which could be allocated having regard to the deep draught of the ship. The distance from the main I.N.C. office and also from the Central Government Pier was about three nautical miles. Work Entailed in the Project 18. The work entailed in the project was three-fold: Firstly, to effect such repairs and renewals to the structure, the fittings, the machinery and the electrical and other equipment, as would restore the ship to Lloyds highest class +100 Al and would entitle her to a Class 1 Passenger Certificate. Secondly, to make such alterations and additions as were necessary to comply with *S.O.L.A.S as modified by fl.m.c.o. 1966, and any additional requirements to allow of an increase in load draught of 7-J- inches. In this the owners were advised by Lloyds who drew up the requirements in conjunction with the U.S. Coastguard. Thirdly^ to renovate and restore the passenger and crew accommodation, public rooms etc., to the standards required for the contemplated service. The total number to be carried in the new service was to be 2,700 made up of 900 students, 900 passengers and 900 crew compared with the total of 3,653 carried when the ship was in Cunard service. 19. In the first category the two large items were the restoration of the six boilers which had been completely out of commission, and a considerable amount of rewiring throughout the ship. The work on five of the six boilers was completed and the sixth was to be attended to in Japan when the vessel went there for dry docking sometime after her sea trials in January. The work on the electric wiring was virtually completed at the time of the fire. 20. In the second category the principal items were: Life-Saving Appliances: Provision of search-lights in some boats; charging facilities for batteries; protection covers; illuminated exit signs in passenger accommodation; and the provision of a Public Address System. This work was substantially completed except that the permanent Public Address System was not yet connected up. Fire Protection Structural Items: A number of additional fireproof bulkheads, additional insulation on existing fireproof bulkheads, stairways, lift trunks, escape trunks and shell doors; steel and insulation protection to the wood treads and risers of stairways in fireproof enclosures; some existing wood doors to be replaced by steel doors; existing fireproof doors to be replaced by doors of an approved type; draught stops to be fitted in air spaces behind linings of ceilings etc. The work in this section was substantially completed, except that 76 fireproof doors were still in process of being fitted. Ventilation: Intakes around funnels and smaller openings to fan rooms were to be fitted with steel shutters; fan and vent rooms to have steel doors; the ventilation of control stations to be independent of accommodation areas; dampers to be fitted in ventilation trunking where it passes through fireproof bulkheads. This work was substantially completed and only some testing remained to be done. The accommodation ventilation system was not in operation at the time of the fire. Sprinkler System: The system to be extended to cover all galley areas, library, writing rooms etc. This work was completed and the system was fully operative at the time of the fire. Fire Fighting System: Remote starts to be fitted to some pumps; additional hydrants to be fitted. This work was completed. Oil Fuel Systems: All oil fuel pumps to be made capable of being stopped from the deck. This work was completed. Damage Control Items: Water-tight bulkhead No. 149 to be extended to the underside of C R* Deck; some solid ballast to be fitted; all portholes between C and *D' Decks to be made permanently non-openable; automatic cross-levelling pipes to be fitted to oil fuel deep tanks. This work was substantially completed except for three portholes which remained to be done, and some of the solid ballast remained to be fitted. Water-tight Doors: The sliding water-tight doors were to be modified to have all-round crank motion handoperated on the opposite side to the existing spanner and ratchet mechanism. This work was completed. * S.O.L.A.S.: Safety of Life at Sea Convention, t LM.C.O. : Inter-Governmental/Maritime Consultative Organization. 15

18 Emergence Generator- The existing two 75 KW generators to be replaced by one 350 KW generator. This \\ork was not completed in that at the time of the fire the new generator was not connected into the electrical system. At the time of the fire, therefore, the only emergency source of power was the batteries, which could only ha\e been of very limited assistance for a very short time. In the event this did not matter, as the main generators \\ere kept running for as long as they were required. 21. In the third category, all the passenger and crew accommodation and public rooms had to be renovated, which entailed the stripping down of much accommodation and the cleaning and repairing of old material and the replacement of many items by new material; also the redecoration and repainting of all spaces. At the time of the fire this work was well advanced particularly in the public rooms in the superstructure, but there was still work being done in the fitting of beds, laying of carpets, and painting. Work was also going on in the officers accommodation, and officers cabins were being used merely as changing rooms until the plumbing and ventilation work was finished. The work of up-grading the vessel and her appointments to the high standard of S.O.L.A.S. LM.C.O. was thus nearing completion. When completed she would have conformed so far as her fabric and equipment were concerned to a much higher standard of fire safety than at any time during her previous twenty-eight years at sea. Organisation and Methods Of Work In Carrying Out The Project 22. The Marine and Fire Services Departments had been in consultation as both were early alert to the potential hazards of the operation and especially to the risk of fire. Meetings had been held with officials of I.N.C. at which fire precautions were discussed and the decision was taken to invite the Fire Services Department to carry out an inspection of the ship on her arrival. A party of Marine and Fire Service personnel went on board "Seawise" on 15th. July, 1971, the day of her arrival and did what was only a superficial inspection. However, a list of criticisms and recommendations was drawn up and passed to I.N.C., and most of the recommendations were included in the organisation and methods of work decided upon, although, as will be discussed later, some important recommendations were not acted upon. The Marine Department also drew up a "Contingency Plan" (Appendix A.3) which included the "Operational Orders" of the Fire Services Department in the event of an emergency. This was also given to I.N.C. 23. The work of the project was undertaken by the Repair Division of I.N.C. assisted by 29 sub-contractors for Radio Equipment, Electrical Repairs and New Installations, Lift Repairs, Telephone System, Public Address System, Carpenters work in cabins, Decorations, Curtains, Carpets and other deck coverings, Bedding, Hull Painting, Cleaning, Refuse Removal, Firewatching, Cargo Gear Survey and other items. The Repair Division set up a Project Engineering Team which co-ordinated their own work and that of the sub-contractors and kept a close watch on progress. (Appendix A.4). 24. Regular twice weekly progress meetings were held on board, chaired by the Master, Commodore CHEN Chia-yien, the designated Master of the vessel who had assumed command on the 15th November, In the later stages meetings were also held on board on Sundays. 25. Up to the end of December, 1971, power for all activities except welding was supplied by the temporary 350 KW generator which had been put on the after-end of 'A* Deck for the voyage from the U.S.A. to Hong Kong. From the beginning of 1972 this duty was taken over by one of the ship's own 1100 KW steam-turbo generators and the temporary generator was kept as a stand-by. The surplus fuel for this temporary generator which had been kept in drums in the open deck aft was removed ashore, leaving one ton of fuel in the tank at the after-end of the deckhouse for the use of the new emergency generator when it was in operation. 26. Power for welding was supplied by a 400 KW generator on a barge moored to the ship, the cables passing up through a porthole and wires were led overhead along main alleyways to working places as required. Gas for burning and oxy-acetylene welding was kept in bottles in two storerooms, one on 6 C Deck aft near a shell door and the other on the open deck of the Sun Deck starboard side. The bottles were distributed each day to the work sites and empty bottles were returned when the new bottles were needed. Empty bottles were sent ashore and fresh bottles brought on board daily to suit the demand. At the time of the fire there were seven full bottles of gas and twenty full bottles of oxygen in the *C Deck store and a few bottles distributed around the ship. On the morning of the fire there were about sixty welders working on board on the funnels, on various sites on T* *M' 6 A' *B* C R* *C* and *D' Decks and in the machinery spaces, principally on the fireproof doors and pipe work and nineteen firewatchers were employed at the sites as necessary. The foremen in charge of the welders were regular I.N.C. employees but the welders themselves were hired on a daily basis. We were told that it was impossible to trace any of the welders who had actually been working upon the ship on Sunday, 9th January but a statement was put in which had been made by Mr. CHEUNG To-yun (witness 88), a welding supervisor, and we are satisfied that this has given a generally accurate account of the numbers involved and the areas in which such work was proceeding. (See Appendix A.5). 16

19 27. Much of the other material for the project was kept on board because of the shortage of storage space ashore, but by the time of the casualty most of the material was in its proper place on the ship. Paints were brought on board in relatively small amounts and stored in the paint store on S B 5 Deck forward from wiiich only day-to-day quantities were issued and a careful check was kept. 28. Rubbish from the ship was removed daily by garbage barges, and in the later stages of the project a twice daily removal was made. 29. To assist the project the I.N. Company installed a temporary Public Address System which covered both the accommodation and the machinery spaces. The microphone was in an office adjacent to the "Project Office" on 4 M' Deck aft, starboard side, in the Sheltered Promenade. For general communication around the ship a temporary telephone system was installed with the switchboard in the public address office and there were twenty lines from various strategic posts in the ship. These included one from the Fire Station on 'R 5 Deck forward and one outside the Deck Officer's Office on 'A' Deck main square, which, in the event of an emergency would be set up as the "Fire Control Centre". Three harbour telephones for communicating with the shore were installed, one in the "Project Office" on C M 5 Deck, one in the Deck Officer's Office on S A' Deck and one in the Main Entrance on *R' Deck. The P.A. office was also in Radio-Telephone contact with I.N. Company's shore office. The temporary P.A. system and the phones in the Fire Station and 'A' Deck Office were manned 24 hours a day, and both systems were also wired to the ship's emergency circuit using the batteries. 30. The work force consisted of engineers, technicians and workmen directly employed by the I.N. Company together with the 29 sub-contractors and their workmen employed for special jobs. Appendix A.6 gives the details of these latter, though not all of them were still employed aboard at the time of the fire. 31. The workmen, who at times might number as many as 2,000, were conveyed to and from the ship by a variety of ferries, and access to the ship was by gangways port and starboard up to 'R' Deck, Main Square amidships from pontoons moored to the ship. 32. In general, the hours of work were from 8.00 a.m. to a.m. and from 1.30 p.m. to 4.30 p.m., seven days a week, with overtime worked as necessary to keep the various parts of the project in step. It was the practice of the welders to knock off morning work at about a.m. and then to check-in at their temporary office on the Main Deck where Mr. CHEUNG To-yun would check them before they went ashore for lunch in one of the company's launches. They would return about p.m. and recommence work at about 1.00 p.m. There were also crew members working on board, some of whom lived on board, although the majority lived ashore. 33. Most of the I.N. Company's own employees went ashore for lunch on launches provided by the company leaving the ship at about a.m. and returning about 1.15 p.m. The crew members ate on board, the men at a.m. and the officers at a.m. Most of the sub-contractors' men ate on board, their times of starting the meal varying from a.m. to 12 noon. The places of eating on board were the 1st Class Restaurant which opened off the after end of 'R' Deck Main Entrance Square, and the adjoining kitchen. Some few workers might bring their own lunch and eat it in one of the cabins. The meal took about fifteen minutes to eat, thereafter the men stayed in the Restaurant or went to some of the cabins elsewhere in the ship to play games or to rest. 34. The vessel was patrolled regularly by fire patrolmen, who were crew members; firemen who were employed by I.N. Company; and security guards who were provided by a sub-contractor. The fire patrolmen were young men without sea-going experience but who were, nevertheless, fit and active and who had, according to the Commodore, a high potential for learning. They had been selected from numerous applicants and had some elementary training on the subject of fires either from a two-day course at a fire school ashore or from the Fire Officer on board. About a hundred of the crew had also attended this two-day course and it was intended that others would attend when the Fire Services School could take them. The Fire Officer was a Mr. WONG Pao-lung (Witness 12) who had been a specialist officer in fire-fighting and damage control in the Taiwanese Navy. The other firemen had been recruited from active or retired members of the Hong Kong Fire Services. The Security Guards' main duties were to check by numbers the comings and goings of crew, workmen and visitors at the main gangways on 6 R' Deck and to mount guard over valuable material and over places where there was a special fire risk. A system of different kinds of passes for workmen, visitors, etc., was in force. Although it was a specific provision in their Standing Orders (see paragraph 7 of Section P on page 3 of Appendix A.7), that no part of the ship should remain unvisited for more than two hours, it is clear that patrolling was a minor consideration throughout their employment on the "Seawise" and was done only to the extent that men were available when they had covered their other duties. They had had no training in fire prevention or fire fighting and in an emergency their main duty would be to assist in the evacuation of workers etc., from the ship. 35. The number of patrolmen at the time of the fire was 12, divided into three shifts of four men, the times of the shifts being 8.00 a.m. to 4.00 p.m., 4.00 p.m. to midnight and midnight to 8.00 a.m. The patrolmen lived on board but were allowed to go ashore when not on duty. The ship was divided into four patrol routes, the same 17

20 routes as those \\hich had been In use by the Cunard Company in former days. These routes covered the accommodation spaces from the Sports Deck down to T' Deck except for the Public Rooms on the Boat Deck and the crew accommodation on *B' Deck forward. There were clocks on those routes but these were only used by the night patrol. Each patrol route took about forty minutes to traverse. The patrolmen set off on their rounds every hour on the hour, one man to each route, starting and finishing at the Fire Station on 'R' Deck forward, about 200 feet forward of the Main Square. The patrolmen rested the last twenty minutes of each hour in their cabins near the Fire Station. There was an exception to the "on the hour" procedure. At a.m. the Patrolmen went to the Restaurant for their meal and were supposed to start their new patrol at about a.m. so as to complete it at about a.m. and then start the "on the hour" patrol at 12 noon. The evidence of the Patrolmen who were on duty on the morning of the 9th January and who gave evidence to the Court showed that this procedure was not followed as they were both at the Fire Station, having just returned from the Restaurant, when they heard the Public Address announcement of the fire, which was about a.m. 36. Special three-man patrols consisting of the Fire Officer, a Cadet and a Fireman were held at 9.00 a.m.., 1 LOO a.m., 1.00 p.m. and 5.00 p.m. Those at 9.00 a.m. and 1.00 p.m. were to look for places where "hot-work" was to be carried out or places where specially inflammable material was stored to ensure that Firewatchers or Security Guards were posted. The special patrols at a.m. and 5.00 p.m. were to see that nothing hazardous had been left behind when the workers stopped for lunch or for the day. A fifth special patrol was made jointly by the Fire Fighting Officer, Firemen and Security Guards on duty at 7.00 p.m. when overtime ceased and all workmen had gone ashore. These special patrols would take about 30 minutes. 37. On the 9th January, the a.m. special patrol took place at a.m. because special visitors were expected, and the route was confined to the superstructure decks and included the places that were to be shown to the guests. It took longer than usual and was not quite completed when the patrol met the Cabin Boys on 'A' Deck alleyway who were giving the first alarm of the fire at about a.m. 38. There were twelve professional firemen employed, divided into three groups of four men, and each group did twenty-four hours on duty and forty-eight hours off, their hour of starting duty being a.m. During their time on duty, one man occupied the Fire Station while the other three patrolled the ship seeing that the fire equipment was in place and in order, or took part in one of the special patrols, or rested in their quarters near the Fire Station. Three of them went to the main Restaurant for lunch at a.m. and then relieved the one who had been left to man the Fire Station. From the evidence it seems probable that the Fire Station was not manned at the time the first alarm was raised, and the evidence shows that it was not manned for about 20 minutes after the Public Address announcement of the fire, apart from those members of the crew and others who went to the Fire Station for extinguishers and breathing apparatus during that time. 39. The Security Guard duty was done by twelve men on each shift, two shifts a day, and consisted in the Entrance duties and Static duties mentioned above plus patrolling when other duties permitted. On the morning of the 9th January, two of the men were on Entrance duty, two were checking passes on the ferry boat nearby, one was in the Security Guards' headquarters office in *R* Deck Main Square, four were on static duty, leaving only three for patrolling. The Security Guards had no specific time for taking lunch and took it in turns, making sure that Entrance duty and Static duty posts were continually manned. 40. Should a fire break out, warning would be given in the Fire Station by an alarm bell and by the lighting of the panel showing the approximate location of the fire. The Fireman on duty in the Fire Station would immediately phone the Public Address Office and tell them to announce the outbreak of the fire and its location. He would then send fire-fighting appliances and gear to the scene of the fire. The Duty Officer of the day would hear the announcement and would set up a Fire Control Centre in the Deck Officer's Office on 'AJ Deck square. He would be kept advised of the progress of the fire by telephone or by messengers, and would take appropriate action. Should a more senior officer than the Duty Officer be on board, he would take command, and whichever officer was in command would decide if and when shore assistance should be called for. The Qfficer-in-Charge at the scene of the fire would decide whether shell doors, water-tight doors, or fireproof doors in the "vicinity should be closed, bearing in mind the need to maintain escape routes for workmen on board and for those dealing with the fire. The Fire Outbreak: Narrative of Events and Outcome 41. Few witnesses looked at their watches at any time during the emergency, and very few observed times, The times logged by the Fire Services, Marine Department, and the Police, and the times of some of the photographs, have been used as anchor points. Witnesses' estimates of times given in their evidence have been checked against actions taken, distances covered etc., and corrected as necessary to give a reasonable correspondence with each other. In some cases witnesses' recollections were, or appeared to be, out of sequence, and this has also been taken into account. The times given in the narrative therefore, while being only tentative, are believed to correspond reasonably with the facts. 18

