Disaster at Whiddy Island, Bantry, Co. Cork

8/14/2019 Disaster at Whiddy Island, Bantry, Co. Cork

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Disaster atW hiddy I s l and ,

B an t r y , C o . C o r kR E P O R T O FT R I B U N A L O F I N Q U I R Y

e s t a b l is h e d p u r s u a n t t o r e s o l u t io n s p a s se d b y D a i l E i r e a n n o n t h e 6 t h M a r c h , 1 9 7 9 , a n d S e a n a d E i r e a n no n th e 8 th M ar ch , 1 9 7 9 .

D u b l i n :Published by the Stationery Office.To be purchased from theGovernment Publications Sale Office, G.P.O. Arcade, Dublin !or through any bookseller.Price: 11

(Pr l . 8911 )


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Th e Minis ter for Transpor t ,Du b l i n .

Th e Re port herein is the Report o f the Tribuna l establ ished pursuant to Resolut ions passed byDail Eireann on the 6th March, 1979, and Seanad Eireann on the 8th March, 1979, to inquireinto the disaster wh ich occ urred at Wh id dy Island, Ba ntry , Co. C ork on the 8th Janu ary, 1979.

Dated 9 th day of May, 1980.

Th e T r i b u n a l .

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C O N T E N T SP A R T I j

I N T R O D U C T I O N , O U T L I N E O F R E P O R T A N D S U M M A R Y /O F P R I N C I P A LC O N C L U S I O N S /

C H A P T E R 1 I N T R O D U C T I O N / P ag e1.1.1 Introduc tion / 31.2.1 Th e Tribunals of Enq uiry (Evidence) (Am end me nt) Act , 1979. 31.3.1 Th e Resolut ions of the tw o Houses of the OireacWtas 41.4.1 Appointment of the Tr ibuna l / 41.5.1 Pub lic Sittings / 51.6.1 W itnesses / 5/1.7.1 Represen tat ion / 61.8.1 Glossary and Abb reviat ion s / 7, , ,

C H A P T E R 2 O U T L I N E O F R E P O R T A N D S U M M A R Y O F P R IN C I PA LC O N C L U S I O N S /2.1.1 Outl ine of the R e p o r / 92.2.1 Summary of the Tr^unal 's conclusions as to the ini t iat ing event of th edisaster / 122 .3 .1 Summary of the /Tr i bun al ' s p r incipal conclusions on the ev idence

conside red by it 12

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P A R T I IT H E F A CT S O F T H E D I S A S T E R A N D R E L A T E D I S SU E S

2929303031323333

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C H A P T E R 3 G E N E R A L I N T R O D U C T I O N T O T H E D I SA S T ER3.1.1 Introdu ction \\3.2,1 W hid dy Island and Bantry Bay3.3,1 Th e oil termina l \3.4.1 The offshore j e t ty \3.5.1 Th e operat ion of the terminal3.6.1 Th e fi re-fight ing system \3.7.1 Th e tugs \3 .8.1 The l ine-boats and the "D on A na rk "


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Page3.9.1 Th e duties of Gulfs personnef on the n ight of the disaster 33

3 ,1 0. 1 M eans o f co m m u n i ca t i o n ^ t h e t e rm in a l 3 43.11.1 The "B etelg eus e" / 353.12.1 Th e "C assio pee " / 363.13.1 Con dit ions on the / i igh t of the 7 th/8th Jan uar y 36

C H A P T E R 4 E V E N T S O F T H E 6 th /7 th J A N U A R Y4.1.1 Introdu ction 384.2.1 Saturday, Jan uar y 6th 384.3.1 Sunday , Janu ary 7th 39

C H A P T E R 5 T H E D I S A ST E R : E Y E - W I T N E S S E V I D E N C E ( G E N E R A L )5.1.1 Introdu ction ' 42

S E C T I O N 1 /5.2.1 Phase 1: 00.31-00.40 appro xima tely * 43

S E C T I O N 2 ^5.3.1 Phase 2: 00.40 to 01.0601 .08 appr oxim ately 49

S E C T I O N 35.4.1 The Garda evidence 56

59

6262

6465686874

767880

S E C T I O N 45.5.1 Ot he r eye-witness evidence

S E C T I O N 55.6.1 n Th e evidence of the Postmistress on W hi dd y Island

^ Summ ary of the Tr ibunal ' s conclus ions

C H A P T E R 6 T H E D I S A ST E R : E Y E - W I T N E S S E V I D E N C E ( G U L FE M P L O Y E E S A N D O T H E R S A T W H I D D Y I SL A N D )6.1.1 Introduction6.2.1 The evidence of M r. J o h n Do wn e y an d M r . B r i an M cGee6.3 .1 Th e ev idence f rom the crew of t h e "B an t ry B ay "6 .4 ,1 The ev idence of Mr . John Con nol ly , the d i spatcher a t Gulf C o n t ro l6.5.1 The evidence of the crew of t h e " D o n e m a r k " :Mr. Bruce Tessyman and Mr. Donal Hurley6 .6 .1 Th e ev idence of the crew of the "Sn ave " :Mr. Desmond O'Sul l ivan , Mr. Michael Kel ly andMr. F lorence O'Dri scol l6.7,1 The evidence of the P lan t P ro tect ion Ope rators :

M r . Ar t h u r O 'C o n n o r , M r . P at O 'Do n n e l l an d M r . J am es Kearn s6 .8.1 Summ ary of conclusions

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C H A P T E R 7 R E S C U E O P E R A T I O N S p a g e7.1.1 Introdu ction 37 .2 .1 Th e "D o n e m a rk " an d t h e "S n av e " 8 37.3.1 Th e act ion of the pumpmen and the P lant

Pro tect ion Opera tors 847,4.1 Th e alert of the tugs 847.5.1 Th e local fire services and Gulf personnel 857.6.1 Th e M ajor Accident Plan ini t iated by the Gardaa 87

