The Marchioness Inquiry
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The ''Marchioness'' disaster was a collision between two vessels on the River Thames in London in the early hours of 20 August 1989, which resulted in the deaths of 51 people. The pleasure steamer ''Marchioness'' sank after being hit twice by the dredger ''Bowbelle'' at about 1:46 am, between
Cannon Street railway bridge Cannon Street station, also known as London Cannon Street, is a central London railway terminus and connected London Underground station in Travelcard zone 1 located on Cannon Street in the City of London and managed by Network Rail. It is on ...
and Southwark Bridge. ''Marchioness'' had been hired for the 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 tide, ''Bowbelle'' travelling faster than the smaller vessel. Although the exact paths taken by the ships, and the precise series of events and their locations, are unknown, the subsequent inquiry considered it likely that ''Bowbelle'' struck ''Marchioness'' from the rear, causing the latter to turn to port, where she was hit again, then pushed along, turning over and being pushed under ''Bowbelle''s bow. It took thirty seconds for ''Marchioness'' to sink; 24 bodies were found within the ship when it was raised. An investigation by the Marine Accident Investigation Branch (MAIB) blamed a lack of lookouts, but their report was criticised by the families of the victims, as the MAIB had not interviewed anyone on ''Marchioness'' or ''Bowbelle'', but relied on police interviews. The government refused to hold an inquiry, despite pressure from the families. Douglas Henderson, the captain of ''Bowbelle'', was charged with failing to have an effective lookout on the vessel, but two cases against him ended with a hung jury. A private prosecution for
manslaughter Manslaughter is a common law legal term for homicide considered by law as less culpable than murder. The distinction between murder and manslaughter is sometimes said to have first been made by the ancient Athenian lawmaker Draco in the 7th cen ...
against four directors of South Coast Shipping Company, the owners of ''Bowbelle'', and corporate manslaughter against the company was dismissed because of lack of evidence. A formal inquiry in 2000 concluded that "The basic cause of the collision is clear. It was poor lookout on both vessels. Neither vessel saw the other in time to take action to avoid the collision." Criticism was also aimed at the owners of both ships, as well as the Department of Transport and the
Port of London Authority The Port of London Authority (PLA) is a self-funding public trust established on 31 March 1909 in accordance with the Port of London Act 1908 to govern the Port of London. Its responsibility extends over the Tideway of the River Thames and its ...
. The collision and the subsequent reports led to increased safety measures on the Thames, and four new lifeboat stations were installed on the river.


Background


''Marchioness''

The pleasure boat ''Marchioness'' was built in 1923 by the Salter Brothers of Oxford for
Joseph Mears Joseph Theophilus "JT" Mears (1871 – October 1935), was an English businessman, most notable for co-founding Chelsea Football Club. He was born in 1871 in Hammersmith, London, the elder son of Joseph Mears, a builder. In 1896, Mears and his b ...
, a businessman whose interests included running pleasure launches on the River Thames. She was long and at the
beam Beam may refer to: Streams of particles or energy *Light beam, or beam of light, a directional projection of light energy **Laser beam *Particle beam, a stream of charged or neutral particles **Charged particle beam, a spatially localized grou ...
, and measured 46.19 gross tons. She spent most of her life on the Thames, including when she was requisitioned during the Second World War by the Thames Hospital Emergency Service, when she was stationed in
Dagenham Dagenham () is a town in East London, England, within the London Borough of Barking and Dagenham. Dagenham is centred east of Charing Cross. It was historically a rural parish in the Becontree Hundred of Essex, stretching from Hainault Forest ...
. Her service included being one of the
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that aided in the 1940
Dunkirk evacuation The Dunkirk evacuation, codenamed Operation Dynamo and also known as the Miracle of Dunkirk, or just Dunkirk, was the evacuation of more than 338,000 Allied soldiers during the Second World War from the beaches and harbour of Dunkirk, in the ...
. ''Marchioness'' was sold to Thames Launches in 1945, when Mears's company was wound up. She was purchased by Tidal Cruises Ltd in 1978 and the upper works were rebuilt to form an upper and lower saloon. The new upper saloon obstructed the vision from the wheelhouse, and there was, the later inquiry established, a lack of easily accessible emergency exits, particularly from the lower decks. ''Marchioness'' had seven life rafts—each of which could support twenty people—and seven lifebuoys—each of which could support two people. Registered in London, she was licensed to carry 165 passengers. From the early 1970s there was an increase in the number of boats for evening or night-time parties and discos, and ''Marchioness'' was part of this market. ''Marchioness'' carried a crew of two: her
captain Captain is a title, an appellative for the commanding officer of a military unit; the supreme leader of a navy ship, merchant ship, aeroplane, spacecraft, or other vessel; or the commander of a port, fire or police department, election precinct, e ...
was Stephen Faldo; the
mate Mate may refer to: Science * Mate, one of a pair of animals involved in: ** Mate choice, intersexual selection ** Mating * Multi-antimicrobial extrusion protein, or MATE, an efflux transporter family of proteins Person or title * Friendship ...
was Andrew McGowan. On the night of her sinking, she also carried two members of bar staff. Faldo and McGowan had a business partnership, Top Bar Enterprises, which provided the bar staff and drink for the party. Faldo was 29 at the time of the sinking. He had begun working on the Thames at the age of 17 and had earned his full waterman's river licence in June 1984. He began work at Tidal Cruises in 1986 and became the permanent captain of ''Marchioness'' in 1987. He had forgotten to renew his riverman's licence in the run-up to the night of the collision, and was technically not entitled to skipper the vessel that night. A later inquiry considered the lack of licence was "a minor point because he was undoubtedly qualified to do so and could have renewed his licence by paying 50 pence". McGowan, age 21, became an apprentice to a waterman in June 1986. By February 1988 he had completed courses at the
Port of London Authority The Port of London Authority (PLA) is a self-funding public trust established on 31 March 1909 in accordance with the Port of London Act 1908 to govern the Port of London. Its responsibility extends over the Tideway of the River Thames and its ...
for chartwork and seamanship, and obtained his apprentice licence in May 1988; he joined ''Marchioness'' as a crew member around the same time.