21 42. Sunday the 9th January., 1972 was a fine sunny day, cool and dry. There had been no rain for some weeks. The sea in the vicinity of the "Seawise" was moderate and the wind was north-westerly at about 12 knots, on the port bow at a slight angle. Thirty-two shell doors in all were open on 'A', 4 B', 4 R' and *C Decks, sixteen of them being on 4 C' Deck. There were also many portholes open. Security Guards were in position as usual at the'r' Deck Main Square shell doors. A small number of officers and crew were living aboard and in addition there were on board the regular shifts of fire-fighters, fire patrolmen, and Security Guards, but from 8.00 a.m. onwards on that morning numbers of people began to arrive in the usual way on Company launches and other craft. These included workers of various kinds and there were also several officers, and many deck crew, hotel staff, engineers etc., who were to be the vessel's duty complement for the day. There was evidence that although the principal visitors were not expected until later in the day, some guests had akeady begun to arrive about 8.00 a.m. 43. The work on board the vessel was very far advanced and the workers involved at this stage appear to have been mainly carpenters, electricians, decorators and the like. There was, however, some hot-work still going on at various points in the ship and we have been told that there were about sixty welders still carrying out operations of this nature. There is no evidence to show that any of this "hot-work" was taking place in any area associated with any of the fire outbreaks. (See Note in relation to this matter in "Evaluation" below). 44. The first sea trials were to take place a week later and numbers of visitors and sight-seers were expected aboard by the afternoon. A large, formal lunch party for official guests was projected and there was evidently considerable activity going on throughout the morning to see that the upper decks and main accommodation spaces were clean and tidy. Decks were being swept and scrubbed and polished and in the "Peacock" Lounge, the First Class Lounge on the Promenade Deck, where the lunch party was to take place, the head waiter, Mr. CHEUNG King-sun (Witness 57) was, from 10 o'clock onwards, organising the decoration of the tables with a number of his staff in attendance. 45. Whatever may have been the position in the previous weeks, the Court is satisfied that on the 9th January these upper decks and accommodation spaces were clean and largely free of major obstructions. Later in that day one of the Fire Services firemen, (Witness 72), Mr. Jo Tai-chang, was to see a quantity of mattresses and plywood sheets stacked along the starboard alley on 'B' Deck, and a quantity of what he described as one-gallon paint drums stacked up about five deep on an open area at the bottom of the forward stairway at 'R' Deck level about 255 frame, a point to which, by then, the fire had penetrated from above. This witness said that the foreman of the Fire Duty Party aboard that day (Mr. Liu fai), had told him that these tins contained paint. Mr. Lui fai,, himself, did not mention this and Chief Officer ZEE when recalled denied that this could have been paint and reaffirmed that all the paint aboard the ship was stored in the forward paint locker. He produced documentary evidence to show that the paint, which had been delivered in recent weeks, had never been delivered in drums of this description. We accept his evidence on this matter. The matter remains unexplained, but Fireman Jo's observations of the drums, together with the mattresses and plywood, was made at a very late stage in the course of the fire fighting operation and it is clear that none of these obstructions can have been even a contributory factor in the outbreak of fire in any area. 46. About a.m. the Commodore arrived aboard and after a routine visit to his office on *A 5 Deck he went on a tour of inspection from 'P' Deck up to the Bridge where he spent a few moments with some colleagues and returned then to the Restaurant on *R' Deck where one of the regular Sunday meetings was to be held. Other persons taking part in this meeting were Mr. W. S. PAU, the Marine Superintendent of the LN. Company, Staff Captain Hsu, who was the senior officer, next to the Commodore, aboard the ship; Mr. John LEE the Manager of the passenger department of the "Seawfse" and certain sub-contractors as well. The Restaurant was fairly crowded at this time with contractors' workmen and others taking their lunch. A number of engineers out of the twenty or so aboard were on duty in the engine rooms. Chief Officer ZEE was Duty Officer of the day and was in the vicinity of the Deck Officers office on 'A' Deck. Chief Officer Liu hen, although not on duty that day, was in that office doing work associated with the expected arrival of the visitors later. 47. Fire was first discovered by three cabin boys who, under the direction of Mr. Jim POON, the Rooms Division Manager, had been sweeping up rubbish on C M' Deck for disposal at one of the recognised rubbish collection points where it was later to be chuted to a collection barge below. These boys, Mr, LIN Hung-sun (Witness 14), Mr. TSIM Fook-shing (Witness 15), and Mr. WONG Chi-kia (Witness 19) had already carried a quantity of sweepings waste paper, carpet scrap, bits of electric wiring and the like in a box from *M* Deck to the disposal point in a cross alley adjacent to an open shell door on the port side of *B* Deck at 110 frame, the time being about a.m. They left that box there near a pile of rubbish which, so far as the rather vague description of it goes would have been twenty or thirty inches high and covering about one half the width of the six foot wide passage-way over an area a few feet in diameter. They then took a smaller box for convenience and, having filled it on *M* Deck with similar waste material, returned to dispose of it in the same way at the same shell door. On their way aft along the alleyway towards the disposal point they saw smoke in the area of the rubbish pile which they had 19

22 previously left and, having dropped the box tiiey were carrying, they hurried to look. They saw what they described as very small Sanies burning on this pile of rubbish, the flames being only a few inches high and covering a small area only of the rubbish pile. They did not try to extinguish this fire and this ^as perhaps unfortunate because a fairly lively draught was sweeping in through the open shell door. Instead, they turned and ran forward, about 100 yards along the alleyway shouting "fire!" and met the special fire patrol party under the ship's fire officer, Mr. WONG Pao-lung, which was just completing its special lunch-time patrol and had almost reached the main square on 'A' Deck with fireman Ko Ngan-wan, one of the four regular duty firemen for the day, in the lead. The cabin boys were unable to give an accurate estimate of the time of sighting the fire but it would seem to have been in the region of a.m. to a.m. Messrs. WONG and Ko ran at once towards the fire and the third member of the party, Deck Cadet KWONG Ving-kuen, was told by Mr. WONG to report to the Duty Officer. Mr. KWONG went across to the Deck Officer's office about twenty yards away repeating the shout of "fire!", Chief Officer Liu hen came out of the office and ordered Cadet KWONG to phone the Public Address Centre and to order the man in charge there to make an announcement about the fire. Chief Officer Liu himself meanwhile went to look along the port alleyway to see what was happening. Cadet KWONG was unable to get through to the Public Address Centre as the line appeared to be engaged. He called out to Chief Officer Liu who was standing at the entrance to the port alleyway and informed him of this fact. The Chief Officer then returned to the office where he met Chief Officer ZEE Su-tang, who had just returned from a tour of inspection of the prospective visitors' route in the course of which he had traversed various decks up to the Main Deck and the Sports Deck. Seeing that the Duty Officer of the day was then present, Chief Officer Liu went at once himself to the Public Address Centre on 'M' Deck and, without waiting to inform any of the persons there of what had happened or to enlist their aid, he sent out an urgent call saying that fire had broken out aft on e A' Deck. Secondly, he called on all firemen and fire patrolmen to go to the scene of the fire, and thirdly he called on the engineroom staff to see to the fire pumps and if necessary to increase the pressure. He believes that he made one further announcement but the substance of it he has since forgotten. 48. The Court is satisfied that this announcement, which was made in Mandarin, was heard by the majority of persons who were in any position to hear any of the ship's many loud speakers. This announcement was repeated in Cantonese shortly afterwards by a Mr. WONG, one of the several radio technicians employed by the Company which had installed the temporary Public Address System, and who, with his companions, was returning to their Company's headquarters far aft on the Main Deck when they heard the first announcement in Mandarin. Neither in Mandarin nor in Cantonese was any general call made to the crew to muster at the 'A' Deck office as Standing and Fire Orders for the ship provided. 49. After making his announcement Chief Officer Liu at once left the Public Address Centre. He does not appear to have seen the radio technician who came and repeated his announcement in Cantonese and it was his evidence that, in fact, he left another Deck Cadet, by name, WONG to stay in the Public Address Centre to make further announcements. Very shortly after the announcement was made in Cantonese, the Public Address System went dead, and Cadet WONG reported to Chief Officer ZEE at the *A* Deck office and was sent by him to gather the lifeboatmen and make arrangements to lower the lifeboats. 50. Meanwhile Deck Cadet KWONG was told by Chief Officer ZEE to phone the shore Fire Services while Chief Officer ZEE went to the site of the fire at 110 frame. Mr. KWONG dialled 999 but was unsuccessful in his first call and then dialled again and although getting through had some difficulty in making it understood that the "Seawlse University" was a ship and not some institution ashore. 51. While these preliminary steps were being taken, the Commodore was presiding in the Main Restaurant on *R' Deck at the project team meeting with the Company officials and sub-contractors. Staff Captain Hsu who was present heard shouts of fire from somewhere outside and above, although this was apparently not noticed by others at the meeting. He went up the main stairway and saw thick smoke at *A' Deck in the port alleyway and returned to report that there appeared to be a serious fire there. The meeting broke up abruptly. He and the Commodore went at once to the C A* Deck office while the Chief Engineer went direct to the engineroorn. It was after they had left the Restaurant that one of their number heard the Public Address announcement by Chief Officer Liu. On his arrival at the *A* Deck office, the Commodore at once received reports of flies elsewhere. One was said to be on the Sun Deck and one aft on 6 B' Deck. We have had no evidence from any person who had actually observed the outbreak of any fire other than that seen by the cabin boys in the cross-alley on 'A' Deck, and save for one, (see paragraph 55 below) the persons who made these reports to the Commodore have not been identified, 52. From this time onward, the Commodore endeavoured to use the *A* Deck office as the Fire Control Centre in the manner required by the vessel's Standing Orders. He was, of course, labouring under a considerable disability in this regard because of the failure of the Public Address System and apart from that there was a good deal of confusion in the coming and going of crew and other persons. From the outset the Fire Control Centre scarcely functioned in the manner intended since all those crew members, patrolmen etc., who had heard the 20

23 Public Address announcement or had otherwise become aware of the emergency, went directly to a known site of fire or else to the forward Fire Station to collect fire extinguishers or other equipment for the purpose of directly attacking the fire. There was therefore no actual muster en masse such as is clearly envisaged in paragraph 3 of the document headed "Fire Fighting Procedure During Renovations in Hong Kong" (page 10 of Appendix A.8). Instead, individual crew members, patrolmen etc., were given missions to perform as and when they appeared and the opportunity afforded itself. 53. As far as possible, however, the Commodore did endeavour to remain at the nerve centre of the operation. He at once dispatched Chief Officer ZEE to collect a fire fighting group which was to locate and deal with the reported fires on 'B' Deck and at the same time he gave him instructions to see to the evacuation of any persons not actually engaged on fire fighting and also to prepare to lower lifeboats. To Staff Captain Hsu he gave orders to investigate the report of fire upon the Sun Deck. Cadet KWONG was sent to the engineroom to warn the Chief Engineer to "put steam on the whistle", as it might become necessary to sound the whistle to attract near-by craft to come and help in taking people off the "Seawfse" and also to announce the occurrence of a grave emergency. 54. The Commodore then told Mr. John LEE, the Manager of the Passenger Department, to contact the Fire Services again. Mr. LEE gave his assistant, Mr. Robert Hoareau, who had just returned from fighting the fire at 110 frame, the task of doing this and Mr. Hoareau made a call on 999 between and a.m. Up to this point the only person who actually consulted his watch was Cadet KWONG who stated that on his second and successful call for help upon 999, he had checked his watch and found that the time was a.m. Mr. Hoaieau made three calls in all at about ten minute intervals. On the first occasion he gave his message to the operator and on the second he was put through to the Fire Services to whom he gave the ship's location and repeated the same message concerning fire aboard. Between the calls he had been watching for fire-boats to arrive and after the second call he went back to the shell door and resumed his lookout. The third call would have been made at about p.m. and at this time the operator confirmed that fireboats were on the way. 55. After instructing Mr. LEE to telephone the Fire Services, the Commodore endeavoured to go up to the Bridge to assess the entire situation from the best point of vantage. One of the first reports made to him about a fire on the Sun Deck had been made by a Mr. SHEN Ti-sien, an engineer whom the Commodore described as "a very responsible person", so he was satisfied that on this score too a personal visit to the Bridge was warranted, although it meant leaving a sub-ordinate in charge at the Control Centre for a short while. The Commodore hoped to be able to see the extent of the fire or fires, to sound the whistle, to look out escape routes for members of the public, and possibly to sound a general alarm. He went up the forward Main Stairway at 255 frame but was driven back by dense smoke when he had gone some distance up that stairway. On his return to the 'A' Deck office, sometime before 12 noon, he was told that Mr. Houreau had succeeded in getting a message to the Fire Services, but because of the seriousness of the situation he phoned again himself, to be told that fire-boats were on the way. 56. In his evidence Commodore CHEN told us that on his first arrival at the S A' Deck square, following the alarm raised by Staff Captain Hsu, and after he had been informed of the existence of other fires elsewhere in the vessel, he had an intuition that something quite extraordinary had happened. The events immediately following would seem amply to have justified his premonition. Chief Officer ZEE immediately upon receiving his orders from the Commodore contacted some of the Security Guards and told them to get everyone off the ship other than those who were actually engaged in fire fighting operations. Thereafter he went via 6 R' Deck to the stairway at 70 frame. There he saw fire burning strongly on the *B' Deck level within the stairway enclosure with a party of men under junior engineer CHING huan already half way up the stairway on the landing between C R' and 6 B* Decks fighting the fire at *B' Deck level. The time would have been about a.m.* It seems certain that these were the first persons to have discovered this fire and that they arrived some minutes only before Chief Officer ZEE. Hoses and fire extinguishers were already being used and Chief Officer ZEE joined in and gave a hand. Because of dense smoke the party had to retreat down the stairway. At this point no one there seems to have been wearing breathing apparatus. Supplies of such apparatus had been taken to the site of the cross-alley fire at 110 frame following the initial announcement, the implication being that this was, from the start, considered either to be the only site of fire or else the most serious site. 57. It was only after their retreat down the central stairway at 70 frame that this party, under Chief Officer ZEE, discovered a fierce fire further aft in the smaller stairway to the port side of the vessel at about 48 frame between *B' Deck and *R' Deck. As with the other fire at 70 frame, the panelling of the stairway enclosure, as well as some of the stairs themselves, were alight. A hose was run out from a near-by hydrant to fight this new fire. Other people arrived with fire extinguishers and joined in the attempt to contain the flames. Seeing how serious the position had then become Chief Officer ZEE returned to report to the Commodore at about a.m. or 12 noon. * Mr. CHING huan (Witness 29) had left his cabin on the Sun Deck at a little after a.m. being one of the few witnesses who actually checked the time on his watch. 21