S u m m a r y of the Trib una l 's conclusions 87\C H A P T E R 8 . T H E S U P P R E S SI O N O F T H E T R U T H

8.1.3 ^ ^ I nt ro du ct io n 898.2.1 Th e logs of Gulf Cont ro l , the "D on em ark " , and Ascon securi ty hut 898.3.1 Th e statements of the five Gulf employees to the Garda i 918.4.1 Th e Bantry Bay Hote l meetings 948.5.1 Senior Gulf personnel 968.6.1 Th e telephonist in the Ban try Exchan ge 998.7.1 Th e object of the ev idence of th e Gulf employees 100

C H A P T E R 9 ] G U L F ' S A L L E G A T I O N S A G A I N S T T H E G A R D A I9.1.1 y Introdu ction 102

Al legations agains t G ar da jo y 1029,3.1 Alleg ations in closing submissions 103

C H A P T E R 10 \ E V I D E N C E R E L A T I N G T O T H E V I C T IM S O F T H E D I SA S T E R10.1.1 -Introdu ction 10410.2.1 ; 'T he location of the bodies 104i10.3,1 Post-m ortem exam ination 10510.4.1 Sum mary of conclusions 106

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C H A P T E R 11 S U M M A R Y O F E V E N T S 109

P A R T I I IT H E T E R M I N A L

C H A P T E R 12 T H E T E R M I N A L12.1.1 Introdu ction 121

S E C T I O N 112.2.1 Th e fire-fighting facil it ies (at the t ime of the termina l 'scommissioning) 121


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S E C T I O N 2 P a ge12.3.1 Ad ditions and modifications to the existing fire-fightingfacilities 124

S E C T I O N 312.4.1 Com men ts on certain modificat ions to the fire-fighting system 128

S E C T I O N 412.5.1 Alte ration s to the escape facilities from the offshore j e t ty 130

S E C T I O N 512.6.1 Th e pressurisation systems on the offshore platform 131

S E C T I O N 612.7.1 Ha zar dou s Are^ classification of th e offshore jetty 134

S E C T I O N 7 112.8.1 Th e Che ck-list and Defect N ot e system ... 136

S E C T I O N 812.9.1 Ma intenan ce and repair of equipment 137

S E C T I O N 912.10,1 Em ergen cy procedures and training 14012.11.1 Index to the Tribunal 's conclusions on the matters considered inthis Ch ap ter 146

C H A P T E R 1 3 T H E T U G S13.1.1 Intro duc tion 149

S E C K O N - 4 ^13.2.1 ^"*G ulf s original operat iona l plan and i ts aba ndon me nt^"^ 15013.3 .1 Th e involvement of the Dep ar tme nt of Transpor t and Pow er 15313.4.1 De velop men ts from 1969 153

S E C T I O N 213.5 .1 Gul fs "Pol icy and Proced ures" Manual 155

S E C T I O N 313.6.1 Further considerat ion of evidence 157

S E C T I O N 413,7,1 Summary of princ ipal conclu sions 159

C H A P T E R 14 T H E O F F S H O R E J E T T Y - P O S T - D I S A S T E R14.1.1 Intro duc tion 161

S E C T I O N 114.2.1 Th e jet ty s tructure and jet ty bui ldings after the disaster 16114.3.1 Th e jetty buildin gs 163


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S E C T I O N 2 P a geTh e oil and ballast and drain age systems after th e disaster

14.4.1 Pipe wo rk 16514,5.1 Th e ballast transfer system 16614.6.1 The bun ker fuel system 16714.7.1 Th e diesel transfer system 16814.8.1 Offshore slops and dra inag e system 168

S E C T I O N 3Th e fire water system and safety system after the disaster14,9.1 Fire wa ter pum ps 168

14,10.1 Condit ion of the escape routes after the disaster 17214.11.1 Programme of examination and tests of certain jet ty equip me nt 17214.12.1 Th e Tri bun al's conc lusions 173

S E C T I O N 414,13.1 Th e electrical installations and co mm uni cat ion systems after the

disaster 17314.14,1 Possible status of electrical system on the nigh t of the disaster 18214.15.1 Ea rthing system 18214.16.1 Catho dic protect ion system 18314.17,1 Co mm unic atio ns system 18314.18.1 T he Tri bun al's conclusion s on this Section 184

S E C T I O N 514.19.1 Th e em erge ncy block valves and the cable to the teleph one kiosk onDo lph in 22, , ' 18414,20.1 Index of the. Trib una l 's conclusions on this Cha pter 185

P A R T I VT H E S H I P

C H A P T E R 15 T H E " B E T E L G E U S E " IT S M O D E O F O P E R A T I O N SA N D P R E - D IS A S T E R H I S T O R Y15.1.1 Introduction 189

S E C T I O N 115.2.1 Th e ship and its mo de of operat ion 189

S E C T I O N 215.3.1 Hu ll classification history 196

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S E C T I O N 3 P a ge15.4.1 Fire-fighting systems 196

S E C T I O N 415.5.1 Ma intenanc e and repairs 199

S E C T I O N 515.6.1 Catho die protect ion 204

S E C T I O N 615.7,1 Conversion of 4(a) wi ng tanks in 1970 206

S E C T I O N 715.8.1 The last voyage of the "Be telge use" and the repairs to the port PB T 206

S E C T I O N 8 ;15.9.1 Th e ship's con ditio n on 7th Jan ua ry, 1979 209/

fC H A P T E R 16 T H E " B E T E L G E U S E " P O S T - D I S A S T E R

16,1.1 Introd uctio n 213S E C T I O N 1St ructural Damage

16.2.1 The salvo rs 'evid enc e 21416.3,1 Structural dam age Post-disaster survey 21616.4.1 Conclusions from the fire-marks on the ship 221

S E C T I O N 2The Metal lurgical Evidence

16,5.1 Metal lurgical exam ination and testing by the IIRS 22216.6.1 Fatigue fractures 228