''Bowbelle''

The
aggregate Aggregate or aggregates may refer to: Computing and mathematics * collection of objects that are bound together by a root entity, otherwise known as an aggregate root. The aggregate root guarantees the consistency of changes being made within the ...
dredger ''Bowbelle'' was launched in 1964 by the Ailsa Shipbuilding Company of Troon, Scotland. She was long and at the beam; her deadweight tonnage was and she measured 1,474.72 gross tons. ''Bowbelle'' was one of six "Bow" ships owned by East Coast Aggregates Limited; they were managed by South Coast Shipping Company Limited. East Coast Aggregates Limited (ECA) was part of the larger RMC Group, a concrete products company. ''Bowbelle'' had a crew of nine: a master, two mates, three engineers, two able seamen and a cook. The ship's captain, Douglas Henderson, aged 31, undertook a Deep Sea apprenticeship until 1978 and joined ECA in November 1987, when he became second mate on ''Bowsprite''. In May 1989 he became the master of ''Bowbelle''. Vessels from ECA, including ''Bowbelle'', had previously been involved in accidents on the Thames. In July 1981 there was a collision between ''Bowtrader'' and the passenger launch ''Pride of Greenwich''; three months later ''Bowtrader'' was involved in a collision with ''Hurlingham'', another pleasure cruiser owned by Tidal Cruises. ''Bowbelle'' collided with
Cannon Street railway bridge Cannon Street station, also known as London Cannon Street, is a central London railway terminus and connected London Underground station in Travelcard zone 1 located on Cannon Street in the City of London and managed by Network Rail. It is on ...
in May 1982 and, the following month, was nearly in a collision with a passenger boat. At the time of the collision with ''Marchioness'', ''Bowbelle'' was carrying aggregate and was trimmed down at the stern; this, along with the dredging equipment, limited the forward vision from the bridge. On 19 August 1989 Henderson visited several public houses over a period of three and a half hours and drank six pints (3.4 L; 120 imp fl oz) of lager. He returned to the ship at 6:00 pm for food and a short sleep; one of the ship's company, Terence Blayney, who acted as the forward lookout that night, was with Henderson, and drank seven pints over the same period.


Jonathan Phang and Antonio de Vasconcellos

''Marchioness'' was hired for a party for the night of 19–20 August 1989. It was organised by
Jonathan Phang Jonathan Phang is a British food writer and chef, best known for his television appearances. Early life Phang was born in London. His father was from China and his mother from Guyana. He began his career as a fashion agent, working with mode ...
, a photographic agent, to celebrate the 26th birthday of Antonio de Vasconcellos, who worked in a
merchant bank A merchant bank is historically a bank dealing in commercial loans and investment. In modern British usage it is the same as an investment bank. Merchant banks were the first modern banks and evolved from medieval merchants who traded in commodi ...
. The pair were good friends and business partners in a photographic agency. Phang paid £695 to hire the boat from 1:00 am to 6:00 am, with extra for the hire of the disco, food and drinks. Many of those at the party were also in their twenties; some were former students and others worked in fashion, journalism, modelling and finance. The plan was for ''Marchioness'' to go downriver from the Embankment Pier near Charing Cross railway station to
Tower Bridge Tower Bridge is a Listed building#Grade I, Grade I listed combined Bascule bridge, bascule and Suspended-deck suspension bridge, suspension bridge in London, built between 1886 and 1894, designed by Horace Jones (architect), Horace Jones and e ...
, then back to Charing Cross to land some of the passengers. ''Marchioness'' would then travel down to Greenwich before returning again to Charing Cross, arriving back at 5:45 am.