24 58. During the tln:e that Chief Officer ZEE was exploring aft and helping fight the fires there, Chief Officer Liu hen, having left the Public Address Centre at a.m. or so, made his way up to the Bridge with the intention of switching off the ventilation system, so as to reduce the draught in all vulnerable spaces. He saw no smoke until he got to the Boat Deck. Then he found thick black smoke in the wheelhouse forward at 247 frame. Since the emergency control for the ventilation fans was in the wheelhouse he opened the door and smoke billowed out. He had to take a deep breath, go in, locate the control, retire and take another breath and then go in again, before he was able to lift off the cover and activate the control. It transpires, however, that this effort was quite unnecessary since the ventilation system had already been switched off by one of the engineers at the engineroom level. Indeed the Chief Engineer's evidence was that throughout the renovations it was only put on at times for testing purposes. Such, however, were the conditions in the wheelhouse that it was impossible for Chief Officer Liu to do anything more and the general alarm was not sounded at that time nor at any time later in the course of the emergency. 59. A few minutes after this the Rooms Division Manager, Mr. Jim POON, having come up the forward main stairway at 255 frame to seek out staff in his department who were believed to be on the upper decks, saw dense black smoke shooting up from under the wings of the Navigation Bridge in the vicinity of the wheelhouse. It would have been a few minutes after this that the Commodore, attempting to make his way to the Bridge, was turned back by dense smoke on the same forward stairway. This accords with the evidence of Mr. POON who told us that, although he himself returned down that stairway, he did so with considerable difficulty and presumably used it because it was then the nearest source of retreat open to him after his inspection of the upper areas. This smoke as described both by Chief Officer Liu and by Mr. POON is of the greatest significance. Although an exact source has never been established, it clearly cannot have been on either 6 B' Deck or 'A' Deck aft. The Court is of the opinion that the source of that fire must have been somewhere in the region of the Navigation Bridge, probably on the Sun Deck where a number of officers' cabins were situated. It should be noted, however, that none of those cabins had yet been permanently occupied. 60. After his uncomfortable experience at the wheelhouse, Chief Officer Liu, in coming down, was compelled by thick smoke issuing from the starboard side of the Sun Deck to make use of certain workmen's ladders attached to the terrace of the Captain's Bridge to gain C P' Deck where he found a lot of smoke in the port alleyway. However, he seems to have seen no smoke on his way from there to the 'A' Deck office, which he reached via a small stairway at 275 frame and where he rejoined the Commodore at the Fire Control Centre. He was then told to go back up to the Bridge to sound the general alarm and make emergency signals. He set off once again, but when be had got as far as the forward end of the Main Deck he looked up and saw all decks above 4 M' hidden in dense smoke. This would have been shortly before noon. He was able to make his way as far as the edge of the Captain's Bridge by use of the same ladders that he had previously employed, but could get no further and so he returned to 'M 9 Deck where he found a number of people, principally workmen, in a state of some fear. These people were gathered there looking for some means of escape. Chief Officer Liu dropped ropes over the side and helped to get a number of them down to sea level where small boats were waiting to pick them up. At this point he encountered Staff Captain Hsu Pang-tsuey (Witness 24). The latter had gone up in obedience to the Commodore's orders to investigate the report of fire on the Sun Deck. He had gone up the forward stairway at 255 frame to the Boat Deck and had seen smoke coming from the Sports Deck above him as well as some smoke blowing from the direction of the stern. He then spent some time helping seven or eight crewmen who were searching the engineers* accommodation on the Sun Deck to see if there was anyone inside the cabins who was unaware of the fire. When no one was discovered and because thick black smoke was coming from fore and aft and from both sides of the forward funnel, he and the others used ropes to get down from the Captain's Bridge to 'P Deck and made their way down a stairway to *M* Deck. There they met Chief Officer Liu who was helping the workmen escape in the manner already described. The time was then approximately 12 noon. 61. About the same time other persons were also endeavouring to appraise the situation on the Sun Deck. One of the top Company executives, a Mr. C. H. TUNG, together with two of his sub-contractors, a Mr. CHU and a Mr. FBI, having encountered Mr. LEE Yung-hua (Witness 38), the Cinema and Photography Officer of the "Seawise* 9, in the vicinity of the Restaurant on *R* Deck, asked him to conduct them to the upper decks to locate the site of fire. They made their way to the Sun Deck and eventually to the wheelhouse inside which they saw smoke but could not, at that level, find the origin of the fire and thought that the smoke was coming from a lower deck. They descended to the Promenade Deck by a stairway starboard about 245 frame and went aft along the Promenade Deck but the smoke was so dense that they could make their way no further down and were compelled to retreat to the Sun Deck again by the same route. From there they escaped to 6 M* Deck by means of a rope suspended from the curved passageway in front of the Sun Deck. They went forward and saw Chief Officer Liu. At the request of Mr. LEE, Chief Officer Liu took Mr. TUNG, the two sub-contractors, Mr. LEE and Staff Captain Hsu, back down by a forward stairway, 320 frame, to the shell door on 'R' Deck Square and Mr. TUNG and the sub-contractors then descended from the vessel on to the pontoon. Chief Officer Liu returned to the Main Deck by the same route to complete the evacuation of the workmen. 22

25 62. Commodore CHEN was being kept advised of the progress of affairs by means of messages and reports, but because of the general confusion, the chain of command was not functioning as smoothly as it should have done. At about p.m. the Commodore moved down to C R' Deck Main Square because by then the smoke on *A' Deck had become so dense that visibility was very poor, but he makes no mention of smoke or flames in the stairway itself at that time. There were many people on 4 R' Deck and much coming and going between there and the forward ike-station. 63. The Commodore then went himself to check the conditions at Stairways 48 and 70, and while there helped with laying out hoses, and helped to get the portside shell door at 70 frame partially closed, but it had to be opened again after a few minutes because of the effect of the smoke on the fire-fighters. On his way through the Restaurant and Kitchen to these fires he saw no signs of smoke, but on his way back he saw smoke at the after end of the Restaurant. When he arrived back at 'R' Deck Square he was told that the fire-boats had arrived. Shortly after, he asked Chief Officer ZEE to go to the nearest fire-boat and explain to the Fire Services Officer the seriousness of the situation and set up liaison with them, Mr. ZEE said that he could not speak Cantonese, so the Commodore went himself and boarded the "Alexander Grantham", leaving Chief Officer ZEE to organise the people on 'R' Deck Square to fight the fire which had appeared in the Main Stairway between C R* and 'B' Decks. 64. Chief Officer ZEE, in the meantime, had been making his attempt to operate the whistle from the control in the wheelhouse but, like Chief Officer Liu, had been driven back by dense smoke inside. His attempt to operate the whistle by the manual control outside the wheelhouse was no more successful, even with the help of some crewmen. Thereafter Chief Officer ZEE and Cadet WONG had gone to assist in the launching of several lifeboats, a task which was successfully accomplished and numbers of workmen were evacuated. 65. Cadet WONG and Chief Officer ZEE then themselves made their way down a rope into one of the lifeboats, the time then being about p.m. Chief Officer ZEE returned in that lifeboat to the pontoon landing below the shell door at 'R* Deck near the main Restaurant. In the Square at 'R* Deck he met the Commodore. A reasonable approximation, in view of the nature of all these events, would put the time then at between and p.m. At this stage the panelling of the main stairway between 6 B* and 'R' Deck was ablaze and many people were fighting the fire. 66. There was one other witness to the likelihood of an early fire on the Sun Deck. This \vas the junior Engineer Mr. CHANG Hui-chiu (Witness 28) who was one of the few persons actually living aboard the ship. His cabin was on the Sun Deck about 140 frame on the port side. He was returning to it when he saw thick black smoke along the alley of the Sun Deck. It seemed thick enough for him to try to locate a site of fire near-by but this he was unable to do and he went off straight away to the engineroom to see to the pumps. It is possible that this fire was the origin of some of the smoke seen in the region of the after funnel from the police boat and the shore stations. 67. We must return now to WONG Pao-lung and his fire fighting party at the original site of the fire at the cross-alley on 6 A' Deck at 110 frame portside. It is clear from the mass movement of men and equipment to that scene that, at the outset, it was regarded as the only serious threat to the ship. At one time or another in the first half-hour after the alarm was raised that site was visited by the majority of the witnesses who have spoken of fighting fire piror to the arrival of the fireboats some twenty-six witnesses in all. From the start this locality swarmed with helpers fetching fire extinguishers, breathing apparatus etc., and making them available to the trained fire fighters and also assisting with the hoses. But it was Mr. WONG Pao-lung and his assistants, Mr. Ko Ngan»wan and Deck Cadet KWONG who played the major part in dealing with this fire. Several people used fire extinguishers including Messrs. WONG, Ko, Hoareau and POON. Indeed, the latter two may well have been the first persons to use fire extinguishers at that scene. The earliest to get to the scene with this equipment must have done so very shortly after its discovery by the cabin boys, but the fire extinguishers proved ineffectual. Fanned by the wind the flames increased rapidly and set the panelling of the alleyway alight. The inboard end of the cross-alley is close to the after main stairway which goes down to 'B' Deck and up to T' Deck. The fireproof door into the stair enclosure was open and at some stage the panelling of this stairway was also set alight. One of the witnesses thought that the fire had started in the stairway enclosure and that it had spread from there to ignite the rubbish at the cross-alley, but this seems unlikely in view of the evidence of the cabin boys and of the principal fighters at the scene, Messrs. WONG, Ko, KWONG etc. Although the Court cannot, with certainty, rule out the possibility of an independent source of fire in this stairway below the *A' Deck level, it seems more likely that some of the burning rubbish blew into this stairway even while the cabin boys were running forward crying "fire!". Three of the day's duty fire fighting team were present there very shortly after the outbreak including fireman Ko. When the fire extinguishers proved of no avail fireman Ko broke a nearby fire alarm and went for a breathing apparatus leaving the others to run out a hose. The time would be about a.m. Fireman Ko, who by then was wearing the breathing apparatus, returned and directed the jet of water into the cross-alley and was helped in this by Fire Officer WONG Pao-lung who had also got a breathing apparatus by this time. 23

26 68. Firemari Ko, ASLMIIS exhcus.cd one Grilling apparatus, went and found a new one laid ready in the alleyway forward 0*" the site of the fire. At this point he heard shouts about a fire on 6 B' Deck and he went to look for it leaving Mr. WONG Pao-lung with Mr. CHOW sang, another of the duty firemen of the day. It seems likely that the news of the other fires had drawn off many of the initial helpers at the cross-alley at "A 5 Deck. Fireman Ko, however, instead of taking the *R' Deck route to seek the source of the 'B 5 Deck fire, as Chief Officer ZEE and others had done, went along 'B' Deck with Cadet KWONG and it was they who discovered fire in the staircase on 'B' Deck level, one deck below the place at which Mr. WONG Pao-lung and his helpers were fighting the fire on C A' Deck. Messrs. KWONG and Ko connected hoses and fought this fire from both sides. Fireman Ko exhausted his second breathing apparatus while doing so. Each of the cylinders can last for up to thirty minutes but it can be exhausted much earlier, depending upon the exertions of the user. He was then going to get another at 'R' Deck Fire Station but, when he got to the Main lobby on 6 B' Deck, he saw that the panelling of the Main stairway between S B' and *A' Decks was on fire. The time then would have been approximately p.m. He retreated from the Main lobby at 'B' Deck level and went down the small stairway about 155 frame on 'B' Deck having shouted to Cadet KWONG the news of the fire at the Main stairway. At 'R' lobby he saw Chief Officer ZEE and others, seven or eight in all, fighting fire on the 'B 5 to C A' Deck level at the Main stairway. Chief Officer ZEE told him that the fire-boats had arrived and sent him to Fireboat No. 2 where he contacted the officer in charge of that boat, Mr. LAM Lok-bun (Witness 70) and requested that a party of Fire Services personnel be sent aboard and this was done. Prior to this the fireboat had been directing its water jets at the superstructure of the vessel with the idea of combating what open fire could be seen and also of cooling down the superstructure. 69. The fire fighting party came aboard at about to p.m. Some time before this the fires aft in the stairways at 70 and 48 frames had been abandoned as being beyond control, and the men who had been fighting them had escaped ashore. The remainder of the fire fighting crew under Chief Officer ZEE was by then engaged in dealing with the fire on the Main stairway at 210 frame between S R' and. C B' Decks. 70. Mr. WONG Pao-lung, the ship's Fire Officer, fully occupied on 6 A' Deck, had not known of the fires on 'B' Deck. He finished one breathing apparatus and then took another from fireman Ko, who had gone to *B' Deck, and returned and manned the same hose at C A' Deck level again. At this stage it appears he was alone. There was some evidence that another crewman had made an effort to get to the far side of the fire at 110 frame and Fire Officer WONG said that he heard the noise of fire extinguishers both from the starboard alley and from the far side of the fire in the port alley during the couise of his opeiations. The result of his efforts and a fact of great importance to the findings of the Court was that the flames at 110 frame on *A* Deck level were eventually wholly extinguished both in the cross-alley and adjacent stairway. The Fire Officer went through the bulkhead doorway and all was then dark although there was much smoke about. At this stage, of course, Cadet KWONG and fireman Ko were fighting a fire at 'B' Deck level in the same stairway but this stair, on its way up to 6 A* Deck turns around a half-landing which must have shut off sight of any flame from below. Also, of course, the whole area on C A' Deck level was still thick with smoke. 71. Mr. WONG Pao-lung went forward towards the Main stairway and on the way he met the engineer LEUNG (Witness 52). This man had originally been among those fighting the fire at frame 110 on 6 A' Deck level but, hearing that there was fire on 6 B' Deck, had gone down and had seen people presumably fireman Ko and Cadet KWONG using hoses at the stairway on the port side below the area in which WONG Pao-lung was still fighting the fire on 'A* Deck. Mr. LEUNG went round to the starboard side of the stairway on C B' Deck level and saw fire gushing through the open doorway of the stair enclosure. He collected a few people to help with a hose which was already being operated there. Finding that the hose lacked a nozzle he went up to *A* Deck to get one, apparently by the Main stair which was not then alight, the time then being approximately p.m. There he met Mr. WONG coming from the extinguished fire, and told him of the fire below. They got a nozzle and went down to *B* Deck by the small stair at about 155 frame. There Mr. WONG found the branch which fireman Ko had left sticking through the doorway into the stair enclosure at 110 frame. He and engineer LEUNG were the only people there at that point and they directed the hose at the flames within the enclosure. Fire Officer WONG heard the noise of the hose being used by fireman Ko at the opposite doorway into the stairway enclosure. The stair panelling and the wood panelling on the transverse bulkhead was ablaze. They got this fire under control. At this point the sound of the hose on the other side ceased and as the Fire Officer's breathing apparatus was almost exhausted he came out and asked Mr. LEUNG to get him another. As this was happening Cadet KWONG came along the port alley and Fire Officer WONG borrowed his breathing apparatus and went in and put out the remainder of the flames in the stairway. The fact that the flames were extinguished was vouched for not only by Mr. WONG and Mr. LEUNG but also by one of the top Company executives who had taken a hand in the fire fighting at that point, Mr. W. S. PAO. It is a token of the fact that this operation was evidently believed to have been brought to a successful conclusion by all who had taken part in it that Mr. LEUNG turned off the fire hydrant on the port side. All of those who had been fighting fire on the *B' Deck level then went forward towards the Main Square only to find that by then the staircase was blazing and they had to go down to 6 R? Deck level by the stairway at 155 frame. They then went forward to the main square where they found many people fighting 24

27 fire on the main stairway, among them Staff Captain Hsu and Chief Officer ZEE. Fireman Ko bad evidently already been sent to contact fireboat No. 2, which arrived a little later. The time of this temporary triumph can therefore be placed only very roughly at somewhere between and p.m. 72. The salient fact emerging from all this evidence is that the fire which occasioned the original alarm was fought for about the space of one hour and a quarter and the flames were finally extinguished. Yet at that very moment of seeming victory nearly eighty yards aft and more than two hundred yards forward of this hard won battle, and quite unconnected with it, there were raging fires of such size and intensity, and so inadequately confronted, that it is clear that the ship was already beyond saving. At the moment that Fire Officer WONG, engineer LEUNG and Cadet KWONG withdrew from the stairway at 110 frame on 'B' Deck the fight against the fires on the stairways at 70 and 48 frame aft on 6 B' Deck had already been abandoned as out of control and the earliest party from the Fire Services had not yet come on board. Yet the fires at 70 frame and 48 frame had clearly not, in all that time, extended to within visual distance of Messrs. KWONG and LEUNG. The Government Departments: Part Played in the Operation 73. Whatever legal and administrative difficulties may have inhibited the Marine Department and the Fire Services Department in their dealings with the Agents of the Seawise Foundation prior to the 9th January, (paragraphs 135 et seq., infra) there can be no doubt that there was an immediate and widespread attempt to come to her aid with all possible speed once the alarm was raised. 74. The first call recorded by the Fire Services Control Centre was not any one of the calls made from the "Seawise" herself, but was the result of a call made by a Police Inspector Ho Sze-ming (Witness 60) from a Police Launch in the vicinity of the "Seawise" on Marine Police duties. He noticed smoke coming from the "Seawise" about a.m. and at once notified Marine Police Headquarters which in turn called the Fire Control Centre, the time of receipt of this call was then noted at the Centre as a.m. Smoke had also been observed from the Marine Department Signal Tower at Rumsey Street on Hong Kong Island at about a.m. and also from the Green Island Signal Tower three minutes later. The Green Island Tower then phoned the "Seawise" and confirmed that there was fire aboard and at once phoned the Fire Services. The Marine Department officer making this call to the Fire Services was then told that the Fire Services had already been informed of the outbreak of fire. It appears therefore that several notifications were made to the Fire Services Control Centre of the outbreak of the fire at or shortly after a.m. but it is the practice in that office to record only the first such call in the 'log' which is kept for the purpose and to make no special note of any subsequent calls to the same effect. (See Appendix A. 9). On receipt of this notification the Senior Officer in the Fire Control Centre of the Department sent out a Number 2 alarm signal, called for a helicopter and notified certain senior officers. These officers hastened at once, some from their homes and some from their places of recreation, to engage with their subordinates in deploying, with all possible speed, a flotilla of fireboats and launches together with the necessary men and equipment, for setting in operation the "Contingency Plan" for the saving of the ship. 75. The vessels set out from various points both on the Island and Kowloon shore line, the earliest to leave being Fireboat No. 2 which left the Government Pier at about p.m. It was followed in quick succession by the "Alexander Grantham" and Fireboats Nos. 1 and 5. Later a vehicular ferry with heavy fire-fighting equipment on board was sent under the command of one of the senior Fire Services Officers. 76. It is unnecessary to detail all the incidents of this massive but ineffectual rescue attempt. A very full picture of the strenuous and unremitting endeavours of personnel at all levels in both departments is to be had from the detailed log of events following upon the first report. A photostat copy of its first page appears as Appendix A. 10. Suffice it is to say that, in the ensuing combined operation, a fleet of Marine, Fire Services and Police boats surrounded the burning vessel and on the "Alexander Grantham" were gathered eventually the Director of Marine, the Director of Fire Services, the Commissioner of Police and a fair number of senior officials from all three departments together with officials of the Island Navigation Company. 77. Mr. Worrallo, Assistant Chief Fire Officer, Hong Kong Island circled the "Seawise" in the helicopter at about p.m. and saw smoke pouring from the superstructure for half the length of the ship from the stern and, on the strength of what he saw, sent out a "disaster alarm". This, we were told, is the extreme signal which means that all the resources of the Fire Services may need to be called upon. The response was instantaneous but from the outset this spectacular assault had no hope of success for by the time it achieved its full momentum it was already too late. The first of the fireboats, Fireboat No. 2 under the command of Mr. LAM Lok-bun was already standing out towards the "Seawise" a few minutes after 12 noon reaching her about p.m. She was followed closely by the principal Fireboat, the "Alexander Grantham", arriving about p.m. and next came Fireboat No. 1 which is properly not so much a fireboat as a fast launch. This boat brought Mr. Worrallo and was in the offing at about p.m. The same launch later brought the Director of Fire Services to the "Alexander Grantham" at about 1.45 p.m., the Director of Marine having arrived on a Marine Department 25

