28 March 2012
Marchioness Public Inquiry
Bereaved and survivors of the Marchioness disaster have finally been granted a public inquiry, over a decade after the small pleasure launch was hit and sunk by the much larger dredger Bowbelle in August 1989. Secretary of State for Transport and the Environment, John Prescott (DoETR 2000) made the announcement following receipt of the Final Report of the Thames Safety Inquiry by Lord Justice Clarke (Clarke 2000). This had been tasked with assessing whether a public inquiry was necessary and if so, what form it should take and what it should examine. Although the Marchioness disaster led to inquests and prosecutions, only a private inquiry was originally held, under the auspices of the then newly formed Marine Accident Investigation Branch (MAIB 1991).
Clarke (2000:7) is clear that "no member of the public has a right to a public inquiry". The public, bereaved relatives' and survivors' legitimate interest "in learning the truth of what happened, without anything being swept under the carpet [will] in some cases...necessitate a public inquiry, whereas in others it will not" (Clarke 2000:7). He refers to the expense of public inquiries and states that they "should only be ordered in exceptional cases" (Clarke 2000:8). The Marchioness disaster was, in his view, such an "exceptional case". He is clear that "if ever there was a suitable case for an FI [formal investigation] after the MAIB was set up, this was it" (Clarke (2000:32). Yet, it is clear that his arguments do not rest upon any principle of a general right to openness or scrutiny.
Clarke's argument for a public inquiry rests not on the emergence, post-1989, of new evidence, but on the fact, "that the MAIB investigation [was] private [and therefore] that the evidence considered by the inspectors has never been publicly scrutinised." (Clarke 2000:35). The Report also notes that the public was particularly disadvantaged by the removal of names, marginal references to evidential sources and appendices in the process of amending the original inspector's report into the published Chief Inspector's Report. The reader of this final MAIB Report therefore "cannot identify the evidence upon which it is based. He (sic) does not even know what evidence the MAIB had available to it" (Clarke 2000:34).
Although not reliant upon "new evidence, or upon a detailed analysis of the material considered by the MAIB" the case for a public inquiry is underlined by a number of features:
"They relate principally to the primary facts, to the issue of alcohol and to the position of the owners of the BOWBELLE" (Clarke 2000:36).
In turning to each issue Clarke does not do so "with a view to criticising the MAIB inspectors...or indeed the MAIB Report itself...[as he does] not see it as part of [his] role to do so" (Clarke 2000:36). This reluctance to criticise the initial investigation, on the parts of both the MAIB and the police, presages the most disappointing (if not entirely surprising) conclusion of his Report, that he is not "persuaded that it would be appropriate to investigate the investigations" (Clarke 2000:65).
The irony is that Clarke's Report itself convincingly demonstrates how appallingly inadequate the initial MAIB inquiry was. It also reveals some of the reasons why. The reader is left aghast that eleven years later, we still don't know. Uncertainty is not only, as might have been expected, over broader contextual questions. Official inquiries commonly under-examine these areas in focusing upon individual failings. The inadequacies of the MAIB Report however, extend even to the "primary facts" of the tragedy. The respective courses of the two vessels, for example, and the location of their collision remain contested. Clarke (2000:67) suggests that "more forensic tests should have been carried out" as this is sometimes of assistance in establishing angle of collision and relative speed. The evidence available on this question however was not gathered by the police or the MAIB but by experts acting on the instructions of solicitors for the bereaved and survivors (Clarke 2000:41).
It emerges that another of the reasons why doubt remains about even the most immediate circumstances of the disaster is that "the MAIB...with one exception...did not have the statements made to the police by the crew (or indeed by the owners of the BOWBELLE...)" (Clarke 2000:38). This startling state of affairs is also "highly significant when one comes to consider the question of alcohol consumption by members of the crew of the BOWBELLE" (Clarke 2000:42). Put simply, the MAIB knew that the police had obtained negative blood alcohol readings, but did not know either that the samples had only been taken many hours after the collision, or that Captain Henderson and crew member Blaney's police statements each detailed prolonged and heavy drinking before the disaster. Yet Clarke (2000:43) again emphasises that he wishes to "make no criticism of either the police or the MAIB for the fact that this information was not known to the MAIB when it made its report."
It was found by the initial MAIB Report (1991:40) that the owners of the Bowbelle had allowed "safety to slip from the forefront of [their] consciousness". The failure to analyse this "slip" was a target of the CSCSJ submission to Clarke (Hartley and Davis 1999). The MAIB assertion (1991:40) when considering such organisational issues that "all this mainly boils down to human nature..[whose]...relevance to the accident is questionable" simply beggared belief. It is good news therefore, that Clarke lists the very many questions that need to be asked of the owners' actions (or inaction) preceding the disaster (Clarke 2000:43-48, 50-1). He also asserts the relevance of the appalling catalogue of collisions and near disasters in which the Bow vessels had been involved before 1989 and the significance of evidence (much of which was excluded by the coroner from the inquests) from previous crewmen of the Bowbelle.