20 August 1989


0:00 am – 7:00 am

The night of 19–20 August 1989 was a clear one; it was three days after the full moon and there was good visibility. There was a negligible wind. It was a spring tide, recorded as one of the highest of the year and the river was at half-tide at the time of the collision; it was running upriver at a rate of three
knots A knot is a fastening in rope or interwoven lines. Knot may also refer to: Places * Knot, Nancowry, a village in India Archaeology * Knot of Isis (tyet), symbol of welfare/life. * Minoan snake goddess figurines#Sacral knot Arts, entertainme ...
. There are several versions of the paths taken by the vessels in the approach to Southwark Bridge and beyond, and no agreement on the point when the two ships collided. Much of the evidence gathered in later investigations was inconsistent and any descriptions of the actions of the ships are based on average speeds and likely positions. At 1:12 am ''Bowbelle'' left her berth at the
Nine Elms Nine Elms is an area of south-west London, England, within the London Borough of Wandsworth. It lies on the River Thames, with Battersea to the west, South Lambeth to the south and Vauxhall to the east. The area was formerly mainly industrial bu ...
pier near Battersea Power Station and radioed her move by VHF radio to Thames Navigation Service (TNS), based in Woolwich. She reported passing Vauxhall Bridge at 1:20 am and Waterloo Bridge at 1:35 am. 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 over the ground. ''Marchioness'' was supposed to leave Embankment Pier at 1:00 am, but was delayed until 1:25 am. No count was made of the number of passengers, but the accepted number on board is either 130 or 131. Faldo was in the wheelhouse, where he stayed until the collision. Heading downriver, just before Blackfriars Bridge, ''Marchioness'' passed her sister pleasure cruiser ''Hurlingham''—which was also hosting a disco that night, and was also heading in the same direction. ''Marchioness''s average speed was about over the ground. She passed through the central arch of Blackfriars Bridge; at this point she was about in front of ''Bowbelle''. At some point after Blackfriars Bridge, ''Bowbelle'' overtook ''Hurlingham'' and steered for the central arch of Southwark Bridge. ''Marchioness'' also went through the central arch, but probably towards the southern side. When ''Bowbelle'' was within of ''Marchioness'', the smaller vessel was affected by the forces of interaction—the water being pushed ahead of the large ship. At about 1:46 am, just after ''Marchioness'' passed under Southwark Bridge, she was hit twice by ''Bowbelle''s bow. The first impact was from ''Marchioness''s stern, which had the effect of turning the smaller vessel to port. The second impact was from the stern, and caused the pleasure boat to pivot round the bow of ''Bowbelle'', and turn it on its side, probably to an angle of 120°. The upper superstructure of ''Marchioness'' was ripped off by ''Bowbelle''s anchor. The lower saloon was quickly flooded and the lights went out. The weight and momentum of ''Bowbelle'' pushed ''Marchioness'' underwater and she sank, stern first, within 30 seconds of being hit. McGowan had been thrown from the boat into the water, but climbed back on board to tie open the port side door, which led to the dance floor, to allow several people to escape. One eyewitness to the crash, Keith Fawkes-Underwood, who viewed the incident from the south bank of the Thames, reported:
The barge collided with the pleasure boat hitting it in about its centre then mounted it, pushing it under the water like a toy boat. Within a matter of about 20 seconds the pleasure boat had totally disappeared underneath the water.
Of the 130 people on board ''Marchioness'', 79 survived and 51 died. The dead included de Vasconcellos and Faldo. No-one on ''Bowbelle'' was injured. ''Marchioness'' sank so quickly that most people were unable to locate or use the life rafts, buoys or jackets. Survival of those on ''Marchioness'' depended partly on their location within the vessel. There were 41 people known to have been on the forward deck and wheelhouse, of whom 9 died and 32 survived, a survival rate of 78%. Of the 13 people known to have been in the lower saloon, 9 died and 4 survived (a 31% survival rate). One of those from the lower saloon who survived was Iain Philpott, who said in his statement to the police:
I remember turning around to head towards the windows to escape the boat, the water started coming in the boat through the window, I knew at this point the boat was going to go down. Within a matter of seconds the general lights went out, everything was in darkness ... I was then thrown forward by a wall of water, the whole boat filled with water instantly ... When I surfaced I was some distance away from the Marchioness which was partly submerged.
''Hurlingham'' was between 45 and 60 metres (150–200 feet) away from the collision, and those on board were in the best position to be eyewitnesses. George Williams, the vessel's captain, put out a call on VHF radio to the
Thames Division The Marine Policing Unit (MPU) is the waterborne policing unit of London's Metropolitan Police Service, forming part of the Met Taskforce (MO7) within Met Operations. Its 22 vessels are responsible for waterborne policing of the River Thames in G ...
of the
Metropolitan Police Service The Metropolitan Police Service (MPS), formerly and still commonly known as the Metropolitan Police (and informally as the Met Police, the Met, Scotland Yard, or the Yard), is the territorial police force responsible for law enforcement and ...
, based in Wapping: "Woolwich Police, Wapping Police, Wapping Police, Emergency, pleasure boat is sunk, Cannon Street Railway Bridge, all emergency aid please". The call was also picked up by the TNS, who misheard the location as Battersea Bridge; Thames Division only heard part of the call, so TNS informed them that the police should be in attendance at Battersea Bridge. After colliding with ''Marchioness'', ''Bowbelle'' hit one of the piers of Cannon Street Bridge, and radioed TNS at 1:48 am to correct the inaccurate reference to Battersea Bridge; at 1:49 am Henderson reported to TNS:
I have to get underway now and proceed out through bridges. I believe I have struck a pleasure craft. It has sunk. I am getting clear of the bridges now. I was distracted by flashing lights from another pleasure craft. My vessel was proceeding outward bound just approaching Cannon Street bridge and, well, I just lost steerage, um and I don't know after that, I can't really say anything else sir. Over.Transcript of radio transmission from ''Bowbelle'', 1:49 am, quoted in
After the radio transmission, ''Bowbelle'' travelled downstream to Gallions Reach, where she dropped anchor. Her crew did not deploy the ship's lifebuoys, flotation devices or lifeboat and she did not take part in the attempts to rescue survivors. All ships in the area were instructed to go to the area to assist with the rescue. ''Hurlingham'' was already on the scene, and the passengers and crew threw lifebuoys and buoyancy aids to those in the water. Many of those from ''Marchioness'' were swept into driftwood collection cages, and ''Hurlingham'' picked up several survivors—the passengers climbing out onto the cages to help people out of the water. The vessel then dropped all passengers and 28 survivors at the nearby
Waterloo Police Pier Waterloo most commonly refers to: * Battle of Waterloo, a battle on 18 June 1815 in which Napoleon met his final defeat * Waterloo, Belgium, where the battle took place. Waterloo may also refer to: Other places Antarctica * King George Island ( ...
(now Tower Lifeboat Station) before it took members of the
emergency service Emergency services and rescue services are organizations that ensure public safety and health by addressing and resolving different emergencies. Some of these agencies exist solely for addressing certain types of emergencies, while others deal wit ...
s back out to the collision site. Waterloo Police Pier was used as the landing point for all casualties and the
first responder A first responder is a person with specialized training who is among the first to arrive and provide assistance or incident resolution at the scene of an emergency, such as an accident, disaster, medical emergency, structure fire, crime, or terr ...
s from the emergency services set up a treatment and processing point there. Police launches rescued more than half the survivors from the river; some reached the river bank themselves. Less than half an hour after ''Marchioness'' was hit, a major incident was declared with an incident room at New Scotland Yard. The police's body recovery team were also deployed, and the first body arrived at Wapping Police Station—where the Thames Division were based—at 6:50 am. The station acted as a holding area for bodies before they were taken to the mortuary in Westminster.