S E C T I O N 3Wa stage and Corros ion of the Vessel

16.7.1 Wa stage in way of the perm anen t bal last tanks and the N o. 4 centretank ' 230

16.8.1 Th e weld ing of the rene we d longitudinal 232S E C T I O N 4The Ship 's Deck

16.9.1 Absence of fire-damage to the deck whe re the ship first brok e i tsback 233

16.10.1 Th e vent pipe on the mid-s ection 23616.11.1 Summary of conclusions in this Cha pter 237

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P A R T VT H E C A U S E O F T H E D I S A S T E R A N D T H E R E S P O N S I B I L I T Y T H E R E F O R

C H A P T E R 17 P O S S I B L E C A U S E S O F T H E D I S A S T E R ( G E N E R A L ) P a ge17.1.1 Introdu ction 24717,2.1 Th e igni t ion on the ship of flammable vapou rs ema nating from

the ship 24817.3.1 Th e igni t ion on the jet ty of flammable vapours ema nating from

the ship ' 25217.4.1 Sm okin g on the jetty or the ship 25317.5.1 O th er possible initiating events 25417.6.1 Con clusio n 255

C H A P T E R 18 P O S S I B L E C A U S E S O F T H E D I S A S T E R T H E J E T T Y18.1.1 Intro duc tion 25718.2.1 A fire in the slop tank 25718.3.1 Th e slop tank pit 25818.4.1 A broken Chiksan arm 26418.5.1 T w o theories suggested by the dam age to the Chiksan arm and

reducer exam ined 26518.6.1 Th e condit ion of the reducer and the inferences from the fi re-marks 26718.7.1 Con clusio ns 269

C H A P T E R 19 T H E H U L L F A I L U R E T H E O R Y T H E S H I P' S B A L L A S T19.1.1 Intro duc tion 27119.2.1 The evidence of Marine Ma nager, Capta in Phil lips 27219.3.1 The evidence of Cap tain Denis Da ly, M r. Michael Ball and M r.

Elias Tsakos jf* 2 7 619.4.1 Th e physical evid ence 27719.5.1 Na val archi tectural evidence su bm it te d^ y Tota l 27819.6.1 Th e eviden ce of form er m em b ers of the crew of the "Betelgeuse" and

of Total 's Tec hnica l mana ger 28119.7.1 Con clusions 284

C H A P T E R 20 T H E H U L L F A IL U R E T H E O R Y T H E M E C H A N I S M O FT H E D I S A S T E R

20.1,1 Introduction 288S E C T I O N 1

20.2.1 The hull failure theor y 288S E C T I O N 2

20.3.1 Stress calc ulatio ns 290x i i i


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SECTION 3 PageThe Explosions in the Permanent Ballast Tanks

20.4.1 Introdu ction 30220.5.1 Th e explosions in the per ma nen t ballast tanks 30220.6,1 The source of the explosive mixture s in the perm anen t bal last tanks

and their ignitio n 30320.7.1 Th e t ime of the explosions in the PB T's 30520,8.1 T w o theories relat ing to the explosions in the PB T's 306S E C T I O N 4

Events subsequent to the initial Hull Failure20.9.1 Th e first phase 309

20.10,1 Th e second phase 30920.11.1 Th e third phase 31020.12.1 Sum mar y of conclusions in Sect ions 2, 3 and 4 of this Ch apte r 311

tC H A P T E R 21 R E S P O N S I B I L I T Y F O R T H E D I S A S T E R

21.1.1 To tal 's respons ibility 32121.2.1 Gu lfs responsibi li ty " 32221.3.1 Th e loss of cargo and dam age to the jet ty 325

P A R T V IT H E R O L E O F T H E P U B L I C A U T H O R I T I E S

C H A P T E R 22 T H E R O L E O F T H E P U B L I C A U T H O R I T I E S22.1.1 Introd uction 32922.2 .1 The Dep ar tme nt of Transpor t and Pow er 32922.3 .1 Th e Dep ar tme nt of Labour 33122.4 .1 Th e Cor k Co unty Counci l 33222.5.1 Th e Trib una l 's conclusions 333

C H A P T E R 2 323.1.123.2.1

P A R T V I IR E C O M M E N D A T I O N S A N D C O S T S

R E C O M M E N D A T I O N SInt roduct ionR eco m m en d a t i o n s

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C H A P T E R 2 424.1.1

C O S T SCostsI N D E X O F A P P E N D I C E S

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PART IIntroduction

Outl ine of Report

Sum m ary of Principal Conclusions\

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C H A P T E R 1Introduction

1 . 1 . 1 I n t r o d u c t i o nThe M.V. "Bete lgeuse" lef t Ras Tanura in the Pers ian Gul f on the 24th N ove mb er , 1978,bou nd for L eixoes, in Portuga l , She was a large tanker (having a gross registered ton nage of61,776) and was carrying a cargo of75,000 metric tonnes (approxim ately) of Arabian Heavycrude and 40,000 metric tonnes (app roxim ately) of Arabian Light crude. Or iginal ly theintent ion was to call f irst at Sines, whic h is south of Lisbon, to l ighten ship but the weathe rwas so bad that she could not enter the harb our. He r plans were further frustrated at Leixoes;a ship sank across the entrance to the harb our and she was prevented from ca l l ing there anddischarging her cargo. She was then instructed to sail to "Whiddy Island, which is situated inBantrv B ay, Co unt y C ork , and w here an oi l terminal is operated by Gu lf Oil Term inals(Ireland) Ltd. She stopped in Vigo to change some of her crew , and sailed for B antry on the30th December. She encountered heavy weather in the Bay of Bisca yand after repor t ing aleakage of oi l was instructed to head tow ards Brest and reduce speed. How ev er, the o riginof the leak was discovered and stoppe d, and the vessel proceeded on passage to Ba ntry,arriving in the Bay on the 4th Janu ary, 1979. She completed berthing at the offshore jet ty(wh ich is si tuated abou t 1,300 feet (396 metres) off W hid dy Island) at 20.00 hours onSaturday , 6 th January ,Early in the mor ning of the 8th Janu ary, a disastrous fire o ccurred whic h e nvelop ed a largesect ion of the ship and the offshore jet ty . The fire was accompan ied by a numbe r ofexplosions, one of wh ich was a massive one. A ll the crew of the tanker, the wife of oneme mb er of the crew , tw o visitors on the tanker, the crew on the jet ty and the ship 's pi lot(fifty person s in all) lost their lives. The vessel was rende red a total w reck and ex tensivedam age w as caused to the offshore jet ty and its installations.O n the 9th Jan uary , 1979 the Minister for Tourism and Trans port appo inted a surveyor inhis Department to carry out an inquiry into the casual ty under the provisions of section 465of the M erch ant Shipping Act , 1894. At the same time an inspector appointe d by theMinister for Labo ur unde r the Factories Act , 1955, began an inquiry into the disaster. It wasalso announced that a public inquiry would be held into the disaster and subsequently it wasstated that this wo uld take the form of a Tribu nal to be establ ished under the provisions ofthe Tribu nals of Inquiry (E vidence) Act , 1921 (hereinafter; "the Act of 1921").