28 launch shortly before that. Fireboat No. 1 was followed at 1.05 p.m. by Fireboat No. 5 and a vehicular ferry carrying heavy fire fighting equipment and some personnel arrived about 1.50 p.m. 78. Prior to the arrival of the fireboats, several Police launches were already in the offing. These included Launch No. 10 under Inspector Ho who had radioed the first signal to be received by the Fire Control Station, and who now proceeded to summon other launches to the scene. Police Sergeant CHEUK Man-ki (Witness 62) in command of Police launch No. 5, as he approached the "Seawise", noticed at about a.m., that flame had broken out at the starboard side of the superstructure aft of the rear funnel and that much smoke was then blowing forward. He took off about 150 people from the pontoon moored below the C R 3 Deck shell door and these included Mr. C. H. TUNG and his son and certain other important officials of the IN. Company. These persons he then distributed to other launches in the vicinity for transportation to the shore. Police launch No. 10 at the same time was picking up people who were coming down ropes and some of whom were retrieved either from the ropes or from the sea. There were also various other privately owned pleasure craft in the vicinity engaged in the work of rescue. When the "Alexander Grantham" arrived some important Company officials were then put aboard her to advise the senior fire officers as to the layout of the vessel and other kindred matters. 79. About the time of the arrival of the fireboats the Commodore's m otley army of fire fighters had contracted to a corps of stalwarts who eventually found their efforts restricted to a last desperate stand in the neighbourhood of the great Main double-flight stairway down which the fire had crept from C A' Deck to 'B' Deck and finally towards the panelled enclosure of the flight leading to the square at C R' Deck, the main escape route to the landing pontoon. Smoke was seen about this time in the Main Restaruant and spaiks were dropping from the ceiling. Throughout the whole period of emergency the fire forward in the Decks above 'A' had gone unchecked because of the scarcity of men to locate and fight it and because of the paramount need to ensure that workers, visitors and others who might be in that area and elsewhere in the ship should be found and conducted to safety. 80. The "Seawise" was pouring smoke from most of her superstructure from the Bridge to the region of the swimming pool aft on 4 P* Deck. The fireboats began at once to train their jets on the blazing superstructure from the port side of the vessel. The starboard side was thickly covered by a pall of smoke which by now was clearly visible for miles down the eastern reaches of the harbour. A command post of sorts appears to have been set up upon the "Alexander Grantham" and it was to that post that the Commodore repaired somewhere between and 1.00 p.m. in order to set up liaison with the Fire Services. It is not clear how long the Commodore remained on board or to whom precisely he spoke. He himself sa>s that he asked for firemen to go on board the "Seawise" and called for what he described as a full scale operation to save the ship, and that he then returned to the "Seawise" about a half an hour later. 81. Meanwhile Fireboat No. 2 under Divisional Officer LAM Lok-bun, had led a party of shore fire fighters aboard at the request of Fireman Ko at about p.m. and had taken command. It was shortly after this that the Commodore returned and saw Fire Services personnel, helped by members of his own crew, pulling hoses up the stairs from *R* Deck in the area of the main lobby. Up to this time the fire in that area had been under increasingly unsuccessful attack by numbers of crew including Mr. WONG Pao-lung who, not surprisingly, was by then close to exhaustion. 82. Fireman Jo Tai-chang (Witness 72), arriving at about p.m. also in Fireboat No. 1, saw flames coming from the area of the Bridge and flame running all the way aft from a point at the rear of the forward funnel. Some time later he and Mr. Worrallo went on board having tied up alongside the "Alexander Grantham" to join the forces already there. The shore party with the help of some of the "Seawise" crew succeeded in driving the fire some distance back up the Main stairway towards *B' Deck level and Fireman Jo penetrated the port alley for about fifty feet. None of the cabins in that area seemed to be afire. He then got two other shore firemen to run a hose along the alleyway while he, at Mr. Worrallo's direction, went looking for the search party under Mr. CHAN Fong, which had been sent by Divisional Officer LAM to search for stragglers in the enginerooms. He went down to *C Deck, shouted, but got no response. He then noticed that there was a shell door, the sill of which, because of the ship's starboard list, was only a little way above the surface of the water. He reported this to Mr. Worrallo and then went up to check on the effect of the hoses on e B' Deck. The smoke there was then such that Divisional Officer LAM Lok-bun ordered them all to retreat. The fire on C B' Deck was controlled for a short while only but then increasing smoke and heat drove the men back down the Main stairway. 83. At some point before this, the Commodore had returned from the "Alexander Grantham" and found the Fire Services aboard and he also saw Fire Officer WONG Pao-lung and Chief Officer ZEE. Mr. WONG told him that all breathing apparatus was exhausted. Chief Officer ZEE and the Commodore took part, with Staff Captain Hsu and other crewmen and some shore firemen, in an independent search for persons suspected to be cut off in the region of the enginerooms. All members of this party were carrying torches. Somewhere in one of the enginerooms water was seen to be pouring down a bulkhead and the engineroom floor was flooded. Water was also seen to be spilling over the sill of a doorway between two of the rooms, but we do not think that any sinister interpretation is to be given to what was then observed. The free water in the engineroom 26

29 spaces was almost certainly due, at that time, to the fact that tons of water had, by then, been deposited upon the upper decks, both from within and without the ship, by the fireboats and by firemen and crewmen on board. A goodly proportion of this must by then have found its way by devious channels down to the engineroom. No lingerers were found in the engineroom spaces by either the Commodore's party or the party sent below by Mr. LAM Lok-bun. 84. The Commodore's order to Mr. Po Sik-kuen at about 1.40 p.m. to shut down the generator must have been given sometime between his return from the "Alexander Grantham" and his mounting of the search party. Upon receiving and obeying that order the Engineroom staff had withdrawn and escaped mainly by a shell door at 'C Deck. When he returned from this search, the Commodore was told by Divisional Officer LAM Lok-bun that it was no longer safe for anyone to go further aft or to go below again. Chief Officers Liu and ZEE were there together with Fire Officer WONG Pao-lung and Fireman Ko. The Commodore then told his men to close fire doors on 'R' Deck if they could and generally to perform whatever other tasks they could by way of lifesaving, it apparently still being in his mind that there might be stagglers somewhere aboard. He estimated that the time then would be around about 2.30 p.m. and shortly after this he left the ship and went aboard a fireboat, presumably the "Alexander Grantham", in order to get an overall impression of how the fire was being dealt with. He also hoped to locate senior officers to discuss with them and presumably with the Fire Services and Marine Department people, what further might be done. One of the Company officials then ferried him in a boat to a Marine Department launch where he conferred briefly with Mr. Matthew concerning the question of beaching (to which we will return later) and shortly after this the Director of Marine ordered fire fighting to stop because of the listing of the ship. All fire fighting operations then ceased. The Commodore told Staff Captain Hsu to stand-by on a small boat and he himself went ashore to the Company's Head Office in order to check from reports arriving there whether any persons had been reported missing. The time of shutting off all monitors is logged as 3.28 p.m. (Appendix A.ll). 85. Prior to this and while the fire fighting operation was still proceeding aboard the "Seawise", and probably after the Commodore had left, Mr. Liu Fai reported to Fireman Jo that a fierce fire was blazing downwards through the main forward stairway at 250 frame. On going to investigate this report Fireman Jo saw, in the stairway enclosure, a pile of what he believed to be paint drums. Before he could fetch a hose to the spot the fire had reached these drums so he retreated and closed fire doors at the forward end of the Main Square at about 217 frame. Thereafter he concentrated on the fire on the main stairs at C B' Deck level. At this point he saw the Director of Marine, Mr. Milburn and the Director of Fire Services, Mr. Wood, together with some senior Police Officers and Mr. Hutchins of the Fire Services in the 'R' Deck square. He went to the starboard gangway and looking out he saw that the sill of the shell door on C Deck level, which he had previously observed, was now under water. He reported this to Mr. Hutchins and Mr. Wood and all three went down to 4 C Deck level and managed with great difficulty to get the door almost closed. They were, however, unable to reach any of the other shell doors which were also open on the same deck. Shortly after this the fire door in the Main Square, which he had closed earlier, blew open as a result of an explosion and a gush of black smoke came through. 86. Mr. Hutchins returned to the "Alexander Grantham" and maintained contact with the two Directors on board in relation to the state of the list and the advisability of withdrawing personnel. On his advice the order to withdraw was given at 3.28 p.m. Thereafter the fire blazed unabated from stem to stern. The monitors in the fireboats continued to play upon the blazing superstructure and by 4.28 p.m. she was listing It has been noted that the "Alexander Grantham" was used throughout these operations as a kind of command post in which the Directors and the Commissioner of Police and other senior officers conferred with members of the Company and also, at some stage, with the Commodore concerning measures to be taken. Control of the actual on-board action was left in the care of Mr. Worrallo, Mr. Hutchins, Mr, LAM Lok-bun and their party of fire fighters. 88. Most of this evidence is unspecific and leaves us with doubts as to the nature and efficiency of the liaison then established or previously existing between the Commodore and his Fire Officer on the one hand and the Senior Departmental officials on the other, but one matter has been firmly established. It has been mentioned that the Commodore shortly after leaving the vessel at about 2.30 p.m., went via the "Alexander Grantham" to confer with Mr. Matthew on the question of beaching. There was some confusion in the evidence at this point but it would seem that the discussions took place by means of a Y.H.F. system, between Mr. Matthew, the Commodore, Mr. C. H. TUNG of the Company and Mr. Wood, the Director of Fire Services, on one of the vessels and the Director of Marine and Mr. Lack at Port Communications Centre. (A typescript of an extract from the taped record of this conversation appears in the Appendix A. 12). It appears clear that Mr. Matthew was pressing for the implementation of the plan for beaching the vessel which had formed part of the contingency plan already sent to Captain LAM. (See paragraph 7 of attachment to Appendix A. 13). It is unnecessary to go into these exchanges in detail. Mr, Milburn made it clear that he was very much against any attempt at beaching but that 27

30 in any event the decision on the matter must rest with the Commodore. (Appendix A. 12) Commodore CHEN was himself obviously dubious about taking any such action. His own account of it was that the matter was merely discussed but that no conclusion was arrived at. Of all the senior technical officials present, Mr. Matthew appears to have been the only one who thought that, at this stage, beaching was a desirable or even a possible course of action. He had expressed initial dismay at the paucity of the data supplied to him, on leaving for the "Seawise" earlier that morning and which, according to his evidence, he had hoped would enable him to make reasonably accurate estimates of the vessel's stability, a factor which he considered to be of utmost importance in relation to the fire fighting operation generally but specifically in relation to the question of beaching. This Court is satisfied, however, that there was no virtue at all in the suggestion of beaching the "Seawfse" in the conditions which then prevailed. Mr. Milburn's observations on this matter, given in the course of his evidence, appear to us eminently sound. Indeed we think it was fortunate that so hazardous a course was not attempted in view of the patent dangers involved in it and the distinctly dubious possibilities of advantage to be derived. (See Note on 'beaching' in 'Evaluation' hereafter). 89. We are satisfied that consultations concerning the continuation of fire fighting operations, the stability of the ship etc., took place before the withdrawal of personnel and that the Commodore and Company officials and the Directors of Marine and Fire Services were involved in these conversations. We are satisfied that it was as a result of these consultations that the order was given to cease fire fighting operations at about 3.30 p.m. when the ship was listing about 17. Sometime thereafter the list decreased by about two degrees and fire fighting operations were commenced in a hit and run manner, fireboats advancing to strike at perceived sites of fire and then backing off again. All these operations eventually ceased at about 7.00 p.m. Long before that the ship had been completely evacuated. Her list was then about 20., and she was steadily shipping water through many of the lower starboard shell doors which were by now below the surface. The lessening in her degree of list at the earlier stage had probably been due to the fact that it was then that the starboard bilge first came in contact with the bottom. Thereafter, however, it would appear that the water continued to pour in and that the vessel, although touching the bottom, was driven further into the soft mud and her list increased. Indeed, we think it distinctly possible that, had the bottom been less yielding, the fall of the tide might have had the effect of shifting the centre of gravity of her partially water-logged bulk sufficiently to port to correct the list to a much greater degree. Given a favourable configuration of the bottom in that area, which, even when she was upright was only a matter of 10 feet below her keel, it is not beyond the bounds of possibility that she might then have come to rest more or less upright on the bottom in a condition of some considerable stability. As it was, her list increased steadily and at noon the following day she very slowly rolled over and came to rest at an angle of about 50 degrees in some forty-three feet of water with her starboard bilge buried deeply in the mud. Even thereafter she continued to burn fiercely through the evening and night. The fire eventually burnt itself out on the 11th January and throughout those three days she continued to be attended by boats of the Fire Services. The Photographs 90. One helpful result of the interest which followed the ship wherever she went was the quite unexpected harvest of photographic evidence which was promptly made available to those in charge of the initial inquiry. We have in these what amounts to a visual record of the progress of the fire from its very earliest beginning. Five different people happened to be by and in a position to record one or other aspect of this most unusual event. Two of these five exhibits consisted of sequences of cinefflm, one taken by an American tourist from the ferry and one by a Mr. LEE Kwok-kong (Witness 11) the supervisor of a local Sea School. The motion pictures, impressive though they are in recapturing the sheer force and magnitude of the conflagration, have not been of any great assistance in resolving the essential questions of cause and sequence. It is quite otherwise, however, with the enlarged reproductions of the colour 'stills' several copies of each of which have been supplied to the Court. There are three sequences of these 'still* shots which for convenience have been labelled the "A", "B" and C4 C" sequences. They have been useful in estimating the times and sequence of events. 91. The "A" sequence is taken from a film made by one of the Decorators working in the ship, a Mr. SZE Chong-ping (Witness 9). It consists of fifteen enlargements of colour prints. This witness was standing on a barge below the *R* Deck shell door exit, having gone down there immediately after his lunch in the Main Restaurant. He had already heard while still in the restaurant that a fire had broken out and had indeed looked out a porthole and seen some smoke. He began to take his pictures, which were taken on behalf of a colleague who had supplied the film, as soon as he arrived on the barge. The time which he gave was about a.m. The first in the sequence shows the starboard side of the ship with a small plume of smoke rising up from about the area of the shell door on *A* Deck at 110 frame. In the same picture may be seen a pleasure junk which was identified by Mr. William Moir (Witness 10) as being the one on which he and some companions were making a picnic trip. This junk is seen heading sternwards towards the shell door along the portside of the "Seawisf 9. Mr. Moir told us that, as he and his companions sailed aft along the side of the ship, he heard what appeared to 28