7:00 am – 0:00 am

Margaret Thatcher, the Prime Minister, returned home early from her holiday in Austria to be briefed by Michael Portillo, the Minister of State for Transport. His senior in the department, the
Secretary of State for Transport The Secretary of State for Transport, also referred to as the transport secretary, is a secretary of state in the Government of the United Kingdom, with overall responsibility for the policies of the Department for Transport. The incumbent i ...
Cecil Parkinson, also returned home early in response. Portillo announced that an investigation would be made by the Marine Accident Investigation Branch (MAIB), but that no decision had yet been made as to whether to hold a public inquiry. Within 24 hours of the collision, the decision was made that there would be no public inquiry, and that the MAIB investigation would be sufficient. A Port of London (PLA) hydrographic surveyor located the wreckage of ''Marchioness'' and, during the late afternoon of 20 August, work began on lifting the vessel. The bodies of 24 party-goers were found on board, 12 of them in the lower saloon. The wreckage was moored against the north bank of the Thames. While the lifting operation was progressing, police arrested and interviewed Henderson and Kenneth Noble, ''Bowbelle''s second mate who was at the wheel for the collision. Both men were
breathalysed A breathalyzer or breathalyser (a portmanteau of ''breath'' and ''analyzer/analyser'') is a device for estimating blood alcohol content (BAC), or to detect viruses or diseases from a breath sample. The name is a genericized trademark of the Br ...
; the police announced soon afterwards that alcohol was not a cause of the collision.


