The Weekly Reflektion 50/2024
The justice system is not specifically set up to identify learning and to prevent recurrence. Its focus is to identify where laws have been broken and who is responsible, apportioning blame and to ensuring justice is done. Unfortunately, the justice system often fails here as well.
Do you ensure that potential learnings are identified, and changes made after incidents in your operations?
Marchioness beached after the accident
At 1:12 am on 20th August 1989, the 1880 ton dredger Bowbelle left her berth on the River Thames near Battersea Power Station in London and radioed her move by VHF radio to Thames Navigation Service (TNS). In accordance with the usual procedure, TNS radioed all river traffic at 1:15 am and 1:45 am, advising them of Bowbelle’s downstream passage. Bowbelle’s average speed was about 5.5 knots (10.2 km/h) over the ground and there was a crew of nine. The 46-ton pleasure boat Marchioness had been hired on the same evening for a birthday party and had about 130 people on board, four of whom were crew and bar staff.
Both vessels were heading downstream, against the spring tide, recorded as one of the highest of the year and running upriver at a rate of three knots. The Bowbelle was travelling faster than the smaller vessel and struck Marchioness from the rear, causing the latter to turn to port, where she was hit again, when she turned over and was eventually pushed under Bowbelle’s bow. It took thirty seconds for Marchioness to sink and 51 of the 130 people on board were killed. 24 bodies were found within the ship when it was raised. No one onboard Bowbelle was injured.
In the days after the collision, bodies were still being found and recovered from the water. The coroner decided that visual identification of many of the bodies would be unreliable due to putrefaction and should not be used. It was decided to remove the hands from many of the bodies to aid identification, and 25 pairs of hands were removed however, no written records were kept. One family was shown the body of the wrong person, then given the right body, but without the hands. These were sent on later with apologies, and a request not to tell other parents about the need to remove them as this was a ‘one-off’ mistake.
The Marine Accident Investigation Branch (MAIB) held an investigation which found that neither vessel was aware of the other’s presence until very shortly before the collision. The dredger was loaded with aggregate and was trimmed down by the stern, which limited the view from the bridge and no one on the bridge of Bowbelle was aware of Marchioness until the collision occurred. The Marchioness has not set up any system for look-out and this was the immediate cause of the accident. No independent inquiry was initiated and the learning from the incident was limited.
A corporate manslaughter charge was dismissed by the judge due to ‘insufficient evidence’. It was concluded that because no individual’s actions could be ascertained as the single cause of the collision, a manslaughter charge would be bound to fail under English law. English law also provides no compensation for fatal accidents, other than for funeral expenses, unless financial dependency at the time of death can be proved. In most cases, the families of the Marchioness victims received little more than the cost of the funeral.