31 be a Public Address announcement from somewhere aboard. This time, we know, can be placed between and a.m., probably nearer to a.m. Mr. Moir and his companions then observed the fire at the shell door above them at 110 frame. None of the external observers of the fire was able to give a certain time for any of the events observed. 92. Of the three persons who took photographs we think that the most accuiate in reckoning the times of his actions was Mr. John Jensen (Witness 36) a representative of Manners Engineering Ltd., who it appears was going to be one of the gusets aboard the "Seawise" that day. It was he who took the "B" sequence of colour 'stills' and that sequence consists of enlarged prints of ten different pictures from the roll of film, the remaining pictures in the same film, although not enlarged, being also made available to us. 93. The third, or "C" sequence, was supplied by a Mr. Abraham Razack (Witness 67) an employee of Messrs. Butterfield and Swire, who was, with some colleagues, on his way to Lamma Island on a Company picnic. His contribution consists of three enlarged colour prints showing close-ups of the "Seawise" over a period estimated by the witness as extending from about to about a.m. We think that this estimate would be roughly accurate. We believe, however, that the timing of the "A" sequence, as accounted by Mr. SZE, leaves too little time between the taking of individual shots and that his estimate that the sequence of fifteen shots took from about a.m. to p.m. is possibly too short by about 20 minutes. 94. We have ventured therefore to assign tentative times to the individual pictures in each sequence and have done so by appraising times given by the photographers and either adopting them or adjusting them where that seemed necessary, having regard to such other items of evidence, mainly from the "inboard witnesses", as seems reasonably secure and which can be related to scenes described in the photographs. Examples are the Public Address announcement in relation to the picture of Mr. Moir's junk and the evidence of Chief Officer ZEE as to the lowering of lifeboats which can be related to two of the photographs in the "A" sequence which actually record the lowering of one of those boats and the abortive attempt by a person aboard the ship to get into the boat which was being lowered. Smoke conditions as described by witnesses at given times and places were also checked against some of the scenes recorded. 95. The shorter sequence of photographs, i.e. the "C" sequence taken by Mr. Razack, gives what is perhaps the clearest visual synopsis of the first chapter in the disaster. Photograph Cl is a full length shot, from starboard, of the ship, resplendent in her new white paint, with no hint of smoke from any porthole or deck or funnel, the time being about a.m. Five to seven minutes later photograph C2 shows the first ominous plume of black smoke wreathing up from a small root of orange coloured flame at the port shell door on *A' Deck at 110 frame. At the time of the taking of this photograph, possibly something in the nature of ten minutes has gone by following the first raising of the alarm by the cabin boys. The earliest fire extinguishers are possibly being used and being found insufficient and the fire fighting party is beginning to collect with its fire extinguishers, hoses, breathing apparatus etc. 96. Sometime shortly before the time of the taking of this photograph, Mr. Moir, having heard the Public Address announcement, had passed below this same door and had seen a little flame which he thought was some routine burning of rubbish. He and his companions thought nothing of it and sailed on looking back and commenting on the ship's fine lines. Indeed the earliest photographs in the "A" sequence also bear testimony to the unconcern shown by everyone who was in the vicinity at the time of this first observed outbreak. The persons who are shown in the first few "A" sequence photographs leaving the vessel by launch scarcely seem to be aware of any threat to the ship although one imagines that some of them at least must have seen some of the smoke coming from the shell door. This insouciance is echoed in the behaviour even of those workers who had heard the alarm aboard the ship, many of whom appear to have done nothing more than continue with their lunch. Indeed the three carpenters who had been working in a cabin just aft of the cross alleyway at 110 frame and who saw smoke and flames as they left the cabin, neither raised the alarm nor joined in the fire-fighting, but simply proceeded, by a circuitous route to avoid the fire, to the Restaurant for their meal. One may perhaps speculate that this reflected their confidence in the crew's ability to deal with fires which had been demonstrated on previous occasions during the course of the renovations, although it may simply have been that they were quite unaware of the effect that a serious fire could have on a ship in her situation. Photograph C3, taken perhaps ten minutes later, shows that the smoke from the shell door has disappeared but now a towering, and far more ominous, mass of dark grey has erupted from somewhere below the boatdeck to the rear of the aft funnel. All this in the space of about fifteen minutes. 97. The eighth photograph in the "B" sequence taken about 35 minutes later and photograph 11 in the "A" sequence, taken at approximately the same time, show plainly the catastrophic deterioration in the situation. By then the upper decks forward in the area of the Captain's Bridge and Navigation Bridge and several decks from *P* to *A' level far to the stern appear to be involved in the fire. At about this time Fire Officer WONG Pao-lung and his small party had apparently brought the earliest detected blaze under control. In photograph 29

32 Bll, taken at almost the same time, bvo regions of dense smoke can be seen, one engulfing the Bridge and Wheelhouse area forward and one thickly massed about the region of the rear funnel while once again, aft of that, the origiral shell door sho\\n in the "A" sequence is seen to be free of flame and smoke. While too much emphasis should not be placed on these appearances, since smoke may be capable of producing illusory effects, the photographs to which we have referred nevertheless help to confirm that there was a rapid swelling from several different sources of fires of disastrous size within a very short time. Perhaps more effective still is it to compare photograph Cl taken about a.m. with photographs B8 and Bll taken less than one hour later to see how in that time the entire superstructure of the vessel is involved to such a degree that, to any eye, the chances of its being brought under control must have seemed remote indeed. The Explosions 98. Many witnesses spoke of hearing explosions at various points and times in the course of the fire fighting events. We have been unable to asceitain the cause of any of these explosions nor have we been able to determine their precise locations, save for one which was heard in one of the lift shafts. (See paragraphs 99 and 100 below). It seems certain that none of the observed areas of fire commenced with any explosion and those which were heard might have been due to many causes, for example, exploding gas cylinders of which there were some in some areas near where welding was going on; or explosive "flash overs" between contiguous areas of fire. 99. There were reports of a fire in the inboard portside lilt shaft, which was one of four lift shafts at the after end of *R 9 Deck Main Square. Chief Officer ZEE heard a noise as of something falling down the shaft, and saw flames shooting out of cracks between the lift doors. Fire extinguishers proved unavailing to control the flames so he organised a gang to pile wads of asbestos sheeting around the lift doors, and the fire in the lift shaft went out. The time would have been between and p.m Other witnesses to this fire also mentioned an explosion, among them Mr. Jim POON and Mr. LEE Yung-hai who said he was knocked over by it. There was no evidence as to the cause of the explosion, but one of the possible causes might be the build up of gases which suddenly ignited in the restricted shaft area. Evaluation 1. Nature of the Operation in General 101. We have given in outline the sequence of events which we deem to be of importance in relation to the purpose of this inquiry and the nature of our conclusions. In doing so, we have restricted ourselves to the principal actors. There were many others whose evidence would have amplified the story already told, but while of intrinsic interest, it could carry the narrative no further Fires were observed and fought in nine separate locations. For completeness we list these below together with the tally of the witnesses who took some part in dealing with each; (a) Fire aft on S A* Deck as witnessed by Mr. Yu Kwok-ming (Witness 55); time about a.m. (b) In the port stairway at 48 frame; (witnesses 23, 24, 31, 33, 35, 43 and 45); earliest observation about 11.50a.m. (e) Central stairway aft at 70 frame; (witnesses 16, 17, 22, 23, 24, 30, 33, 34, 35, 40, 43, 45, 46, 48 and 56); about a.m. (d) Cross alley 110 frame; (witnesses 8, 12, 13, 14, 15, 16, 17, 18, 19, 20, 23, 25, 27, 30, 31, 32, 33, 34, 38, 39, 43, 49, 50, 52); time approximately a.m. (e) Central stairway aft of 110 frame 'A 5 Deck; (witnesses 18, 22,26, 33 and 56); time approximately to a.m. (/) Central stairway 4 B* Deck 110 frame; (witnesses 8, 12, 20, 21, 44, 52 and 56); time approximately 12 noon. (g) Main stairway 'A'/'BY'R* Deck levels; (witnesses 12, 13, 16, 17, 18, 20, 21, 22, 23, 24, 25, 27, 28, 30, 31, 32, 33, 37, 38, 39, 41, 42, 44, 49, 50, 52 and 54); time approximately p.m. (K) Inboard lift shaft port side of 'R' Deck lobby; (witnesses 12, 13,23, 33, 38, 39,46 and 54); time approximately to p.m. (/) Forward central stairway approximately 255 frame; (witnesses 13,22, 23, 24,38 and 39 who only saw smoke at an early stage and 27 and 72 who fought it very late on in the emergency, perhaps after 2.30 p.m.) In addition to these there were observations of smoke which might have indicated sources of fire on both the Promenade and Sun Decks although no fire fighting actually took place on either deck. 30

33 104. How many independent sources of fire there were on board the "Seawise" on that day it is not possible to say, but this Court, after a most serious scrutiny of the formidable body of evidence put before it, has come to the conclusion that there cannot have been less than three. Of these only one, that at the cross alley at 110 frame on C A' Deck, has been precisely located. A matter of minutes after it was detected there were reports which proved reliable of a fire 40 yards aft of it on 'B' Deck, and a fire 150 yards forward of it in the area of the Sun Deck close to the Captain's Bridge and wbeelhouse. The precise sources of these fires have not been identified The possibility of the spread from this one precisely known source, by conduction of hot gases or flame with explosive sudden ess, to the other areas through connecting alleyways and ventilation trunking even with fire doors and dampers open is too remote to be reasonably entertained. In the first place, few of the ventilation trunks pierced the fireproof vertical zone bulkheads, and none which did so opened into any of the stair wells. Secondly, the time factor is against such a possibility. Thirdly, there was abundant evidence that during the fire fighting on 'B' and 6 A' Deck levels, there was much scurrying to and fro of persons engaged either in fire fighting or in flight between the three major areas we have referred to. Their presence in these areas alone sufficiently disposes of the theory of any explosively sudden conjunction of three widely sepaiated fire points. The Court has therefore concluded that there cannot have been a common source for the three major sites of fire located within a matter of a few minutes only from the earliest alarm What remains obscure is the location of the other two sources. It is probable that the fires which were fought in the stairways at 70 frame and 48 frame on C B' Deck had a common source, possibly on 'A' Deck above them. Mr. Yu Kwok-ming (Witness 55), one of the engineroom staff, who lived aboard the vessel, having come up to the after end of 'A* Deck from his cabin on *D' Deck, saw very dense black smoke rolling aft along the open port alley on 'A' Deck, the smoke glowing as though it concealed a large flame. He saw about twenty crewmen using two hoses to fight this fire and he went forward some distance to help them but the flames began to extend towards the stern and all of them were forced to retreat down several ropes and rope-ladders from the stern into a Police Launch which was standing by below. He estimated that he had spent about one hour helping fight this fire and that it was almost one o'clock when he was rescued by the Police. His first encounter with this fire would have been about a.m Regarding the forward major site of fire, that reported in the area of the Wheelhouse, none of the witnesses who spoke of signs of fire in this area saw any flame. The Court is satisfied, however, that there must have been a source of fire somewhere beneath the Navigation Bridge, possibly in the Officers' quarters as previously mentioned. The witnesses who went up to the Sun Deck and Bridge were primarily concerned to locate and report, and there is no evidence that either fire extinguishers or hoses were used. The density of the smoke, its rapid increase, and the labyrinthine nature of the accommodation in the area would have made it impossible, as well as extremely hazardous to carry out a systematic search for the source. As most of the Commodore's resources had been at once directed, or had gone to the known sites of fire on 'A' and 6 B* Decks, there were not enough personnel to deal with that additional emergency. For this reason the fire on the superstructures forward spread unchecked with greater rapidity even than those aft and it may well have been the source of the fires which eventually were observed in the Main stairway between 4 A* and 'B' and 'B' and 'R' Decks and, later still, in the forward main stairway at about 255 frame. This appears to be the most likely supposition, but it remains possible that each of the three great central stairway fires had itself an independent origin It is of inteiest that the burnt out hulk of the "Seawise", even as now visible above water, shows two major areas of collapse. One is forward in the region of the Bridge and one aft and slightly forward of the swimming pool where several decks appear to have buckled and fallen in upon each other through the intolerable stress of heat. If there was a common source for all the separate fibres observed and fought forward of 200 frame it must have been a source of great size and intensity to bring about so widespread and so catastrophic an involvement reaching downwards five or six decks and involving two of the principal stairways within the space of one hour It is unfortunate that the one positive means of establishing the times and locations of the separate outbreaks should have yielded such meagre results. Had it been vigilantly observed, the control panel in the forward fire-station would have been able to provide, by its arrangement of coloured lights, information as to when and where any fire had started and which alarm had notified its existence, at least up to the time when fire interfered with its operation. On his own evidence Mr. Liu fai, the foreman of the party of four firemen on duty that day, cannot have been at his post in the fire station when the first alarm was raised by Mr. Ko at about a.m., as he only heard the bell and saw the red indicator light just before he heard the Public Address announcement which was made by Chief Office Liu hen about a.m. Moreover, he left the fire-station almost immediately with equipment and went to the scene of the fire where he stayed to help for about twenty minutes before returning to the fire-station, where he saw more lights on the panel. The Court has thus been deprived of evidence which might have been of inestimable value in pin-pointing the times and places of the various outbreaks. 31

34 2. The Commodore, The Officers and Crew 110. Although lacking a Public Address System and faced with a state of increasing confusion owing to reports of several fires in different areas, there was a genuine attempt by the Commodore and his Officers to set up and maintain an Emergency Fire Centre on 'A' Deck. The procedure described in the attachment to the ship's Standing Orders (Appendix A.8), although cursory was admirable at least in that it did provide for a jfull muster of crew at *A 9 Deck on the outbreak of fire, but it crumbled under the pressure of events and the action became increasingly incoherent and unco-ordinated. Although that pressure was extreme it must be recognised that the comparative breakdown in the fire organisation, is directly related to the fact that there had been no regular musters or fire drills involving all members of the crew aboard at any given time, Restaurant staff included. It may be added that lacking an adequate organisation of the sort envisaged in the Standing Orders, the Commodore and Ms officers have to be commended for the energy and initiative shown by them in endeavouring to see that contact was maintained with each separate site of fire fighting and that the combatants at each place were directed and encouraged So far as fire fighters, patrolmen and deck crew are concerned, it is plain that their understanding of the Fire Orders which were posted up at various places on the ship (see page 10 of Appendix A.8), stopped short at such immediate reactions as the sounding of an alarm and proceeding to the site of the fire although this is a duty which was specifically assigned only to the actual fire fighting personnel. Not only was there no call for the rest to muster at 'A' Deck office but the actions of all persons other than to the professional fire fighters seem to indicate that none of them can have been aware of that important secondary duty which in paragraph 3 of the Fire Orders is expressed (in the English translation) in the following terms: "3. The Duty Officer, in case of fire alarm, should assume the responsibility promptly to command the fire fighting on board, notify personnel concerned with fire fighting to contact shore Fire Services, to announce necessary information to all crew members to be mustered at the Fire Control Centre and organise reinforcement teams to render immediate assistance to fire fighters in the fire zone." 112. Within the limitations of their training and their understanding of their duties the motley force which rallied immediately after the alarm endeavoured to deal with an appalling situation with great courage and tenacity. It would be invidious to single out individuals in this matter. All who dealt with the fires, the carrying of equipment and relaying of messages, etc., acquitted themselves well Although the nomination of individuals and their duties had been recommended by the Director of Marine (Appendix A. 13, page 2 of paragraph vi), no instruction of this sort appears to have been given and such formal nomination as there was, (Appendix A. 14), was in the most general terms only. The fire patrolmen knew virtually nothing about ships and some of them had only been on board two days and had little training of any sort. The actual number of patrolmen was inadequate and should, in our view, have been at least double the number in order to ensure effective patrolling of the main parts of the ship every hour. As Master designate, the Commodore was at least technically responsible for any deficiency in the patrol and fire fighting arrangements. But it was the I.N. Company through the project team which was effectively in contiol of such matters as numbers of fire fighters and patrolmen to be employed and it must be noted that Captain LAM had been advised by the Director of Marine that patrolling should be done by men in pairs and that this was never done. In this connection, however, it should be added that neither the Commodore nor the Company officials seem at any time to have been given an estimate, either by the Marine Department or by the Fire Sei vices Department, of what was considered to be an adequate minimal figure of fire fighters. Had there been closer liaison between the Commodore and his crew and members of either of the Departments even on the basis of informal visits and discussions and had it become apparent that there was no adequate back-up force of trained crewmen to assist the four trained fire fighters on duty, it seems likely that some revision of the arrangements in force would have been suggested on the lines which have been indicated in this paragraph and in paragraph 123 hereunder. Within the limits of the roles adopted by the Fire Services and Marine Departments (see paragraphs 135 et seq infra) the liaison between the heads of departments, the ships company and the officials of the I.N. Company itself was good, but there appears to have been little liaison, if any, between the Company's men and the "Seawtie" crew, including the senior officers. An obvious example was when Chief Officer Liu hen went to the Public Address Centre to make his announcement about the fire and did not recognise any of the men in or near the Centre, nor did they recognise him Notwithstanding the foregoing criticisms or any appearing hereafter it must be added that the Commodore handled the emergency in a most impressive manner. Any mistakes which he may have made were due to Ms inexperience in relation to what could happen to a passenger ship of this size if she caught fire in the unusual conditions of her refitting. This Court is of the view that if he had had the opportunity of assuming command with a fully trained crew at sea he would have run Ms smp with the utmost competence. Although he may not have reacted with sufficient insight to some of the less favourable aspects of Ms inherited situation, yet on the day of the fire he did act with judgement and determination in an impossible situation and in the best traditions of Ms cloth. It reflects much credit on him that no lives were lost. 32