1.2 .1 Th e Tr i buna l s o f I nqui ry (Ev i dence ) (A m e nd m ent ) A c t , 1 97 9Before the present T ribu nal was established it was decided to amend the Act of 1921, and theTribun als of Inquiry (Evidence) (Am endm ent) Bil l was passed by the tw o Houses of theOirea chtas on the 20th Februa ry, 1979. The a men ding A ct (hereinafter: "th e Act of 1979")provided by sect ion 2:

"2 {]) A tribunal may consist of one or more than one person si t t ing with or without anassessor or assessors appointed by the instrument appointing the tribunal or anyinstrument supplemental thereto.(2) An assessor appointed under this section shall not be a member of the tribunal inrelat ion to which he is so appo inte d."

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Section 3 of the A ct crea ted offences inter alia for non com pliance with the t ribunal 's orders .Sect ion 4 provided:"4 A tribunal may make such orders as i t considers necessary for the purposes of i tsfunctions and it shall hav e, in relation to their ma king , all such pow ers rights andprivi leges as are vested in the Hig h Co urt or a Judg e of that C ou rt in respect of them ak i n g of O rd er s . "

Sect ion 5 deal t w ith the non-adm issibi li ty in criminal proce edings of evidence given totribunals and sect ion 6 gave, for the fi rs t t ime, a powe r to a t ribunal establ ished under theAct of 1921 to aw ard costs . I t prov ided :"6 "Where a t ribunal , or, i f the t ribunal consists of more than one m emb er, thechai rman of the tribunal, is of the opinion that , having regard to the findings of th etribu nal a nd all other rele vant m atters, there are sufficient reasons rend ering itequitable to do so, the t ribunal or the chairm an, as the case may be, may by ord erdirect that the w hole or part of the costs of any person app earing before thetribunal by counsel or sol ici tor, as taxed by a Tax ing M aster of the High Co urtshal l be paid to the person by any other person named in the order."

Applicat ions for costs unde r this sect ion w ere subsequently m ade. Th e ma tter is deal t with inChapter 24 of th i s Repor t .

1.3.1 T h e R e s o l u t i o n s o f t he t w o H o u s e s o f t h e , ;Oi rea chta sPursuant to the provisions of the Act of 1921, Dail Eireann passed a resolut ion on the 6thMarch, 1979, and Seanad Eireann passed a resolution on the 8th March, 1979. The terms ofthe resolutions we re as follows:

"That i t is expedient that a t ribunal be establ ished for1. inqu iring into the fol lowing defini te matters of urgen t public im portanc e:

(1) the im med iate and other causes of, and the circumstances of and leading to, theexplosions and fi res on an d in the vicini ty of the ship "Betelgeuse" and the jet tyof the terminal of Gul f Oi l Terminals ( I re land) Limi ted a t W hid dy Is land ,Ban try, in the Cou nty of Co rk on the 8th Janu ary, 1979.(2) th e circumstances o f and lead ing to the loss of life on and in the vicinity of th e

ship and jetty on the 8th Jan ua ry , 1979.(3) the measures, and their adequ acy, taken on and before the 8th Janua ry, 1979,on, in the vicinity of and in relation to the ship and at, in the vicinity of and inrelat ion to the terminal to prevent , and to minimise and otherwise to dealw i t h

(a) fires and explosions of the kinds aforesaid, and(b) the occurrence of circumstances of the kinds that led to the loss of lifeaforesaid;

and2. making such recommendations (if any) as the Tribunal having regard to its findings,th inks proper" .

1.4.1 A p p o i n t m e n t o f t h e T r ib u n a lThe Order appoint ing this Tribunal was made on the 9th Apri l , 1979, by the Minister forTour i sm and Transpo r t . Af ter reci t ing the terms of the Resolutions passed by the two Housesof the Oirea chtas, the O rde r provide d as fol lows:

"1, A Tribunal is hereby appointed to invest igate and report to the Minister forTourism and Trans port on the said defini te matters of urgen t public im portance.2. The H ono ura ble Mr . Just ice Declan Costel lo is hereb y nom inated to be the solem em b er o f th e T r i b u n al ,


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3. The fol lowing persons are hereby appointed to be assessors to the T ribu nal:Dr . H ugh Kenneth Black B .Sc.Ph .D , , Scien ti fi c Co nsul tan t , 79, Popes Avenu e,Twickenham, Middlesex , England .Captain Donald George Hindle , Mas ter Mariner , "Brands Hatch" , Quecnswalk ,Cleveleys, Blackpool , Lanes. , England.Mr. Gerard Van Zon , Chief Engineer , Rober t Kochs t raat 13 , Hen gelo , Hol land .Mr. Jens The odor Wi lse , N aval Archi tect , Senior P r incipal Surveyor . Det NorskeVeri tas , Ver i tas Cent re , Os lo , Norway,4. Th e Tribun als of Inquiry (Evidence) Act , 1921 (as adapted by or und er subsequentenactments), shal l apply to the Tribunal ,"