Inquests and inquiries


1989 to 1997

On the day following the collision Paul Knapman, the
coroner A coroner is a government or judicial official who is empowered to conduct or order an inquest into Manner of death, the manner or cause of death, and to investigate or confirm the identity of an unknown person who has been found dead within th ...
for the
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, opened and adjourned the
inquest An inquest is a judicial inquiry in common law jurisdictions, particularly one held to determine the cause of a person's death. Conducted by a judge, jury, or government official, an inquest may or may not require an autopsy carried out by a coro ...
into the deaths. In the days after the collision, bodies were still being found and recovered from the water. To help with the
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process, Knapman opted to use several methods, including dental records, identification of personal items and clothing descriptions from descriptions provided by the families, and fingerprints. As part of their approach, Knapman decided that:
With those bodies which were not recovered from the ''Marchioness'' and which would be likely to surface only when putrification and bloating meant that they would float, the following would apply:
During the
post-mortem examination An autopsy (post-mortem examination, obduction, necropsy, or autopsia cadaverum) is a surgical procedure that consists of a thorough examination of a corpse by dissection to determine the cause, mode, and manner of death or to evaluate any dis ...
s, 25 pairs of hands were removed; no written records were kept of the removal. No guidelines were issued over which hands should be removed and no individual was given responsibility for making the decision. The majority were identified through other means—visual identification of the face, or through identification of clothing or personal items, and only four of the victims were identified through their fingerprints. Families of the victims later complained that they were not told in a timely fashion that bodies had been recovered, that some were denied access to view the bodies of their relatives, and were not told of the processes that would be used—including that the hands would be removed. 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. On 24 August ''Marchioness'' was taken from her mooring near Southwark Bridge, and towed downstream to Greenwich, where she was broken up. The MAIB issued an interim report towards the end of August, with recommendations as to increasing safety on the Thames. These included a requirement that vessels over had to have a forward lookout in contact with the bridge by radio, and tighter controls on the passage of vessels along the upper Thames. Their investigation continued with a reconstruction of the events on the night of 16–17 September; ''Bowbelle'' took part, and a PLA launch was used as a stand-in for ''Marchioness''. This was later criticised by Brian Toft, a disaster and risk-management expert commissioned by the Marchioness Action Group (MAG), as being unsatisfactory. Toft identified that there were several problems, including no second pleasure cruiser, no fare-paying passengers and no disco lights or music included in the re-enactment. In October 1989 the companies behind ''Bowbelle'' and ''Marchioness'' agreed to pay up to £6 million in compensation to the families of the victims, without either company admitting any liability for the crash. The sum offered was under a calderbank condition that the offer stood to be withdrawn if a judge awarded a lower amount. A week later a report was compiled for Allan Green, the
Director of Public Prosecutions The Director of Public Prosecutions (DPP) is the office or official charged with the prosecution of criminal offences in several criminal jurisdictions around the world. The title is used mainly in jurisdictions that are or have been members o ...
(DPP), which recommended that criminal charges should not be brought against Henderson. That December, Knapman met the DPP to discuss the progress of the inquests. Green agreed that the first part of the inquest should go ahead—dealing with the causes of death—irrespective of the other investigations of the police and the possibility of later criminal charges. A second part of the inquest—establishing the responsibility of the crash and making safety recommendations—would be discussed at a later stage. When Knapman re-opened the inquest on 23 April 1990, he was critical of the DPP for taking eight months to decide on whether to bring criminal charges against anyone, which meant that a full inquest could not take place in case it prejudiced any future trial. The inquest was, in effect, a series of what the legal scholar Hazel Hartley calls "mini inquests", one each for each of the 51 bodies. On 26 April the DPP stepped in to stop the inquest, stating that charges would now be brought against Henderson. Because of his decision to stop the inquest, the information on how the collision occurred, who was to blame or what could be done to ensure it could not be repeated, was not considered. Henderson was charged under the
Merchant Shipping Act 1988 The Merchant Shipping Act 1988 c.12 was an Act of Parliament of the United Kingdom. It aimed to prevent foreign fishing fleets from fishing in British territorial waters. In the Factortame case, its provisions in Parts I and II, Registration of ...
for failing to have an effective lookout on the vessel. The case against him opened on 4 April 1991 at the
Old Bailey The Central Criminal Court of England and Wales, commonly referred to as the Old Bailey after the street on which it stands, is a criminal court building in central London, one of several that house the Crown Court of England and Wales. The s ...