Despite his refusal to recommend "investigation of the investigation" Clarke again highlights just how flawed it was. Revisions to standing orders, changes to operational practices and consideration of accidents "at senior management level" are cited (Clarke 2000:46) as only some of the issues still requiring investigation. He also asserts (2000:45) that:
"the police did not apparently take any statements from any managers or senior personnel at SCS (South Coast Shipping) or ECA (East Coast Aggregates)..." (Emphasis added)
While the police did take company documents, they "related almost entirely to the period from mid-1988 onwards" (Clarke 2000:45). The MAIB did not even have documents "relating to the revision of standing orders in 1987 (other than the revised orders themselves) or the reasons why the 1987 revision removed any reference to lookout or watch-keeping on the Thames. Indeed, apparently it did not even have any documents relating to the policy of posting an officer forward or as to the circumstances in which the policy had ceased to operate" (Clarke 2000:45).
As Clarke suggests, the public inquiry may consider these and other aspects of the investigations as part of its evaluation of evidence with which it is presented. He also calls for consideration to be given to a framework for inter MAIB-police work. He dismisses suggestions that a "corporatist bias" tainted Marchioness inquiries in a manner analogous to racist tainting of the Stephen Lawrence investigation (Clarke 2000:64). "The Stephen Lawrence Inquiry" he states "raised questions of fundamental human rights, whereas this aspect of the Inquiry does not" (Clarke 2000:64).
The Marchioness families may beg to differ. Their relatives are dead and no person or company has been held accountable. Clarke's own Report demonstrates how, and to some extent why an investigation into massive loss of life failed to secure either justice or truth. Numerous tragedies, both small and large, have left familiar trails of failed prosecutions, narrow inquests and ineffective inquiries. Such failure is routine. It would not be tolerated had the killers been individuals.
Clarke sets out in detail how and why the original decision not to hold a public inquiry was consolidated and perpetuated within the Department of Transport. One reason was that the Department feared that "if an FI were to be ordered after the publication of the MAIB Report the newly formed MAIB would lack support or credibility" (Clarke 2000:31). This clearly demonstrates how public interest, when defined in private, becomes conflated and confused with dominant or establishment interests, in this case the perceived interests of the investigative apparatus itself. After Hillsborough police officers' statements were suppressed or altered by an organisation on the defensive (Scraton 1999). This did not become known until a decade later.
After the Marchioness disaster it was not culpability for the disaster, but an inadequate investigation that was kept hidden. Further, contrary to Clarke's assumption, there is no reason to believe that the public scrutiny required to counter such tendencies only becomes necessary in "exceptional cases". If, after the deaths of 51 people, necessary statements were not taken, previous incidents were not explored, forensic tests were not made and crucial documents were not obtained, why should there be any expectation that in less "exceptional" cases inquiries will be any more rigorous? Their lower public profile and the deployment of fewer resources might indeed indicate the contrary.
Clarke's Report did not recommend that a public inquiry should examine the removal of hands from many of the victims of the disaster for fingerprinting. This was done without informing relatives. The submissions of families and of the Centre for Studies in Crime and Social Justice (Hartley and Davis 1999) argued strongly that this issue should be examined. Powerful concerns have developed around the politics of the bodies of deceased people, for example in the Alder Hey controversy and it is to be welcomed therefore, that Clarke's view was not accepted by John Prescott. A non-statutory public inquiry will examine this aspect of the tragedy.
Disasters large and small elicit the political mantra of "a full" and a "thorough" inquiry. The immediate needs of the bereaved indeed, are routinely subordinated to the requirements of the evidence gatherers (Davis and Scraton 1999). The Clarke Report illustrates once again the reality of shoddy investigations yielding poor outcomes. It is a matter of serious regret given the force implicit in Clarke's own account, that once again the investigation lies beyond investigation.
Update: The Inquiry into the Identification of Victims following Major Transport Accidents has begun: Any organisation or individual who wishes to submit relevant written evidence/documentation or participate in the non-statutory inquiry should give notice to: Mr A J Sandal, Secretary to the Inquiry, 6th Floor, Romney House, 43 Marsham Street, London SW1P 3RA.
Sources: Clarke LJ (2000) Thames Safety Inquiry: Final Report The Stationery Office, Cm 4558, London; Davis H and Scraton P (1999) "Institutionalised Conflict and the Subordination of "Loss" in the Immediate Aftermath of UK Mass Fatality Disasters" Journal of Contingencies and Crisis Management Vol.7, No.2. pp86-98; Department of the Environment, Transport and the Regions (2000) Press Notice 106 17.1.00; Hartley H. and Davis H (1999) Thames Safety Inquiry Written Submission; 2nd November 1999 CSCSJ; Marine Accident Investigation Branch (MAIB) 1991 Report of the Chief Inspector of Marine Accidents into the Collision between the Passenger Launch Marchioness and the MV Bowbelle with Loss of Life on the River Thames on 20 August 1989 London HMSO; Scraton P. (1999) Hillsborough; The Truth Mainstream Publishing, Edinburgh.
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