1 .5 .1 Pu bl ic Si t t ingsTh e firs t public s i t t ing of the Tribuna l was held on 26th A pri l , 1979, the si tt ing havin gpreviously been advert ised in the public press in this country and in France, The hearings onthat day we re devoted to the considerat ion of applicat ions for l iberty to be legallyrepresented at the hearings.Th e firs t public s i tt ings of the Tribunal at which oral test imony was received were held onthe 14th M ay , 1979. In all (inc ludin g the sittings on the 26th April) the T rib un al sat for 72days throughout the year 1979.Its s i t t ings were held in the West Lodge Hotel , Bantry on the 26th Apri l , the 14th-18th May,the 21s t-25th May, the 28th M ay -l s t j un e, and the l l th -1 5th June. The hear ings were thenadjourned. As appears later in this Report (see, in particular, Chapter 16) it had been possibleto raise only port ion o f the wr eck (the forebody of the vessel) before the hearings started,and i t was considered desirable to awa it the evidence w hich w ould be avai lable from theraising of the m id-sect ion before resuming the hearings.Th e T ribun al sat again in Bantry from the 1st Oc tobe r to the 5th of Octob er. I t thenadjo urn ed to Dub lin and held public hearings in the premises of the Incorporated La wSociety in Blackball Place. The Tribunal sat on the 8th-12th October, the 15th, 16th and19th October , the 22nd-26th October , the 30th October-2nd November , the 5 th~9thNo vem ber , the 12th-16th No vem ber , the 19th-22nd Novem ber , the 26th-30th N ove mb er ,the 3rd-6th December, the 11th and 12th December, and the 17th-20th December.Most of the witnesses heard in Bantry we re local witnesses; most of the expert evidence inthe case was heard in Dublin.At the conclusion of i ts public hearings the Tribunal indicated that it did not require toobtain any further evidence, includ ing the results of any further surveys or exam inations ofthe mid-sec t ion of the "B etelg eus e". Th e reasons for this decision are given later in thisRepor t .

1 .6 .1 WitnessesTh e T ribu nal heard evidence on sixty-five days and oral submissions at the end of theeviden ce for s ix days.O ne hundred and eighty-four wi tnesses were heard , of wh om seventy-eight gave technicalor expert test imony. Ninety-seven gave evidence relevant to the facts of the disaster. Othersassisted the Tribun al b y the produ ction of photo grap hic and other m iscellaneous types ofevidence.All the oral testimo ny, as we ll as counse ls' submissions, was taken do w n in shorth and andt ranscr ibed overn ight in to Books of Evidence.The proc edur e adopte d in relat ion to the oral test imony w as as fol lows. All witnesses we recal led by the T ribuna l 's counsel and fi rs t exam ined by him. Th ey were then avai lable forexam ination b y counsel for the part ies to wh om the right of representat ion had beengrante d. P rior to their oral examina tion, a wri t te n statement of the witness 's evidence w as

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circulated. In the case of expert witnesses, reports were obtained and circulated. In most casesthe w ri t ten statement or repo rt was accepted by the Tribun al as part of the witness 'stest imony; i t was, however, in most cases supplemented by oral evidence.Th e l ist of witnesses w ho gave evidenc e is given in Appendix 1 to the Report .An alphabetical l ist of witnesses was prep ared by the Tribu nal 's registrar and this , togetherwith a reference to the Bo ok of Evidenc e in wh ich the witnesses' oral test imony is to befound, is given in Appendix 2.Those witnesses who se statement or report was accepted in evidence are identified inAppendix 1 by the letter " S " o r "R ', as the case may be, after their nam es. These statementsand reports are forwarded, as are the Books of Evidence , w ith this Repo rt .A list of exhibits is give n in Appendix 3.

1.6.2 Th e persons legal ly represented before the Tribun al had, in many instances, carried outsurveys and examinations of the "Bctelgeuse" and the terminal and jet ty, and had obtainedreports aris ing from such surveys and examinations. These w ere forwarded to the Tribunalwith a request that the expert who prepared the report be called as a witness. In nearly allcases these requests were com plied with . It will be found conv enient to refer to suchwitnesses as, for exa mple, a "Gu lP ' w itness or a "T ot al " witness, even though , s trict lyspeaking, al l witnesses w ere cal led by the Trib unal i tself to give evidence.The Tribunal was not in any way restricted in i ts inquiry to the evidence or witnessesproposed by those legal ly represented before i t . Imm ediately after the disaster theDepa r tment of Tour i sm and Transpor t had engaged as consultan ts Mr. Anthony Viner , anaval archi tect in the Hull Structure De par tme ht .of Lloyd's Register of Shipping, and Mr.Gor don Victory , a char tered engineer and a former member of the Marine Division of th eDe par tm ent of Trade of the Bri ti sh gove rnment and a past P res ident of the Ins t itu te ofMarine Engineers . Both Mr. Viner and Mr. Victory assisted the Tribunal 's legal advisers andgave evidence before the Tribun al .Th e IIRS and Lloyd's Register of Shipping w ere requested by the Tribunal to carry outcertain examinations and tests , and their reports were part of the evidence considered by theTr i b u n a l .Furth erm ore, Mr. John De nha m, a Chief Engineer in Irish Shipping Ltd. , was seconded toassist the Tribu nal and he supervised a numb er of exam ination s, tests and surveys andrepor ted on them to the Tr ibunal .