and ran to 14 April. The jury failed to reach a decision; the DPP decided that a retrial would be in the public interest. This took place between 17 and 31 July the same year; it again ended with a hung jury. At the end of July 1991 Ivor , the husband of one of the victims, began a private prosecution for
manslaughter Manslaughter is a common law legal term for homicide considered by law as less culpable than murder. The distinction between murder and manslaughter is sometimes said to have first been made by the ancient Athenian lawmaker Draco in the 7th cen ...
against four directors of South Coast Shipping Company, the owners of ''Bowbelle'', and
corporate manslaughter Corporate manslaughter is a crime in several jurisdictions, including England and Wales and Hong Kong. It enables a corporation to be punished and censured for culpable conduct that leads to a person's death. This extends beyond any compensation t ...
against the South Coast Shipping Company. Two weeks later the Transport Secretary, Malcolm Rifkind, took the decision to publish the MAIB Report, repeating that because an appropriate body had undertaken an investigation, there was no requirement to have a public inquiry. Families of the victims were angry with the move, pointing out that Rifkind had delayed publication of the report on the basis that publication could prejudice the case against Henderson, but that the publication could now jeopardise private prosecution. The DPP demanded that hand over the papers for the case, stating he would take it over, then drop it; refused to comply, stating that it was out of the remit of the DPP, and that it was for a magistrates' court to decide if the case was adequate. The DPP withdrew and allowed case to proceed. The case was dismissed after the magistrate stated that there was insufficient evidence. The MAIB report considered that ''Marchioness'' had altered her course to port, which put her in line with ''Bowbelle''s path. The report concluded that:
18.3  ... no one in either vessel was aware of the other's presence until very shortly before the collision. No one on the bridge of BOWBELLE was aware of MARCHIONESS until the collision occurred. 18.4  The principal contributory factors were that:
The families of the victims criticised the MAIB report. They pointed out that the investigation had not directly interviewed anyone on ''Marchioness'' or ''Bowbelle'', but relied on the police interviews; they stated that there were errors in methodology, approach and fact within the report. Toft provided a critique of the MAIB's work and concluded that:
The inconsistencies, contradictions, confusions, conjecture, erroneous conclusions, missing and inappropriate recommendations as well as epistemological, ontological and methodological problems, created by the then current maritime safety culture ... raises serious doubts as to the objectivity of the investigation, the validity of the findings, the judgement of the Department of Transport in holding an inquiry of this type, and as a result whether or not all the appropriate lessons were uncovered during the MAIB's inquiry into this tragedy.
The report was handed to Rifkind, who again declined to open a public inquiry, but commissioned a private one—the Hayes Report, published in July 1992—that looked at health and safety on the Thames, rather than the sinking of ''Marchioness''. In 1992 the families of the victims became aware that the hands had been removed from many of the bodies. In March that year an account in '' The Mail on Sunday'', "Cover up!", was published; when Knapman met the two journalists to deny the accusation of a cover-up, he advised them not to base reports on what Margaret Lockwood-Croft, the mother of one of the victims, said: he described her as "unhinged". He also showed them photographs of the victims, without discussing the matter with the families. In July, Knapman informed the families that the inquests—suspended since April 1990 because of the case against Henderson—would not be recommenced. The families tried to apply for a judicial review on the basis that "the use of the word 'unhinged' and reference to a number of 'mentally unwell' relatives betrayed an attitude of hostility, however unconscious, towards ... members of the Marchioness Action Group". Initially turned down by High Court, the
Court of Appeal A court of appeals, also called a court of appeal, appellate court, appeal court, court of second instance or second instance court, is any court of law that is empowered to hear an appeal of a trial court or other lower tribunal. In much of t ...
then found in favour of the group to allow an appeal. In June 1994 Knapman and his assistant were stood down and replaced by another coroner, John Burton. He was initially dismissive of the concerns of the MAG, accused their solicitor of trying to mislead the Court of Appeal and indicated that he was inclined not to grant any further inquests. Burton was told that another judicial review would be applied for if he refused to hold the inquests, and he subsequently announced that they would go ahead. The resumed inquest took place in March and April 1995. When questioned about the MAIB report, Captain James de Coverley—one of the report's authors—withdrew the suggestion that ''Marchioness'' had steered to port in the last moments before the crash, saying it had never been his intention that the text could be understood that way. In summing up, Burton instructed the coroner's jury that a verdict of unlawful killing could not be applied to anyone who had already been cleared by a court. The jury retired for four hours and returned a verdict of unlawful killing. Burton asked them "Did you understand my Direction?", although the decision stood.


