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Thames Safety Inquiry THAMES SAFETY INQUIRY Final Report by Lord Justice Clarke Presented to Parliament by the Secretary of State for the Environment, Transport and the Regions by Command of Her Majesty January 2000 Cm 4558 Thames Safety Inquiry ii CONTENTS Final Report Page A INTRODUCTION 1 Introduction 1 B PART ONE 2 Errata 2 3 Further Conclusions 2 C PART TWO 4 Introduction 6 5 Purpose of a Public Inquiry 7 6 Was This a Suitable Case for a Public Inquiry? 9 7 Why Was a Public Inquiry Not Held? 11 8 Should a Public Inquiry Have Been Ordered? 31 9 Should an Inquiry be Held Now? 48 10 What Should the Inquiry Investigate and What Form Should It Take? 56 11 What Topics Should be Included? 61 12 Treatment of the Deceased 76 13 Summary and Conclusions 84 ANNEXES A Additional Contributors to the Thames Safety Inquiry Parts One and Two 95 B Interim Report Errata 99 C Chronology 103 D Disasters and the Law: Various Papers 155 E MAIB Press Notice relating to Publication of the MAIB Report – 15th August 1991 173 F List of Appendices to the Inspectors’ Report 185 G The Identification of the Deceased Following Mass Disaster Metropolitan Police – January 1994 and Association of Chief Police Officers of England, Wales and Northern Ireland Emergency Procedures Manual 1999 – Sections 6, 14 and 15 189 GLOSSARY 249 iii Thames Safety Inquiry iv Introduction A Introduction 1.1 On 26th November 1999 I finished my interim report and sent it to the Deputy Prime Minister under cover of a letter of that date. It was subsequently published on 2nd December. This final report should be read together with that report. With very few exceptions, I shall not repeat here what I said there because it would be superfluous to do so. Annexed to that report are a number of documents which are relevant to this report. I shall not annex them again to this report. References in this report to Annexes 1 to 34 are references to the annexes to my interim report. The annexes to this report will be referred to as Annex A, Annex B and so on. Annex A is a list of those who have contributed to the Inquiry in addition to those listed in Annex 5 (at volume 2 page 247). I shall use the same abbreviations as in my interim report, where they are set out in the glossary. 1.2 This report will be divided into two parts. Part One is my final report on Part One of the Inquiry. It has two purposes. The first is to correct errors in my interim report which have been pointed out to me. The second is to set out such further conclusions as I have reached in the light of submissions which I have received since I made my interim report. Part Two of this report is my one and only report on the issues raised by Part Two of the Inquiry. 1 Thames Safety Inquiry B Part One 2 Errata 2.1 A number of errata in my interim report have been drawn to my attention. None of them strikes me as of any great significance, but I have set them out, with my comments, in Annex B. 3 Further Conclusions 3.1 Since making my interim report I have received a number of submissions relevant to Part One of the Inquiry. All of them are included in Annex A. Most of them relate to matters to which I have referred in my interim report but were not sent in response to it and do not call for detailed comment. 3.2 One example is an interesting submission from the Association of Riparian Owners on the Avon River, which is, however, outside the area with which I am concerned, namely the part of the tidal Thames described in paragraph 1.4 of my interim report. See also the caveat entered at paragraph 26.7 of that report. 3.3 Other examples include submissions relating to pilotage. I made some reference to pilotage in paragraphs 1.5 and 12.25 to 12.29. As I see it, most of the problems relating to pilotage arise in the part of the Thames which is downriver of the Inquiry area. In these circumstances, while not wishing to belittle them in any way, I do not think that it would be appropriate for me to make any further comment in this regard. 3.4 Other examples include a submission from City Cruises, which I found of considerable interest, but which does not call for any further comment, except in two respects. The first is that potential difficulties are mentioned with regard to applying the ordinary licensing laws to vessels on the river. I have discussed this point briefly in paragraphs 13.31 and 13.32 of my interim report. I adhere to the views I expressed there, although I recognise that there are differences between licensing premises ashore and afloat and that any change in the law would have to take those differences into account. These are matters for discussion with the industry, since I entirely accept that it is important to have a flexible approach to the licensing of vessels, which sometimes operate for much of the night. 3.5 The second point arising out of the City Cruises submission which I would mention shortly is their concern at the suggestion that the cost of SAR should be paid by passenger vessel operators, when they pay pier fees to LRSL. I referred to the question of who should pay for SAR facilities on the Thames in paragraphs 21.33 and 21.34 of my interim report. I simply repeat the point made there that who should pay is really a political question. 3.6 I turn to a number of areas which do call for some further comment. The first is the question who should owe a statutory duty of the kind identified in paragraphs 21.22 to 21.24 of the interim report. The second concerns the role of the PLA, the third concerns VTS and the fourth relates to access to and from the river. 2 Part One SAR – Who Should Owe a Statutory Duty? 3.7 I discussed this question in paragraphs 21.25 to 21.32 and 27.43. I made it clear that it is really a political question, and therefore not for me to say, although (subject to that) I did express the view that it should either be the GLA or the PLA. The PLA has now suggested that the appropriate body upon whom to impose such a duty would be the Department or the MCA. As I see it, the PLA correctly identifies potentially relevant criteria as including democratic accountability, expertise, capability, jurisdiction (along the whole of the tidal river) and access to appropriate funding. It then submits that the PLA meets three of the criteria, namely marine expertise specific to the Thames, jurisdiction and capability, that the GLA meets two of them, namely democratic accountability and access to direct funding, but that the Department meets all five. 3.8 The PLA submits that in these circumstances the option of allocating the appropriate statutory duty to the Department merits further consideration. I agree that it does. I would only say this. The reason why it seemed to me that, if democratic accountability were not the crucial factor, the PLA would be the appropriate body upon which to impose the duty was that it has specific expertise on the Thames and would be the best entity to carry out a risk assessment and to keep it under review from time to time. It seemed to me that such a duty would fit in well with its duties as a CHA, especially in the light of the detailed provisions of the Port Marine Safety Code. In short, it seemed to me that the PLA was best placed in practice to devise and provide an appropriate system. I am still of that view, although I recognise that a final conclusion will only be reached after considering the problem in the context of the provision of SAR services elsewhere and of democratic accountability. 3.9 One possible solution would be for the duty to be placed on the Secretary of State or the GLA (as thought appropriate) but for the body with the duty then to make arrangements with the PLA, perhaps by way of a legally binding MOU, to enable the PLA to devise and provide the appropriate system on behalf of that body. I also recognise that there are other possible views, as noted in another valuable submission from Mr Nigel Spearing, but I do not think that I can usefully add further to the debate at this stage. Role of the PLA 3.10 In the course of another helpful submission, Mr Chris Pond MP, in addition to returning to concerns about pilotage, has reiterated his concern about a conflict between the regulatory duties of the PLA and its commercial activities. I have not, however, changed the views which I expressed in paragraphs 5.15 and 5.16. It seems to me that there is no real conflict between the notion of promoting the Port of London, which is what is referred to in the passage from the 1997 Handbook quoted in paragraph 5.15, and the role of the PLA as CHA. In any event, I have seen no evidence that the PLA is not discharging its statutory duties properly because of any conflict of interest of this, or indeed any, kind.
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