1 . 7 , 1 R epres enta t i o nUn de r the provisions of the Act of 1921, the Tribun al had pow er to authorise therepresentat ion before i t by counsel or solici tor of any person "a ppe aring to be interested ".A n u m b e r of applicat ions for representat ion were made on the 24th Apri l and on subsequentdays. Part iculars of the applicat ions and of the names of the legal representat ives of thosewhose applicat ions were granted are given in Appendix 4.There is one part icular aspect of the subject of the legal representat ion before the Tribunal towhic h reference sho uld here be made. O n previous occasions when tribunals wereestablished unde r the provisions of the Act of 1921, the evidence was obtained by the C hiefState Solicitor and presented by counsel instructed by him on behalf of the Attorn eyGe nera l. In the present instance the Atto rne y Ge neral sugg ested that this practice sho uldnot be adhered to and that, instead, he would assign solicitor and counsel to the Tribunal whowould act as i ts sol ici tor and counsel . This suggest ion was readily accepted by the Tribunaland i t has been found to be of immense value. A tribunal establ ished under the Act of 1921 isnot a court of law hearing evidence adduced by opposing, part ies; i ts funct ion is to c onductan inq uiry. In the present instance, i t would have been very difficult for i t adequately tocarry out its statutory functions if it had not been able to consider, with its own solicitor andcounsel , what evidence should be obtained, and direct what s teps should be taken in thesearch o f the cause of the disaster. A further reason for adop ting this procedure arose fromthe fact that the role of the public authori t ies could come under the scrut iny of the Tr ibunal ,


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and i t was obviously not desirable that the Attorney Generalwho would represent thegovernment departments involved and the Garda authori t iesshould at the same t ime beresponsible for the presentat ion of evidence to the T ribun al .As pointed out above, a t ribunal establ ished pursuant to the provisions of the Act of 1921differs fundamentally f rom a cour t of l aw. For ease of reference, the persons to w hom theright to appear by sol ici tor and counsel was grante d we re referred to thro ugh out theproceedings as "part ies". But i t should be borne in mind that such persons have nei ther thestatus nor the functions of parties in a civil suit.

1.8.1 Gl o s s a ry a nd A bbrev i a t i o nsInevitably a great numb er of technical terms, with w hich the general reader of this Reportmay be unfamil iar, oc curred in the course of the evidence. A G lossary has been pre pared andis included in Appendix 5. A list of Abbreviat ions used in the R eport is contained inAppendix 6.

1 .9 . 1 Ex pres s i o n o f the Tr i buna l ' s g ra t i tudeIt is right that the public record of the Tribun al 's wo rk should contain a reference, how eve rbrief, to those w ho assisted i t , and an expression, how eve r inadequate, of the Trib una l 'swa rm appreciat ion and dee p sense of grat i tude for that assistance.Th e Tribu nal could not h ave ad equately carried ou t its funct ions witho ut the assis tance of itsassessors. It was most fortunate in hav ing available to it experts who we re quite o utstan dingin their ow n pa rticula r specialist fields. Dr . Black ha d, in addition to his high acad emicqualifications, muc h expe rt know ledg e gleaned both as Chief Inspector of Explosives in theHo me Off ice of the Brit ish governme nt and as a memb er of commit tees of in ternationalorganisat ions conce rned with dangerous substances. His kno wle dge and experience wereconstant ly made avai lable to the Tribunal up to his ret i rement on the 6th October, 1979.Captain Hindle has a wealth of sea-faring expe rience and has com man ded tw o of the largestships in the wo rld. He has a specialist know ledg e of the manage men t and operat ion of oiltankers and the ope rat ion of oil terminals and has made a part icular s tudy of tanker safety,hav ing con tributed ma ny papers on the subject to various professional bodies. Mr. V an Z onis a Chief Engineer with wid e experienc e of product and crude oi l tankers. His experienceand knowledge embrace not only the pract ical operat ion of oil tankers but also their designand construct ion. Mr. Wilse is a naval archi tect and senior principal surveyor of Det No rs k eVeri tas , He has represented De t Nors ke Veri tas on a num ber of wo rking groups of theInternat ional Cha mb er of Shipping concerne d with tanke r safety and has taken part as anexpert assessor in a num ber of inquiries w hich fol lowed tanker casualt ies . Captain Hind le,M r. Van Zon an d Mr . "Wilse not only helped thro ugh out the ent ire of the Tribunal 's publichearings but advised an d assisted during the draft ing of its Report . N o Tribun al could hopeto have more sage advice or more unstinting assistance.O n the Trib una l 's sol icitor, Mr. James Do neg an, fell the onerous task of organising thepresentat ion to the Tribun al of the ent ire evidence, w ri t ten and oral , which the Tribu nalobtained , of conduct ing a great vo lume of correspondence, of br ief ing counsel andconsult ing w ith them , of carrying out the Trib unal 's requirem ents and meeting with theTribunal at least once a day during the Tribunal 's hearings as well as many other funct ionsincidental to a long pub lic inquiry . He outstan dingly performed his many duties not onlywith h igh professional skil l but also with a s tandard o f efficiency which i t would beimpossible to exceed.Mr. M acD om hna il l w as the Tribuna l 's Registrar unt i l his appointment as Registrar of theSupreme Court and the Tribunal was great ly assis ted by the experience he had gained asRegistrar of previous Tribunals establ ished under the Act of 1921. After the first prelim inarypublic s i t ting, M r. G erard Frew en acted as the Tribun al 's Registrar. As such, the length andcomplexi ty of the Tr ibunal ' s hear ings imposed m any funct ions on h im, a l l o f which hefulfi lled with the efficiency with whic h those associated w ith him in the Courts w il l befamiliar. But, in add ition, be assisted in the prepa ratio n of and edi torial work associated withthe Trib unal 's R epo rt . H e gave this assis tance with a rare combinat ion of talentsan