1997 to 2001

Following the 1997 election, which brought the Labour Party to power, the MAG petitioned John Prescott, the Secretary of State for the Environment, Transport and the Regions and Deputy Prime Minister, to open an inquest. In August 1999 he instructed Lord Justice Clarke to undertake a non-statutory inquiry into safety on the Thames. Clarke reported in February 2000, concluding:
I was asked to advise My answer to that question is yes.
Prescott accepted the recommendation and the public inquest took place in October and November 2000, with Clarke chairing proceedings; the report was published in March 2001. Clarke concluded that "The basic cause of the collision is clear. It was poor lookout on both vessels. Neither vessel saw the other in time to take action to avoid the collision." The underlying causes on why neither vessel saw the other were that Henderson did not ensure a proper lookout on ''Bowbelle''; that Blayney the lookout was not equipped with suitable radio equipment to inform his captain; that Faldo had not set up a lookout system on ''Marchioness'', nor did he keep a lookout aft himself. Focusing on Henderson, Clarke wrote "We cannot stress too strongly how much we deprecate Captain Henderson's conduct in drinking so much alcohol before returning to his vessel as master"; Clarke added "but we do not think that it is shown on the balance of probabilities that Captain Henderson would have acted differently if he had not consumed the alcohol or had the amount of sleep which he had". The captain was also criticised for his actions after the collision, when he did not broadcast a
mayday Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications. It is used to signal a life-threatening emergency primarily by aviators and mariners, but in some countries local organiza ...
call and did not deploy either the lifebuoys or life raft, in contravention of section 422 of the
Merchant Shipping Act Merchant Shipping Act (with its variations) is a stock short title used in Malaysia and the United Kingdom for legislation relating to merchant shipping. Merchant shipping acts and regulations also exist as well in other countries, and they are so ...
1894. Clarke also found that the owners and managers of the vessels held some blame. For ''Bowbelle'', the owners "must bear their share of responsibility for the collision for failing properly to instruct their masters and crews and for failing thereafter to monitor them"; the owners of ''Marchioness'' gave no instructions about all-round lookouts; and failed to adequately instruct, supervise or monitor their boats' captains. Clarke also allotted blame to the Department of Transport, who, he said, were "well aware of the problems posed by the limited visibility from the steering positions on both types of vessel" yet failed to deal with the problem. The PLA also failed to act in this regard, and should have issued instructions for the placement of lookouts on such vessels. Clarke found that because no individual's actions could be ascertained as the single cause of the collision, a manslaughter charge would be bound to fail.


Compensation

English law 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.
Louise Christian Louise Hilda Christian (born 22 May 1952, Oxford) is a British human rights solicitor. She is the daughter of Jack and Maureen Christian. Christian was admitted to the Law Society as a solicitor on 16 January 1978. In 1985,The ''Telegraph'' arti ...
, the human rights solicitor who acted for the families of the victims, wrote that "When young unmarried people die in circumstances of gross negligence as here, death comes cheap and the boat owners and their insurance companies suffer little in the way of financial penalties". Civil claims for compensation were brought on behalf of the victims' families; the amounts received ranged between £3,000 and £190,000. Eileen Dallaglio, the mother of Francesca Dallaglio, one of the victims, reported that she had been awarded £45,000. After the costs of having to go to the Court of Appeal to obtain damages, and the bills for the memorial and funeral service, she was left with £312.14. According to
Irwin Mitchell Irwin Mitchell is a full service law firm in the United Kingdom, established in Sheffield in 1912. The firm offers legal and wealth management services from its 17 offices, and employs more than 2,500 people. In 2018 the company was ranked 21st ...
, the solicitors who represented the families, the amounts were "modest" because many of those killed were young, without dependants and had no established careers. Under the
Fatal Accidents Act 1976 The Fatal Accidents Act 1976 (c 30) is an Act of the Parliament of the United Kingdom, that allows relatives of people killed by the wrongdoing of others to recover damages. Background The Fatal Accidents Act 1846 had allowed claims for damages ...
, damages were only paid to certain categories of people, and were based on the
economic loss Economic loss is a term of art which refers to financial loss and damage suffered by a person which is seen only on a balance sheet and not as physical injury to person or property. There is a fundamental distinction between pure economic loss and ...
to the victim.