35 115. Of the Engineers it might be said that they came perhaps closest to adhering to conformity with the Standing Orders. Almost without exception they moved to their posts at the pumps and other machinery and waited in conditions of considerable suspense, and eventually of great discomfort from smoke, for orders and for news of the progress of the fire The Chief Engineer and his subordinates maintained good discipline and carried out the Commodore's request to remain at their posts until the signal came to switch off the generator. This was done as late as 1.40 p.m. at which point water from the Fire Services and other hoses was streaming down into the darkened enginerooms and the ship was already listing appreciably to starboard. Early in the emergency the Chief Engineer, Mr. WONG Chung-wing (Witness 7) had ordered Mr. Po Sik-kuen (Witness 37) to check that the fans were shut off and also to switch off the ship's hotel lighting fore and aft in order to minimise the risk of fire through shorting of electric wires. He also organised a team of six of his men to go help with fire fighting and having found the telephone was dead between the engine spaces and 'A' Deck office he organised a relay of his staff to carry messages to and from the Commodore. Messages were relayed in this way on several occasions the last of them being that relayed by Mr. Po Sik-kuen at 1.30 p.m. to switch off the generators. When the generators were shut off the pumps stopped and the engineroom staff left their posts being among the last of the crew members to leave the ship. Many of them escaped through a shell door on 'C Deck. Before this, of course, the Fire Services had come on board and were making a last ditch stand against the fire raging at the Main stairway from 'R' Deck upwards. 3. Shutting of Fire Doors and Dampers 117. Only in the later stages of the operation on the 9th January were any fire doors closed, some by Chief Officer ZEE, some by the Commodore himself, and others by Fire Services personnel. No fire dampers were closed at any time nor was any order to close them given. The Commodore had been greatly impressed by the Jumbo Restaurant fire disaster and had called a meeting in the course of which it was decided that the shutting of fire and shell doors should be left to the discretion of the officer-in-charge at the particular locality as the occasion arose. There was no general intimation of the importance of this action and on the day of the casualty at no time was any general order to shut doors given by any officer. There seems to have been no good reason for leaving the fire dampers open once the work of fireproofing in the various trunks and ducts containing the dampers had been completed. With the dampers open the draught throughout the ship after the outbreak was facilitated, but it must be said only to a minor extent The importance of seeing that fire doors and dampers are closed whenever possible has been stressed by Courts of Inquiry in findings on previous similar disasters and is also stressed in the 1950 "Ministry of Transport Working Party Report on Fire Prevention and Fire Fighting In Ships in Port" (which for convenience we shall refer to hereafter as the Working Party Report). It is understood that the difficulty of deciding when to shut fire doors may be considerable when the operation covers a very large area under conditions of confusion such as prevailed upon the "Seawise" on the day in question. But the real criticism here is that no general instruction appears to have been given as to the importance of carrying out this manoeuvre and this once again reflects a weakness in the nature of the instructions given and the failure to hold musters and drills. 4. Ship's Side or Shell Doors 119. It was well understood that these doors produced a problem. There was on the one hand a genuine necessity for many of them to be open for various purposes in the course of the renovations. There was, however, an overriding necessity to keep the number open to a minimum at any time. This is especially true of those at the lower levels. Mr. Lack's letter of the 31st August, (Appendix A.15) had drawn attention to the danger involved but nothing was done to minimise the risk from this source. Reasons were given for keeping open each of these doors but we are of the view that the stated purposes could have been well served with fewer doors open. No effort was made to keep the number open on *C Deck level to a number such as could have been coped with by a few men in an emergency. The Commodore gave the safety of life and the need to maintain emergency exits as one of the principal reasons for not having more of these doors closed and, in the event, some of these doors were used by people effecting their escape. Nothing in the evidence however has persuaded us that this paramount necessity would not have been equally well served, even as events fell out, by keeping open a sufficient number of doors on the higher 'R* and C B' Decks and providing them with rope ladders permanently at the ready for lowering to the water. The sealing of *C 9 Deck by closing the shell doors in time might have saved the vessel from capsizing The closing of shell doors is a considerable labour involving the co-operation of several men at each door. After the fire aft on 6 B' Deck had been reported there was no time or personnel available to close these doors. Nor was any order ever given to do so. The efforts of Mr. Hutchins, Mr. Wood and Fireman Jo in partially closing one of the *C Deck shell doors, commendable though it was in view of the conditions then prevailing, was of no avail in stemming a major source of danger to the ship's stability The photographs show a large number of portholes open, and although it was stated that on completion of work in cabins all port-holes were closed, it is a reflection on those charged with inspection or patrolling that 33

36 there were so man w cpen. Duting :be emergency no order was ghen to close the portholes and there is no evidence that any were closed Whatever the difficulty, we believe that the only sound way to have approached the question of fire security on so large a ship In so vulnerable a state was to have treated her as though she were a ship at sea. A full and comprehensive "Station Bill" had already been prepared and would have come into force when the vessel went to sea. (See "Station Bill" attached to Appendix A.16). Appendix A.16 includes a Statement made by Chief Officer Liu hen in the course of the inquiry in answer to certain questions suggested by the Court and put to him by counsel for the Director of Marine. Paragraph 7 of that statement is of interest in relation to this question of instructions as to closing of fire doors, dampers etc. According to Chief Officer Liu the Fire Fighting Officer was responsible for conveying to all fire fighting personnel a general order which is described in the following terms: "All fire doors, fire dampers, port lights and port shell doors must be closed when fire has occurred." This instruction, with other instructions aboard the ship, was lost by fire and one can only say that if such a general instruction was in existence and had been made known to the responsible officers, no attempt to implement it appears to have been made in the course of the emergency on the 9th January It is not suggested that the sea-going "Station Bill" was capable of being implemented while the work of refitting continued and the ship was at anchor in the harbour since crew was being steadily recruited throughout that time and the numbers of those recruited swelled rapidly in the last couple of weeks before the fire. It was incumbent however, on the Master to have found some reasonable half-way house between full sea-going organisation and the desultory combination of verbal instruction and practical shore training which was relied upon. For a ship the size of the "Seawise" anchored so far from shore, it was highly advisable for her security to have had permanently available on board a force of fully trained fire fighters possibly twice the size of the entire force of twelve actually employed and only four of whom at any time were likely to be aboard. This, combined with a back-up force of crewmen with some fire training and with clearly nominated duties, might have been able to deal with any reasonably foreseeable emergency and, in case of a multiple emergency of crisis proportions, it might have been capable of holding up the spread of fire until further forces could have assembled from the shore. Although we think that the Commodore and the Company officials could have been given more advice on this matter from the two Departments primarily concerned, it must be repeated that the responsibility remained that of the Commodore in conjunction with the Company. If the provision of such a force as we have suggested was physically or financially impossible then it would have been prudent to have had the work carried out at a port where the ship could have been moored alongside a few minutes' distance only from immediate large-scale help from the shore Fire Services. In these latter circumstances a very much smaller force, and one more of the size actually employed, would probably have been adequate to confront majoi emergencies. 5. The Sprinkler System and Fire Pumps 124. The evidence shows that this system operated efficiently up to the time when the generators were switched off, although few witnesses actually saw the Sprinklers working. The evidence of the Chief Engineer and one of the junior engineers, coupled with the fact that yellow sprinkler lights appeared upon the Control Panel confirm, this conclusion. Onl> six to eight fire hoses were used in all and we are satisfied that the pumps maintained an adequate pressure in these at all times while the operation proceeded. Furthermore, there were five other pumps available to maintain and increase pressure had the need arisen. 6. Switching Off of Ship's Lights 125. This was the result of a direct order by the Chief Engineer Mr. WONG Chung-wing (Witness 7). The order was carried out by Mr. Po Sik-kuen, the "Seawise" electrician (Witness 37) at about to a.m. The intent was to prevent further outbreaks as the result of the electric wiring shorting. In the circumstances the order, although it undoubtedly increased the difficulties of evacuation, and, to some extent, of the fire fighting operation, when torches had to be used extensively, cannot be regarded as an act of neglect or default and was probably justified by the circumstances. Furthermore it did not contribute materially to the rapid deterioration of the whole situation. 7. Failure of Public Address and Temporary Telephone Systems 126. The temporary Public Address System and the temporary telephone system both went dead just after the announcement of the fire in Mandarin and then in Cantonese, which would be about a.m., coinciding as nearly as can be estimated with the time that the lights in the after part ot the ship were switched off from the generator station. The systems being merely temporary, were most likely wired into a near-by lighting circuit, and as the main generator was kept running, the emergency battery circuit would not take over. If the failure of these systems was due to the switching off of the lights, then, although that failure made the Commodore's task more difficult, it did not materially affect the outcome because the site of the headquarters of the Public Address 34

37 and Telephone Systems would have had to be abandoned in any case very soon after because of smoke and flame in the vicinity The manual and sprinkler alarm systems in the forward Fire Station were the ship's permanent systems and would have had their own circuits, so they would not be affected by the switching off of the lights. The lights on the Panel would stay on and further lights would come on by the operation of the manual and sprinkler alarm systems accordingly as the latter came into operation until of course any part of the system was put out of action by fire, and Mr. Liu fai's evidence that lights did come on can be accepted. There is no evidence to show why, in view of the many areas eventually affected while he was still in the fire station, no more than eight lights were lit on the Panel. 8. Performance of Fire Services After the Raising of the Alarm 128. Echoing the sentiments of the Working Party Report, Mr. Wood, Director of Fire Services, gave it as his opinion that the opening minutes of any fire are the vital minutes which decide between whether it is to be a minor affair or a serious outbreak. He was of the view that had trained firemen been present almost at once in significant numbers it might have made a material difference as they would have at once endeavoured to attack around the perimeter of each perceived site of fire. A half-hour's delay in this matter is very often decisive. This makes it all the more strange that the earliest arrivals from the Fire Services waited about half-an-hour after arriving at the "Seawise" before putting a party on board The photographs alone are unmistakable proof of the huge dimensions of the task facing the Fire Services at the arrival of the first of the Fireboats. The Court takes the view that it would have been advisable for the Fire Services Officers to have put some of their men on board the entrance on the e R' Deck at the earliest opportunity, where their training and skills could have been better used in that way than by simply directing water on the superstructure. Their failure to do so has not been explained. Since it was certainly not due to any lack of desire to render prompt assistance it may perhaps have been the result of poor liaison, prior to the emergency, between the Departments, the I.N. Company officials and ship's company. Subject to this criticism, however, it should be added that, within the limits of the opportunities still available to them on arrival at the "Seawise", both the Fire Services and the Marine Department personnel did their utmost to contain a situation which was, by then, beyond the bourn of recovery at least in regard to the putting out of the fire. The situation was, even by p.m., such that it was unlikely to have been retrieved even had the earliest Fire Services personnel gone aboard at once. When they did go on board, the firemen, including some of their senior officers, at considerable risk to themselves, worked in conditions of extreme discomfort and danger in a clearly deteriorating situation, for some two to three hours before eventually abandoning the ship. 9. Evacuation 130. Most of the persons on board the "Seawise" on the 9th January, were workmen but there were also numbers of visitors and guests. The Commodore is to be commended therefore on his early recognition of a very serious situation and his early action in giving the orders to have the ship cleared of all persons not required to fight the fire. In this matter the Security Guards gave good service, standing in prominent positions in public squares, alley-ways etc., rallying and directing people. They, together with some crewmen, kept crowds of people moving steadily towards the principal exits on 'R' Deck. Chief Officers ZEE and Liu hen were likewise prominent in helping many confused and somewhat frightened people to escape by ropes, rope-ladders or lifeboats, for which the expectations of the day and their normal occupations had ill-prepared them. In the later stages, with the ship beginning to list heavily and many areas smoke-logged, the persistence of some crewmen, Fire Services personnel and senior ship officers including the Staff Captain and the Commodore, in conducting orderly searches in the nether regions of the ship in areas grown unfamiliar with the darkness and the list, down companionways slippery with streaming water from the hoses, is none the less commendable for being the discharge of a necessary duty. Considering the size of the ship, the disastrously rapid advance of the fires, the general lack of co-ordination resulting from the various causes already mentioned, the lack of light at all levels and the steady encroachment of smoke, it is an astonishing fact that not a single soul was lost. The only serious casualty in fact occurred when one of the Company officials who had been fighting the fire in the stairway at frame 70, while escaping with a companion through a porthole, fell into a launch below and broke his leg and several ribs. The only other injuries reported consisted of minor cuts and rope burns Apart from the work done by the officers and crew and the Fire Services personnel and the Marine Department personnel on board the "Seawise" and in her vicinity on the day in question we would like to add that the Police are to be congratulated on the rapid and efficient mobilising of their launches and other craft in the vicinity to rescue survivors from the sea and from the vessel itself. The use of loud hailers was obviously of considerable assistance in keeping those on board aware of the location and proximity of help. Loss of life from a combination of shock and drowning was a present possibility and it says much for the orderly combination of all three Services together with various private helpers such as Mr. Moir, that no one escaped the fire only to perish in the sea. 35

38 10. Note on 132. In its contingency plan in the event of a serious outbreak of fire aboard the "Seawise" the Marine Department considered the possibility of beaching the vessel and came to the conclusion that in the event of fire the decision \\ould have to be made at a very early stage. The Commodore promulgated a plan together with a description of the personnel required for this operation. (Appendix A.8) Without power available for the windlass it would take at least two hours to break the cables and slip the wires; and with or without the use of the main engines at least four tugs with the combined total of 10,000 h.p. would be required. The ship would have to be under control before releasing operations could begin. On the 9th January, such tugs were not at hand The Director of Marine said that moving the ship when already on fire, fore and aft, to a place where she could be safely beached was highly undesirable and dangerous on account of proximity of the oil installation on Tsing Yi Island, a power station, a container ship berth at Kwai Chung and an explosives depot at Green Island. He also said that even if it had been possible to release the ship from her cables and wires, she might become a grave danger to other shipping in the harbour. With all these observations we are in full agreement. The 'Public* Authorities: General Interest of Government Departments Concerned: Advice, Supervision, Liaison etc We have been specifically asked to say whether any Government Department had any statutory responsibility in respect of the "Seawise* 9, and if so, whether such responsibility was duly discharged. It would be convenient at this point, therefore, to consider the relevant provisions of the law and then to examine the action taken prior to the outbreak of fire on the 9th January, with a view to determining whether either of these two departments or any other Government department failed to take any preventive measures which they ought reasonably to have taken. It is clear that both Departments had taken very definite positions as to the scope of their actual duties and powers and the demarcation of their separate responsibilities. According to Mr. Alexander, the Deputy Director of Marine, while the safety of shipping and port installations in general is the responsibility of the Marine Department this does not extend to working conditions on board ships anchored in the harbour. He told the Court that the Department takes the view that it has no authority to interfere with or to direct the course of work aboard ships unless the ship-owners or the Master has applied for a 'dead ship' permit. Provided the ship has a Master and is not a 'dead ship* then the Marine Department, in his opinion, has no legal responsibility for what might happen aboard as a result of work in progress. Once the ship was a 'dead ship', however, (within the meaning of paragraph (b) of Regulation 5(5) of the Merchant Shipping (Control of Ports) (Regulations), then, he conceded that the Director would be fully equipped with all necessary powers to give directions, and to see that they were enforced, for the safe conduct of work aboard the ship. He also said that if the Department thought a ship was 'dead* in fact and if the permit had not been applied for the Director might intervene to require this to be done As for the Fire Services Department, Mr. Hutchins, the Chief Fire Officer (Hong Kong Island), told the Court that it was not considered that the department had authority to lay down and enforce safe conditions of work aboard ships but only to make recommendations and that, furthermore, there was a departmental understanding between the Fiie Services Department and the Marine Department that the primary responsibility for seeing to safety factors aboard ships undergoing renovations was to rest with the Director of Marine, although it would be the duty of the Fire Services to deal with actual fire outbreaks on board ships whenever called to do so In the recent inquiry held under the Commissions of Inquiry Ordinance, Cap. 86, into the "Jumbo" floating restaurant disaster, the Commissioners had occasion to inquire into the relevant legislation as it affected three different Government departments. These were the Maiine Department, the Fire Services Department and the Labour Department. This Court finds itself in sympathy with the dissatisfaction expressed by the Commissioners concerning the legislative position generally in relation to vessels being built or repaired at anchorages other than those in the precincts of a shipyard. (Paragraphs 78 to 92 of the Report of the Commissioners). The Commissioners came to the conclusion that Section 78 of the Merchant Shipping Ordinance, although it was arguably wide enough to give the Director of Marine power to exercise supervision over such matters as work methods on ships in the harbour, was, nevertheless, an unsatisfactory provision for this purpose, if only because no penalties are provided for any failure to carry out any directions which he might give. The Commissioners rightly regarded it as a dubious transplant from legislation with quite a different purpose (paragraphs 84 and 85 ol the Report). Whether the Commissioners were right in their view that the enabling words were not limited in any way is another matter. The power expressly given in Section 78 "... of taking all such measures as may be necessary for providing against fire or other accidents...", ample though it looks in isolation, is clouded by the prior context where a specific distinction appears to be drawn between the power to direct the conduct of any policemen on board a ship and the power merely to inspect and observe the conduct of all other persons employed in lading or unlading. Read as a whole, these provisions convey the impression that what the Legisla- 36