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exceptional o rganising abi l i ty, a meticulous con cern for detai l , and an inquiring andjudicious mind .Counse l for the T ribun al ensured that all witnesses were given a full and adequateopp ortun ity to assis t the Tribun al and they h elped, by their skilful quest ioning, to clarify thema ny issues that arose during the hearings. Coun sel for those legal ly represented before theTribu nal not on ly ful ly p rotected their cl ients ' interests but also, by their thor oug h cross-examinations, great ly facil itated the search for the t ruth of the facts of the disaster and i tscause. T he co-o pera t ion given in full m easure to the Tribuna l 's sol icitor by the sol ici tors forthose to w ho m the right of representat ion had been given eased many problem s andconsiderably improved i ts smooth funct ioning.Responsibi li ty for the prac t ical aspects of the establ ishment of the Trib una l and theorganisat ion of its public hearings w as discharged by M r. H um phre ys and a small group ofhis col leagues in the Department of Touri sm and Transpor t , They overcame many problemsswift ly and unobtrus ively. T hey served the Tribunal with zeal and care and maintained thehighest t radi t ions and standards of the pub lic service of this cou ntry.The oral evidence and counsels ' submissions were taken down in shorthand and transcribedover nigh t into Books of Evidenc e. The ent ire proceedings were simultaneously t ranslatedfrom English into French and vice versa as required . Bo th note-take rs and interpreters ha dto cope at t imes with technical terms and complex concepts . They did so expert ly andwith out a pparen t difficul ty. Th ey supplied a s^tvice to the Tribuna l of an exc eptional lyh i g h o rd e r o f co m p e t en ce . ,The Tribunal part icularly welcomes this opportunity to express i ts thanks to those in thepub lic service and from the office of the Tribunal 's sol ici tor who typed this Report and i tsprel im inary drafts with c lari ty and expedit ion. B y so doing , they great ly eased theTribunal 's own part icular responsibi l i t ies .


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C H A P T E R 2

2.1.1 Th e eviden ce considered by the Tribunal J , -of different Chapters , as fol l ow ! conclusions on i t are deal t with in a num berP A R T I of the Report contains a general in troduction and this C hap ter.P A R T II T H E F A C T S O F T H E D I S A S T E R A N D R E L A T E D I S S U E S

C ha pter 3

C ha pter 4out lines the pr incipal events of the 6 th /7 th January , a numbe r of which are ofconsiderable s ignificance to some o f the issues on wh ich conclusions are reached in laterChapters ,

C ha pter 5considers the evidence of the eye-witnesses to the disaster, other than that of thewitnesses who were bn duty on and near the Island on the night when the disasterhapp ened . It is divided in to five sect ions and considers the evidence of witnesses w hosaw the disaster at different t imes and from different points around the B ay,itC ha pter 6discusses the evidence of the Gu lf em ployees on the Island and that of the crews of th es tand-by vessels , The ev idence of f ive of th e ; Gulf em ployees was i r reconci lab lycontradicted by the eye-witness test imony referred to in Cha pter 5 and the Tribun al 'sreasons for re ject ing that of the Gul f employees are g iven .

C ha pter 7Th e efforts mad e to effect a rescue after the alarm had be en raised are deal t with in thisC h ap t e r .

C ha pter 8Th e Tribu nal 's prim ary funct ion was to ascertain the cause of the disaster. False evidencewas given to the Tribu nal b y some w itnesses and efforts were m ade to suppress the t ruthrelat ing to the act ions of certain Gulf em ployees o n the night of the disaster. Theevidence on this is considered in this C hap ter.

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C ha pter 9Con trove rsy arose in the course of the hearings as to the circumstances in whichstatements made to the Gardaf were taken, and verbal remarks made during the m. Th eevidence given by m embe rs of the Gardai was chal lenged by Gulf durin g the course ofthe hearings and serious al legat ions were made against the Gardai . These al legat ions areconsidered in this Chapter.Chapter 10The locat ions in which the bodies of some of the victims of the disaster w ere found andthe post-m ortem evidence raised impor tant inferences w hich were of s ignificance forindicat ing w hethe r the ini t iat ing event of the disaster occurre d on the ship or on thejet ty, and also the natu re of the disaster in its early phase. These matters arc conside redin this Chapter.Chapter 11The principal facts established by the eviden ce considered in Part II are given in tabularform in th is Chapter .

P A R T III T H E T E R M I N A LCha pter 12 ;Th e T ribun al 's terms of reference required i t ' to inq uire into the measures taken at theterminal to pre vent and m inimise fires and explosions. This Chap ter considers theevidence relevant to this part of the terms of reference. It is divided into nine sect ionsand gives the Tr ibu na l's con clusions o n the fire-fighting systems, escape facilities,hazardous area classificat ion, maintena nce and repair procedures, emerg ency proceduresand t ra in ing of Gul f employees in emergency procedures.

Chapter 13Th e tug on eme rgenc y stand-by duty was so posi t ioned as to be out of s ight of theoffshore jet ty and the "B etelg eus e" and at such a distance that i t took ab out twe ntymin utes to rea ch th e scene of the disaster. Th e evid ence on this aspect of the disaster isconsidered in this Chapter.Chapter 14Th e evidence arising from surveys and exam inations carried out on the offshore jet tyand i ts instal lations was of para mo unt impo rtance in ascertaining the cause of thedisaster. It is discussed in this Chapter.