Aftermath

After recommendations made in the Clarke report relating to the improvement of river safety, the government asked the
Maritime and Coastguard Agency The Maritime and Coastguard Agency (MCA) is an executive agency of the United Kingdom that responsible for implementing British and international maritime law and safety policy. It works to prevent the loss of lives at sea and to prevent marine ...
(MCA), the PLA and the
Royal National Lifeboat Institution The Royal National Lifeboat Institution (RNLI) is the largest charity that saves lives at sea around the coasts of the United Kingdom, the Republic of Ireland, the Channel Islands, and the Isle of Man, as well as on some inland waterways. It i ...
(RNLI) to work together to set up a dedicated
search and rescue Search and rescue (SAR) is the search for and provision of aid to people who are in distress or imminent danger. The general field of search and rescue includes many specialty sub-fields, typically determined by the type of terrain the search ...
service for the Thames. In January 2001 the RNLI agreed to set up four lifeboat stations—at
Gravesend Gravesend is a town in northwest Kent, England, situated 21 miles (35 km) east-southeast of Charing Cross (central London) on the Bank (geography), south bank of the River Thames and opposite Tilbury in Essex. Located in the diocese of Ro ...
, Tower,
Chiswick Chiswick ( ) is a district of west London, England. It contains Hogarth's House, the former residence of the 18th-century English artist William Hogarth; Chiswick House, a neo-Palladian villa regarded as one of the finest in England; and Full ...
and Teddington—which were opened in January the following year. Following the report, Prescott ordered the MCA to conduct a competency review into the actions and behaviour of Henderson. This took place in December 2001. The MCA picked up on something that had been raised during the Clarke inquiry: that Henderson had forged certificates and testimonials of his service from 1985–1986. They stated that they "deplored" the forgeries, which Henderson had used to gain his Master's Licence. The MCA concluded that he should be allowed to keep his master's certificate as he met all the service and medical fitness requirements; they stated that the agency "accepted that events which occurred in 1986 have no practical relevance on his current fitness". In 2001 the Royal Humane Society made nineteen bravery awards to people involved in rescuing the victims of the collision, many of whom were passengers on ''Hurlingham''. Eight policemen on duty that night were given the Metropolitan Police Commissioner's High Commendation. Following the Clarke report and a subsequent review of emergency planning procedures, the government introduced the Civil Contingencies Act 2004 that provided a coherent framework and guidance for emergency planning and response. Clarke's recommendations to examine the coroner system were a major factor in the overhaul of the system that resulted in the
Coroners and Justice Act 2009 The Coroners and Justice Act 2009 (c. 25) is an Act of the Parliament of the United Kingdom. It changed the law on coroners and criminal justice in England and Wales. Among its provisions are: *preventing criminals from profiting from publica ...
. The events surrounding the sinking of ''Marchioness'' have been examined or depicted on television several times, including a documentary on Channel 4's '' Dispatches'' in December 1994, a drama-documentary in the
BBC Two BBC Two is a British free-to-air public broadcast television network owned and operated by the BBC. It covers a wide range of subject matter, with a remit "to broadcast programmes of depth and substance" in contrast to the more mainstream an ...
series ''Disaster'' in March 1999 and a 2009 documentary focusing on Jonathan Phang. A drama about the events surrounding the disaster was scheduled for broadcast on
ITV ITV or iTV may refer to: ITV *Independent Television (ITV), a British television network, consisting of: ** ITV (TV network), a free-to-air national commercial television network covering the United Kingdom, the Isle of Man, and the Channel Islan ...
in late 2007. Some of the victims' families requested that the programme should not be broadcast, although some thought it positive that it was going to be shown. Speaking at the Edinburgh International Television Festival that August, the former ITV Director of Drama Nick Elliot confirmed that the drama would not be shown "in its present form"; it has since been shown on French television. In September 1989 a black granite memorial stone was uncovered in the nave of Southwark Cathedral, about from the site of the collision. The stone lists the names and ages of those who died. Memorial services have been held at the cathedral on anniversaries of the sinking. ''Bowbelle'' was sold in 1992 to Sealsands Maritime, operating out of Kingstown, Saint Vincent and the Grenadines; she was renamed ''Billo''. Four years later she was sold to Antonio Pereira & Filhos of Funchal,
Madeira ) , anthem = ( en, "Anthem of the Autonomous Region of Madeira") , song_type = Regional anthem , image_map=EU-Portugal_with_Madeira_circled.svg , map_alt=Location of Madeira , map_caption=Location of Madeira , subdivision_type=Sovereign st ...
, who named the vessel ''Bom Rei''. She broke in two and sank off Madeira the same year with the loss of one crew member.


See also

*
List of disasters in Great Britain and Ireland by death toll The following list of disasters in Great Britain and Ireland is a list of major disasters (excluding acts of war) which relate to the United Kingdom or Ireland, or to the states that preceded them, or that involved their citizens, in a definable ...
*
2021 Baltic Sea incident On 13 December 2021, one person was killed in an incident in the Baltic Sea off the coast of Sweden. Two vessels collided of which one capsized. Two people have been detained. Events The Danish motor hopper cargo vessel MV ''Karin Høj'' collid ...


Notes and references


Notes


References


Sources


Books

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Reports

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Journals

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News articles

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Internet

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External links


Marchioness-Bowbelle Formal Investigation Website
In the UK Government Web Archive *


Marchioness Action Group
{{authority control Maritime incidents in 1989 Maritime incidents in England Shipwrecks of the River Thames History of the River Thames History of the City of London Port of London 1989 disasters in the United Kingdom 20th century in the London Borough of Southwark Transport disasters in London 1989 in London August 1989 events in the United Kingdom Little Ships of Dunkirk