39 ture intended to confer was a power to board and inspect and to deal, ad hoc, with any anomalous or dangerous situation perceived to exist rather than any right to formulate and enforce a safe system of work. The possibilities of challenge to any enthusiastic interference with the working habits of shore labour or crew are all too clear In our own case two other provisions have been resorted to for the same purpose with no better issue. As to Section 66 of the Merchant Shipping Ordinance, the Court is in agreement with Mr. Somerville that the power given therein should be regarded, conformably with the subject matter of the section as a whole, as being restricted to such orders only as seek to regulate the movements of shipping in the harbour or acts ancillary thereto The only other provision which might be employed to provide the Director of Marine with power to direct and control the manner of carrying out repairs aboard a ship is to be found in Regulation 5 sub-paragraphs (4) and (5) of the Merchant Shipping (Control of Ports) Regulations which is in the following terms: " (4) Except with the prior permission of the Director, no dead ship shall be anchored, moored or secured at any place within the waters of the Colony nor, except with such permission, shall any repairs be undertaken upon any ship which is so anchored, moored or secured which will result in such ship becoming a dead ship. (5) For the purposes of paragraph (4) (a) Any permission granted by the Director may be granted subject to such conditions as the Director may think fit in the circumstances; and (6) The expression 'dead ship' means a ship that is unable within 24 hours notice to have her main propulsion machinery capable of effectively propelling the ship." This provision was valueless as a means of coercion since throughout the period of renovation the "Seawise" was never regarded by the Director as a dead ship. On the evidence before us we are satisfied that he was at least technically justified in taking that view although the Court entertains some doubt as to just how "effectively" the "Seawise" could have been propelled under her own power within the specified time (and even more in doubt as to how effectively she could have been manoeuvred) In their consideration of the position of the Fire Services and Labour Departments the Commissioners of the "Jumbo" Inquiry, drew attention to the manner in which, finding the law's patchwork a dubious cover for control of shipboard operations, those authorities had purported to limit or extend their areas of responsibility by administrative consensus. Thus the Director of Fire Services and his subordinates who, by virtue of Section 7 of the Fire Services (Amendment) Ordinance 1964, might seem to be the department most directly and least equivocally endowed with the necessary regulative powers, had apparently resolved the problem of over-lapping duties by administrative arrangement between themselves and the Marine Department. This was done by agreeing to limit their operations aboard ships to the fighting of fires when called out for that purpose. We have not actually been shown the minutes in which this administrative agreement is recorded but we have no doubt, as a result of the evidence referred to above, from the Marine and Fire Services Departments witnesses, that such an agreement was in force. (In this connection see also paragraph 80 of the Commissioners' Report in the "Jumbo" Inquiry) By contrast the Labour Department, which formerly bad restricted the use of its powers, under Section 11 of the Factories and Industrial Undertakings Ordinance, to the repressing of dangerous practices aboard ships in registered shipyards, has, we understand, recently and presumably by way of administrative reappraisal resolved to extend its own area of responsibility to take in ships elsewhere as well. (Paragraph 90 of the Commissioners' Report in the "Jumbo" Inquiry). This latter instance is mentioned solely to illustrate the present confusion among authorities with over-lapping interests in relation to shipping. It has never been suggested in the present inquiry that the Labour Department bore any responsibility for the "Seawise" nor do we think it reasonable to suppose that it did. This is not primarily because of the difficulty (adverted to by the "Jumbo" Commissioners) of placing a sea-going vessel within any of the categories which, at law, constitute the definition of a Factory or an Industrial Undertaking. Where common sense required it mere ingenuity might well succeed in doing that since both of these concepts pivot in their turn upon the readily debatable category of "place". In ruling out statutory liability for the Labour Department the obvious technical objections are surely subordinate to the consideration that the Factories Inspectorate is simply not geared to regular seaborne operations The Fire Services (Amendment) Ordinance, 1964 gives the Director powers to enter any premises (a word which is defined as including any "place") for the purpose of determining whether or not any fire hazard exists therein, (S. 7A), and, if satisfied that such exists, he may serve an abatement notice requiring all necessary remedial action to be taken within a specified time, (S. 7B(1)). Failure to comply is an offence, (S. 7B(3) ), punishable by fine. Power is also given to apply to a magistrate's court to enforce compliance with the provisions of any such abatement notice by the making of a fire hazard order, subject to heavier penalties for non compliance, (S. 7B(5) ). 37

40 143. In t! ie *jj^ot, t.-^cive., it \vou!ct appear to be the Fire Services Department which, as a matter of legislative intention^ comes closest to direct responsibility for the "Seawfse" regarded as a potential fire hazard. We agree with the Commissioners, however, that even this is not beyond debate and for these reasons we have answered question 62 in the negative. Clearly it is an unsatisfactory situation when the legislative cover for controlling ship repair operations in the harbour is left sufficiently doubtful to justify the distribution of duties between Government Departments on a "territorial" basis by administrative practice There remains, however, the question whether, short o'f strict statutory liability, the Fire Services or the Marine Department were wanting in the due performance of any more general duty to provide against dangers arising from the "Seawfse" scheme. We think the question does arise, although not specifically proposed, firstly, because it is part of the general intention of their respective Ordinances that these departments be charged with the duty of safeguarding the public against dangers arising from things within their general spheres of interest and secondly, because the heads of both departments have, while not acknowledging any strict statutory responsibility, made it quite clear that they felt morally bound to interest themselves in the way in which the operations were to be conducted Reference has already been made to the findings of the Commissioners in the "Jumbo" Inquiry since there are obvious parallels between that case and the present case and the observations of the Commissioners are in many respects most helpful and in point. It is well at this juncture, however, to note two outstanding distinctions between the two cases, particularly in relation to the evidence tendered. On the evidence put before the Commission it appears that, effectively, the part played by the Marine Department in the building of the "Jumbo" was to approve the various plans and to sanction the movement of the craft from its shipyard round to Aberdeen: while the Fire Services Department does not appear to have taken any part in the affair whatsoever until the fire broke out. On the evidence as a whole the Commissioners in that case were able to say, of the Owners and Contractors, (paragraph 12 of the Commissioners Report): "But the question of safety, particularly of fire risk does not seem seriously to have been taken into account by any one at all"; while at paragraph 91 they were drawn to summarise the performance of the Government departments in the following terms: "91. The net result was that although each of the three departments was possibly in a position to take some form of action before the fire, each of them, by reason of the matters we have just outlined, deliberately refrained from making any attempt. It is unfortunate that the situation was left at rest in this manner until brought to attention by so grave a tragedy." Nothing of the sort could be said in the present case. In the first place, as we shall see, the concern of the Marine Department and of the Fire Services Department was evidenced early on by a considerable amount of consultation and forward planning involving both departments and the I.N.C., even before the vessel had arrived from the United States Secondly, it was possible for the Commissioners in the "Jumbo" case to be certain of the immediate cause of the fire and to assign, as a secondary cause of the disaster, a chaotic and dangerous work system which included such matters as "unwatched" welding (itself the primary cause of the outbreak), the indiscriminate distribution of dangerous and inflammable material throughout the craft, a considerable deficiency in fire-fighting equipment and a virtually total absence of fire patrols and fire-fighting personnel. Whatever may be said of the situation aboard the "Seawise" it was very substantially different from the situation there described In view of our finding as to the probable causes of the fire and our assessment of the vessel's chances of survival there is little to be gained from pursuing the question of contributory causes and it must be said at once that, notwithstanding the criticisms and recommendations appearing herein, we do not intend to suggest that the observance in substance of any of the recommended measures would, in the event, have been certain or even likely to have saved the ship. Nevertheless, a high degree of interest in her future was shown and this coupled with the sense of moral obligation for her security which top officials of both departments have expressed obliges a scrutiny of the degree to which liaison was maintained and the manner in which it was sought to discharge that obligation. Even if the Director of Marine regarded his powers as being restricted to advice and exhortation it was evident he was prepared to offer both. The Director of Fire Services and his department were interested to assist in this and the LN. Company was prepared to listen It was recognised that, even if the "Seawfse" did not become a 'dead ship', a passenger ship of such size was bound to become a serious fire hazard while undergoing extensive renovations. The risks inherent in such a situation especially as regards passenger ships is strongly stressed in the Working Party Report. It is clear that this Report was the basis of all the recommendations actually made to the Owners* representatives by both departments. It was therefore necessary, in the interests of the safety of ships and installations in the vicinity of the "Seawise", for the Director of Marine to cause contingency plans to be made. This was done in con- 38

41 junction with the Fire Services Department and a copy was forwarded to the Owners' representative on the 13th September, The plan, together with the covering letter appears in Appendix A.3 to this Annex. It will be noted that there are exhibited as Appendices thereto; (a) a list of "additional conditions" applicable should a dead ship permit be applied for; and (b) a copy of the operational orders which had been specially prepared by Mr. Hutchins of the Fire Services Department before the arrival of the "Seawise" covering Fire Services procedures in case of emergency This composite document is, effectively, the end product of the liaison between the Company and the two departments on questions of security and is the document referred to in paragraph 22 above. Thereafter, apart from one visit by Assistant Marine Officer LAM of the Marine Department, on the 7th November, 1971, there is no evidence of further actual contact with the owners until the fire outbreak on the 9th January. In the time immediately before her arrival and up to the submission of the contingency plan (Appendix A.3), there was, however, considerable activity by way of meetings and correspondence involving the two departments and the owners representatives In the early stages at any rate there was evidently a degree of concern in the Marine Department as to the conditions aboard the ship. (See letter from the Principal Marine Officer to Captain LAM on the 31st August Appendix A. 15). Again, even before her arrival, the Senior Surveyor of Ships, at that time, Mr. Matthew, had recommended that Marine Department and Fire Services officers should be nominated to supervise the way in which all departmental recommendations were carried out. Mr. Matthew's suggestion was made in a report attached to a Minute to his departmental superiors (see Appendix A. 17 paragraph 8 (iv), page 6 of attachment B). This thorough and painstaking report (Appendix A. 17) was the result of Mr. Matthew's own research into the whole topic of fire security aboard ships. It is the final form of an earlier Minute prepared as the basis for discussion with officers of the Fire Services as to the nature of the precautions against fire which should be recommended for the "Seawise" before she had arrived. It was Mr. Matthew who, when the "Seawise" was nearing Hong Kong, had been requested by the Deputy Director to enter into consultations with the Fire Services Department on behalf of the Director of Marine to discuss such safety measures It will be seen from his report that, although Mr. Matthew recommended, among other matters, supervision of the operations aboard the "Seawise" by officers of the Fire Services and Marine Departments, Mr. Matthew was himself aware that there was little in the way of legal cover for implementing that suggestion. His report was, in effect, a comprehensive attempt, based mainly on the Working Party Report, to cover all conceivable aspects of fire security irrespective of the strict practicability of several of the remedial measures suggested therein. As will be noted the Deputy Director of Marine, in line, of course, with the view of the Director himself, took the view that unless a 'dead ship' permit was applied for the Director had no power to supervise and enforce the carrying out of any recommendations he might make. This in itself was sufficient reason for not complying with Mr. Matthew's suggestion of direct supervision. But it was not the only reason. The Deputy Director did eventually issue a list of recommended procedures to the owners' representatives. These are contained in a letter to Captain LAM dated. 19th July, 1971 (Appendix A.13). Priorto this the owners'representatives, (I.N.C.) had shown no unwillingness to co-operate with the department. On the contrary their attitute is fairly revealed by the exchange of letters between Mr. Alexander and Captain LAM following a meeting on the 8th January, That meeting was primarily concerned with problems of pilotage and anchorage but Mr. Alexander told us that he had also stressed the dangers peculiar to ships during refitting and that conditions relating to 'dead ships* were also covered as was the necessity for maintaining regular fire patrols. These letters are attached as Appendices A. 18 and A A similar harmony prevails in the Minutes of the meetings held on the 18th February, 1971 in the office of the Senior Marine Officer. This meeting was convened to sort out problems associated with the arrival of the "Seawise". Once again Captain LAM was present on behalf of the C. Y. TUNG group, (Appendix A.23). Again in the Minutes of the meeting held on the 29th June at the Marine Department under the same chairman, Mr. Habesch of the Marine Department, at which fire precautions were discussed, there were no less than three high executives of the I.N. Company in attendance and there is no reason to suppose that the discussion was other than serious in intention and amicable in atmosphere. (Appendix A.20). It was at this latter meeting that the decision was taken to invite the Fire Services Department to carry out an inspection of the vessel on her arrival in particular of her fire-fighting equipment and arrangements. A party composed of Marine and Fire Services personnel which included Mr. Matthew of the Marine Department and Mr. Worrallo, the Assistant Chief Fire Officer of the Fire Services Department (Hong Kong Island), went on board the "Seawise" on the 15th July, the day of her arrival. A less propitious occasion could scarcely have been chosen. The vessel had arrived to fanfare. By common admission she was very much 'down at heel'. There were hundreds of visitors and sight-seers wandering about in various areas. The Captain was, no doubt, caught up in the usual end of voyage formalities and discussions; the crew 'at ease* after the tensions of a long and 39

