The Office of the Ombudsman today issued a damning report on the Marine Department’s “follow-up mechanism on recommendations made in marine incident investigation reports”.
The Ombudsman’s direct investigation was prompted by the “Lamma Incident” in October 2012, where it was it was found that one of the vessels [Lamma IV] involved was not fitted with a watertight door, resulting in water ingress and rapid sinking of the vessel after the collision. It was later discovered that in 2000, a Government vessel under maintenance at a dockyard sank after water had entered its hull because the watertight bulkheads on board were not intact.
“While the relevant incident investigation report had already recommended that the Marine Department examine the watertight bulkheads for all vessels of the same type, the occurrence of the Lamma Incident cast doubt on whether the MD had fully implemented the recommendations of marine incident investigation reports,” the report stated before setting out its criticism of the MD.
Prior to June 2013, when the marine department introduced a computer system to input post incident recommendations for follow-up, the MD had adopted a “lax” approach to following up on recommendations made in incident reports, the Office said.
Under the old mechanism the MD would inform the related agencies of the recommendations, who would be left to follow-up. However, there existed no mechanism for monitoring if the said agencies had indeed followed up.
During the period January 2005 to May 2013, the MD completed 114 marine investigations and issued 308 recommendations. But the Ombudsman’s investigation discovered five cases where no follow-up action was taken for a number of years; in one case follow-up was only subject to retrospective action eight years and seven months after the initial investigation. In a further case follow-up action was initiated swiftly but upon investigation by the Ombudsman no record of the follow-up action taken by the MD could be discovered. This necessitated retrospective follow-up action.
The report goes on to allege that where multiple recommendations were made following an incident some follow-up actions were omitted and only pursued retrospectively after the Ombudsman began its investigation.
The new computerised mechanism installed in 2014, brought improvements, according to the report, but was neither comprehensive nor rigorous. Considered a first step toward effective monitoring, nevertheless the Ombudsman saw fault in the continuing practice of relying mainly on progress reports from shipping companies and agencies to monitor the implementation of recommendations.
“Moreover, where the subject is a vessel not registered in Hong Kong, the MD will only notify the related parties but will not monitor the implementation of recommendations. Such practice is not desirable because the vessel may still represent a hazard when re-entering Hong Kong waters,” the report noted.
The Ombudsman’s recommendations that the new mechanism be adopted to process the incidents prior to its adoption the MD rejected the proposal because of resource constraints. That the MD should alter its stance on adopting the new mechanism is still a recommendation.
Other recommendations included;
- to actively verify whether all the recommendations in incident reports are implemented, instead of relying on reports by the related agencies or parties, and to include this procedure in the regular routines for following up on implementation of recommendations;
- to take appropriate follow-up actions on implementation of recommendations regarding cases involving vessels not registered in Hong Kong or not certificated locally;
- to consider reviewing the information on cases under the Old Mechanism to prevent the problem of confusing records and to ensure that appropriate actions will be taken to follow up on recommendations made in the incident reports; and
- to review regularly the follow-up actions on all recommendations made in incident reports under the New Mechanism and ensure the achievement of expected results.
The MD accepted the recommendations of the Ombudsman and has started taking follow-up actions.