42 somewhat unlucky ^ jyage. In the I'pshct there was no Inspection worthy of the name. Instead there was a brief and unsatisfactory Meeting with an unidentified Chief Officer and a fairly lengthy interview with the Fire Officer, Mr. George Vollmer, in the Fire Station, concerning the vessel, her equipment and organisation generally. It will be remembered that Mr. Vollmer had travelled over as Instructor and Fire Officer on the way from the United States. His contract expired upon the day of the ship's arrival in Hong Kong. He did not appear as a witness but it would seem that he gave a gloomy account of the state of the ship's fire security and that it was on this strength and not pursuant to any actual inspection that a meeting was held on the 16th July at the Fire Services Department Headquarters, at which a list of criticisms and recommendations was drawn up. This appears to have been a discussion at the highest Fire Services level. Those present included the Director (Witness 76), Mr. Hutchins (Witness 75), Mr. Worrallo (Witness 68) and a Mr. Lane. These proposals were embodied in a memorandum (Appendix A.20) which was discussed the same day at the Marine Department by Messrs. Lane and Hutchins of the Fire Services with Messrs. Lack and Alexander of the Marine Department. At this discussion Mr. Alexander was told, that, in the view of those who had seen the vessel, there was a grave fire risk existing aboard her. It is not altogether clear whether Mr. Matthew took part in this discussion. Mr. Alexander seems to imply that he did. Mr. Matthew does not mention it but says that on the same day, and apparently independently, he discussed with Mr. Alexander his own report on the visit to the "Seawise" which he had already circulated in the form of a memo (Appendix A.21) and that he too stressed the fire hazard At all events Mr. Alexander in issuing the combined Marine and Fire Services Departments' comments and recommendations to Captain LAM on the 19th July (Appendix A. 13) clearly leans heavily on the report of the Fire Services Department to the Marine Department. It does not seem unreasonable that he should have done so since, in the exhortatory/advisory role to which he felt the Director of Marine was restricted, it was natural that he should rely principally on the experience of the department primarily concerned with all matters relating to the prevention and control of fire. The Fire Services Department recommendations (Appendix A.22) formed the substance not only of the Director of Marine's recommendations to Captain LAM (Appendix A. 13) but also of the "additional.conditions for 'dead ship' permit" attached to the fire contingency plan sent to Captain LAM, as owners' representative, on the 13th September to which reference has already been made above (attached to Appendix A.3) On the 3rd August, 1971 a further meeting took place at the Director of Marine's office at which the Director of Marine presided and Captain LAM and Mr. C. S. WONG of the I.N. Company and Mr. Alexander were also present. The conditions set out in the letter of the 19th July were discussed and assurances were given that the following measures would be, or actually had been, carried out; (a) that the fire mains would be brought under pressure; (b) that to offset the dismantling of part of the sprinkler system the hiring of extra fire equipment would be considered; (c) that a fire control centre had been established and that regular fire patrols were being maintained twentyfour hours a day; (d) that fire extinguishers had been provided where hot-work was being carried out; (e) that arrangements were being made for the removal of waste oil and rubbish from the ship; (/) that a Staff Captain had been appointed as Fire Safety Officer; (g) that at least one Chief Officer and fifty ratings would be aboard at all times. It was at this meeting that Mr. Alexander stressed with Captain LAM that the responsibility for fire precautions aboard the "Seawhe" must remain with her Master. Subsequently Captain LAM informed him on the telephone that the rubbish contractors had arranged with the Urban Services for the removal of oil and waste to the Lai Chi Kok rubbish dump In passing it might be remarked that some of the criticisms made by the party which went aboard the "Seawise" on the 15th July were somewhat captious, and illogical When the vessel arrived she was, admittedly, below par in many respects but the whole purpose of her coming to Hong Kong was to have her brought up to scratch. That the sprinkler systems and other fire equipment should be found in less than perfect condition was scarcely surprising Mr. Alexander and the then acting Principal Marine Officer, Mr. Lack, followed up this meeting with a visit to the ship on the 3rd September and were generally well impressed with what they saw. They did comment however on the accumulations of rubbish that they saw adjacent to the shell doors and subsequently the collection of garbage by barges was stepped up to removals twice daily Mr. Alexander also gave advice concerning the need to minimise the risk of file on this occasion. In general he said that he saw nothing so dangerous as to make him wish to report at once to bis Director. He concluded by saying that liaison between I.N. Company and the Director of Marine was good and that on previous 40

43 occasions the Company had proved responsible and responsive to advice from the Department. evidence to the same effect. Mr. Lack gave 158. From all this it seems fair to conclude: (a) That even if a 'dead ship' permit had been applied for the conditions to be imposed would have been very much the same as those which were in fact recommended; (b) that the senior officials of the Marine Department considered that they were getting sufficient co-operation to make it unlikely that a regular system of supervision by Marine and Fire Services Department officials would need to have been enforced in any event even if that were possible; (c) that in limiting himself to the recommendations which were made, the Deputy Director chose, from the several sources available to him, those proposals which were, in his judgement, best suited to the circumstances as a whole and in the reasonable certainty that they were likely to be carried out Of the many proposals in Mr. Matthew's report (Appendix A. 17) to his superiors which were not included in the letter with recommendations sent to Captain LAM (Appendix A. 19), three seem to us to bear upon matters of importance in which the "Seawise" organisation was deficient. These are as follows: Page 7 of Part B of the attachment to the Minute (Appendix A. 17): "(10) Supplementary Equipment And Personnel (1) As the vessel will be about 40 minutes from the nearest fireboat and due to the undesirabiuty from overall operational consideration of posting a fireboat adjacent to the vessel, a temporary fire post beside the vessel must be maintained. There should be a large lighter moored alongside the vessel. The lighter will be equipped in accordance with Fire Services' recommendations. Its equipment will include pumps which would be permanently connected into the ship's fire main and sprinkler system. Independent hose supplies and distribution manifolds will also be established aboard. The lighter will duplicate any of the functions of the Fire Centre aboard the vessel to which it will act as an alternative in case of a major outbreak of fire. This centre will have full communication with ship and shore and contain all the information essential to the officer in charge of fire fighting. (2) The personnel for this duty and to man the shipboard control centre and to possibly conduct or supplement fire control should be provided by the Hong Kong Fire Services. This could well require in the order of two officers and twenty men. (Full consideration of the abilities of the ship's staff and crew and their training will have to be made before definite figures can be recommended)." The second item is to be found at Page 9 of the same Appendix under the heading General Proceedings: " (iv) Parties of Fire Service personnel will be given the opportunity of familiarising themselves with the vessel." And finally upon the same page, the following: " (v) Daily fire-drill should be held in various parts of the ship." 160. While the Court may not be prepared to agree with these suggestions in every detail, we agree that they show a clear grasp of the importance of estimating the size of a fire fighting force sufficient to cope with a ship of the size and in the location and condition of this ship. Four professional fire-fighters, which was all the number that could be expected to be aboard at any given time, was quite inadequate to deal with an emergency even of lesser dimensions than that which actually occurred on the 9th January. Secondly, the Court strongly supports his view of the importance of fire drills aboard and of liaison with the Fire Services personnel ashore, 161. For the list of procedures actually recommended by the Director of Marine see page 2 of the Director's letter to Captain LAM (Appendix A. 13). It will be noted that in the letter of 13th September, 1971, the owners' representatives are reminded once again of the requirements relating to 6 dead ships' and are advised of the possibility of help available to the Company from the Fire Services Although a 'dead ship' permit never was applied for we are satisfied that the greater part of the Director's recommendations were carried out to a substantial degree. There were, however, some significant deficiences. The fire dampers in the ventilation ducts were kept open during the renovation. Patrolling was not done by pairs of patrolmen as recommended and indeed could not have been done in that manner with the number employed as against the number and size of the routes to be patrolled. It will be noted, however, that these recommendations make no mention of the desirability of keeping shell doors and fire doors closed as far as possible during renovations. Although there was displayed on the ship a list of Fire Stations in Port (Appendix A. 14) this is in the most general terms and simply refers to one ordinary seaman as charged with the duty of assisting in closing fire doors and dampers. 41

44 163. As to the siell dcors, a further visit had been paid to the "Setwise" on the 13th August by Mr. Hall of the Marine Department and it was as a result of Ms observations that a letter signed by Mr. Lack and dated 31st August (Appendix A. 15) was sent to Captain LAM, making reference to certain matters including the leaving open of almost all shell doors especially on C C Deck level. No further question, however, seems to have been raised on this subject. In the time between the letter and the visit to the "Seawise" however, she had survived the fury of typhoon Rose which struck the Colony on the 16/17th August and it may be that the Marine Department officials were sufficiently impressed with the ability of the crew to manipulate shell doors in time of emergency not to pursue the matter fuither. Summary And General Observations On Liaison And Advice 164. It will be seen therefore that throughout the period preceeding the casualty the Marine Department and the Fire Services Department played something of the role of god-parents to the scheme, at all times interested and concerned and occasionally anxious. But at no time does there appear to have occurred any crisis of confidence or anxiety in either department such that attempts a direct control by way of peremptory demands were attempted Officials of both departments were no doubt aware of the extent to which their recommendations had been complied with and as the work progressed their anxieties must naturally have been diminished and the adoption of the purely advisory role must have seemed progressively better justified The earlier phases of the work were necessarily those of greatest danger. The fire-fighting equipment and installations were below par; the organisation was untested and the project team was still feeling its way; extensive welding opeiations were in progress; all kinds of materials were distributed over many areas; a large work force was everywhere in the ship, yet she survived all this with a few minor fires which those on board had coped with without difficulty. As the time of completion approached, the risk of fire from these sources diminished, and the lively apprehension of danger in the minds of responsible officials of both Departments inevitably receded and the moral responsibility acknowledged by the Departments must have seemed within reasonable reach of full discharge Although, as has been said, a great part of the recommended procedures had been adopted without demur, more might have been done by way of advice, visiting, and informal liaison. The Marine Department and the Fire Services Department, from their greater experience, could have emphasised to the inexperienced Master and Owners the additional dangers inherent in this great ship being two and a half miles from the Company's workshops and twenty minutes sailing time from the nearest help from the Fire Services Department, and the consequent need for adequate patrolling and fire-fighting forces backed up by a trained crew having regular musters and fire drills. The Fire Services Personnel should have sought opportunities of familiarising themselves with the ship and her officers whereby their value in an emergency would be greatly enhanced. Valuable time was wasted on 9th January because there was no immediate contact between the ship's senior officers and the Fire Services personnel. General Conclusions 168. As stated above this Court is satisfied that there were at least three major sites of fire, all of them occurring within minutes of each other and there may have been other independent sites as well. While there is no direct and conclusive evidence on the matter, the Court is also satisfied that by far the most likely cause of the fires was a series of deeberate acts by a person or persons unknown. Conducing to this view to which we have come with reluctance and after a most serious weighing of evidence are the following factors; (a) The number and size of the independent outbreaks. The speed with which each gained ground and became uncontrollable denotes an initial outbreak of considerable size and of great immediate spread indicating the possibility of the use of some highly inflammable reagent; once firmly alight in several places, of course, the immensely rapid spread was due principally to the readily inflammable miles of seasoned timber, panelling, and furniture, with the plentiful supply of air through the long open corridors and with the huge open squares acting as chimneys. (6) The outbreak occurred when virtually all the workmen had withdrawn for lunch either in the Restaurant or ashore when most of the areas initially affected could reasonably be expected to be, and to a large extent were, free of human traffic. The mere timing of the outbreaks is, therefore, in itself, significant We would eliminate such causes as welding and cigarette smoking. The evidence shows that the precautions prevailing aboard the ship in relation to both these hazards were adequate. As to the first of them the Court is satisfied that there is no evidence that welding was the cause of any fire. In the first place no welding work was being done near to any of the areas in which fire or a strong concentration of smoke indicating fire, was first observed. Secondly, the places where welding was going on had been visited by numbers of persons including 42

45 the Commodore, Mr. POON, Professor SUNG Howe and other senior officers up to and after a.m., the time when the welders went off duty, and nothing amiss was observed. Thirdly, so far from it being the case that there was a last feverish endeavour to get the bulk of welding work done, the situation was that the major welding work was already finished and the welding force had run-down to less than a third of what it had been at the height of the operation. Fourthly, of the thirty-odd fires which had broken out aboard the "Seawise", prior to the 9th of January, the majority had been caused by welding or hot-work and each of these had been adequately dealt with We are satisfied that fire watchers were employed and efficiently deployed in the course of the renovations. In any case the odds against three independent serious welding fires breaking out in localities considerably distant from each other are so high as not to be worth consideration The same observation applies, a fortiori, in relation to the second most prolific cause of such fires viz: cigarette smoking. Indeed the possibility of three separate major fires breaking out at approximately the same time as a result of any common cause of a purely accidental or negligent nature or even a combination of such causes, is obviously a very remote one There has been no evidence that any of the outbreaks observed on the "Seawise" can have been due to faulty electrical wiring and we think that this is a possibility which requires no further discussion The Court has been impelled to what may seem a somewhat dramatic and disturbing conclusion. It has made no attempt to assign blame for any criminal act nor has it sought to determine the identity of the person or persons who, if we are right, must be responsible for the casualty. There is nothing in the evidence which could fairly be said to support even speculation in the matter, nor do we believe that the pursuit of any line of inquiry in the present forum, beyond those actually pursued before us, could have resulted in more than the promotion of speculation In this connection it may be well to mention, for the sake of completeness, that in the course of the inquiry we received one anonymous letter purporting to identify a named individual as the begetter of the scheme to destroy the ship. This letter, we understand, has been investigated by the Police and we wish only to say that the form and tenor ot it were such that we felt obliged to disregard it wholly and that it has played no part whatsoever in the conclusion to which we have come. As for that conclusion it will, no doubt, be a matter for the relevant authorities to consider what, if any, further investigations are advisable We have had occasion to make a number of criticisms of various aspects of the organisation, but in the final anal} sis all such criticisms remain academic. Even if everything had been done on the scale and according to the more stringent prescriptions which the Court believes to have been necessary to control any emergency of reasonably foreseeable character and size, it is the conclusion of the Court, in the circumstances as they occurred and in view of the extraordinary extent and nature of the outbreak, that the "Seawise" would not have been saved from total destruction by fire As to her capsizing, while it is true that the major cause of that was the inflow of water through the open shell doors, yet had they been closed and had fire-fighting with hoses continued from the outside, such external operations, by then the only possible operations, would not have succeeded in extinguishing the fire. Had they been continued it is reasonable to assume that her list, which was substantial at the time that the shell door sills went under, would have continued to increase, and it is not possible to say that she would not have capsized before she burned out. While therefore the leaving open of the shell doors was clearly a mistake, and one which made her capsizing inevitable, it does not necessarily follow that had they not been open her final position would have been any better, but there is a possibility that it might have been. Recommendations 177. This Court finds itself in substantial agreement with the recommendations made by the Commissioners of the "Jumbo" Inquiry, concerning the tidying of the present legislative tangle. The inadequacies of the present situation are admirably dealt with in paragraphs 96 to 101 of that Report. Of the alternative recommendations put forwards, the Court favours the suggestion that the Director of Marine be given overall control of such operations as relate to the repair, renovation and refitting of shipping in the harbour. There is already in existence a Code of Safe Practice for the Shipbreaking Industry; a copy of this Code was given as a precautionary measure, together with the contingency plan, to Captain LAM. It is a detailed Code but most of its provisions were of no direct relevance to the operations going on aboard the "Seawise". We have, however, been informed by Mr. Alexander, that a Working Party comprising private interests and Government Departments was formed in October, 1971 for the purpose of drawing up a complementary code in respect of the shipbuilding and shiprepair industries. We understand this Code is not yet in existence. The existing Code for the shipbreaking industry and the projected Code for the ship repair industry are intended for the guidance of shipowners, masters etc. They are not themselves enforceable as legislative provisions. 43

46 178. Strict compliance \*ith any such Code could, however, be made a condition of the issue of a 'dead ship' permit. Not knowing the terms of the proposed Code, the Court is, of course, unable to say how effective such a condition might be If the Director of Marine is to be made responsible for the manner of carrying on ship repair activities the overhaul of the legislation may require some time and it will certainly require considerable thought. As we have seen there are three Ordinances and three Departments with dubious and over-lapping areas of responsibility. If effective control is to be given in this respect to the Director of Marine, it may require not merely the setting up of an Industrial Safety Division within the Marine Department, as was suggested by the Commissioners in the "Jumbo" Inquiry, but possibly also the provision of an additional special Advisory Unit within that Division to deal with the prevention and detection of fires aboard ships. The Court can also foresee that the delimiting of the zones of responsibility between the three Departments, to which reference has been made in this Report, may be a matter of some complexity Meanwhile, to avoid delay, it is suggested that a satisfactory interim solution might be found by a simple amendment to the Merchant Shipping (Control of Ports) Regulations (Cap. 281 of the Laws of Hong Kong) providing that no repairs should be undertaken upon any ship without the Director's permission. The first part of this new provision could be achieved simply by deleting the words which follow the word "secured" in the penultimate line of Sub-Regulation 4 of Regulation 5 so that that sub-regulation would then read as follows: "(4) Except with the prior permission of the Director, no dead ship shall be anchored, moored or secured at any place within the waters of the Colony nor, except with such permission, shall any repairs be undertaken upon any ship that is so anchored, moored or secured." The remaining provisions of Regulation 5 could then be left as they are although it would no doubt be advisable to add a penalty clause to cover the failure to apply for the Director's permission. It would then be the duty of the Owner or Agent or Master of any vessel, whenever repairs of any kind were to be carried out aboard, and subject to penalty for failure to do so, to apply, for such a permit to the Director who would issue it upon such conditions as he saw fit. The conditions to be imposed would, of course, be directly geared to the size of the works to be undertaken. It would be open to the Director in minor cases to impose no conditions at all or, at the other end of the scale, to impose serious and drastic conditions of the sort which we think might have been imposed in the present case. It should be stressed, finally, that if such an interim measure were introduced, it would be highly advisable for the Director and his officers to consult with the other departments primarily concerned, in particular the Fire Services Department and the Labour Department, in working out the conditions to be imposed Thought might also be given to amending the present definition of a 'dead ship' in such a way as to increase the Director of Marine's powers in relation thereto by: (a) giving him power to declare a ship dead whether the owners approve or not; (b) providing that a ship should be capable, not merely of being effectively propelled, but also of being effectively manoeuvred within the time limit; and (c) by giving the Director a discretion in relation to this time limit: something on the following lines is very tentatively suggested: "The expression 'dead ship' means a ship that in the judgement of the Director of Marine is unable to be effectively propelled and manoeuvred within twenty-four hours notice or within such lesser time as the Director shall in any given case appoint," 44

47 I

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