P A R T IV T H E " B E T E L G E U S E "Chapter 15Th e sh ip 's method of operating and its pre-disaster history are discussed in this Chapter.It is divided into seven sections, whic h conside r the ship's fire-fighting system, theevidence relat ing to i ts repair and mainten ance (whic h is of part icular s ignificance to thetheory that the cause of the disaster was a failure of the ship 's hul l) , the cathodicpro tect ion of the ship, and the ship's permanent ballast tanks. This Chapter also containssections dealing with the last voyage of the "B etelg euse " and surveys of the ship carriedout on the day prior to the disaster.Chapter 16The Tribunal had available to it the results of inspect ions and examinations of the fore-bod y and m id-sect ion of the "Be telgeu se", the resul ts of metal lurgical exam inations,


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photo grap hic evidence , video tapes and reports from the salvors of the vessel . Thisevidence is discussed in this Chapter.P A R T V T H E C A U S E O F T H E D I S A S T E R A N D T H E R E S P O N S I B I L I T YT H E R E F O R

Chapter 17Total submit ted that the disaster prob ably happen ed as a resul t of a fire in the vicinity ofthe slop tank pit on the jetty. This theory is cons idered in Ch apt er 18. A second the ory ,which was supported by a very considerable w eight of evidence, was that the hullbuckled due to bad maintenance and improper bal last ing and that this ini t iated thedisaster. This theory is considered in Chapters 19 and 20, This Chapter considers otherpossible ways in which the disaster might have occurred.Chapter 18This Cha pter deals with the evidence from wh ich i t was suggested that the disaster onthe ship was initiated b y a fire on the jetty .Chapter 19A considerable a mo unt of evidence was given as to the probable am ount of bal lastwhich the ship had taken on when the disaster occurred, and i ts l ikely distribut ion. Thatevidence is exam ined in this Chap ter.Chapter 20Th e hull failure theor y is here considered. Th e Cha pter is divided into four sect ions.Sect ion 1 outl ines the hull fai lure theory and gives the Tribun al 's conclusions on i t .Section 2 considers the stress calculations given to the Tribunal by naval architects in thecourse of their ev idence. Sect ion 3 deals with the explosions in the perman ent bal lasttanks, and Section 4 deals with the events of the disaster following the explosions in thepermanent bal last tanks.Chapter 21It was concluded in.Chapter 20 that the ini t iat ing event of the disaster was the bucklingof the ship's hull. T he re sponsibility for this initiating even t is discussed in this C ha pte r,This Chap ter also considers G ulfs responsibi li ty for loss of life and damage to proper tyarising from the absence from the Con trol Roo m of the dispatcher w hen the disasterbegan, the posi t ion of the duty tug, the absence of sui table escape craft on the jet ty, andthe al terations w hich had been effected in the fire-fighting systems on the jet ty .

P A R T V I T H E R O L E O F T H E P U B L I C A U T H O R I T I E SChapter 22The D epar tme nt of Transpor t and Pow er (and la ter the Depar tm ent of Tour i sm andTranspor t ) , the Depa r tment of Labour , and the Cork Cou nty Coun ci l (as p lanningauthori ty and fire b rigade a uthori ty) had funct ions in relat ion to the construct ion of th eterminal a nd/o r i ts subsequent supervision. Those functions and the man ner in wh ichthey w ere fulfi lled are discussed in this Ch apte r.

P A R T V II R E C O M M E N D A T I O N S A N D C O S T SChapter 23The Tribunal 's recommendations are set out in this Chapter.

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Chapter 24The O rde r m ade in relation to the costs of the Tribuna l is given in this Cha pter, as arethe reasons for it .

2.2.1 Sum m a ry o f Tr i buna l ' s C o n c l us i o ns a s to the I n i t i a ti ng Ev en t o f the D i s a s t erThe ini t iat ing event of the disaster was the buckling of the ship s structure at or abou t d eck-level and in wa y of the perma nent bal last tanks forward of the ship 's manifold. This wasimm ediately fol lowed by explosions in the perma nen t bal last tanks and the breaking of th eship 's back. These events w ere pro duce d by the conjunc t ion of two separate factors: aseriously weakened hull due to inadequate maintenance, and an excessive stress due toincorrect bal last ing on the n ight of the disaster.

2,3.1 Su m m a ry o f the Tr i buna l 's P r i nc i pa l C o nc l us i o n s o n the Ev i den ce C o ns i dere d by it(1) Th e eve nts o f the 6 th/7th Januar y 1979 (Chap ter 4 )

(a) Th e "Be telg eus e" w as mo ored to the offshore jet ty in a norma l mann er on theevening of the 6 th ja nu ar y . Before d i scharg ing any cargo , the procedures requi redby Gulf s Safety-check l is t were carried out on board by the Pollut ion C ontrolOfficer conscient iously and efficient ly. Th e f discharge of the parcel of A rabianHe avy crude began at 23.15 hours and was Comp leted the fol lowing day at 18.00hours .

(b) A discussion con cer nin g ballasting the vessel too k place at 11.00 hours on Sun day7th Janu ary, and as a resul t ballast ing of the PB Ts com men ced at about 11.30 hours.Ballast ing of some o f the vessel 's centre tanks began at 18,35 hours.(c) Transfer operat ions betw een the ship and shore we re carried out in a norm al

fashion and with out incident .(d) The P C O on duty o n the 7th Janu ary carried out in a prope r man ner therequi rements of Gul fs Manual , including a check of the contents of the cent replatform slop tank. W he n the jet ty c rew left at 20.00 hours nothing unu sual hadoccurred ei ther on the ship or on the jet ty. H ad a nythin g of a hazardous natureoccurred between then and 23,30 hours, the PPO at Dolphin 22 would have

warn ed the sk ipper of the "Sea L ance " of i ts ex i stence w hen h e left re turn ingmem bers of the ship 's crew at the offshore jet ty.

(2) Th e ev ent s o f the d is a st er , a s e s ta b l is hed by i nd epend ent ey e -w i tnes s ev i denc e(Chapter 5 )(a) Th e First Phase of the disaster began in the morn ing of the 8th Jan uar y very shortlyafter 00.30 hours, in the region of 00.31-00.32 hours, at wh ich t ime sounds l ikedistant thunde r wer e heard. A fire was observed w hich appeared to be a small andlocalised on e and to be on the ship just forward of the manifold. It graduallyincreased in intensity a nd sud denly spread on bo th sides of the vessel givin g theimpression on the starboard side that it had developed aft of the manifold along the

whole length of the sh ip .Th e fire w as accompanied by a large plum e of dense smoke, w hich was notobserved on the north -we stern coast of the bay, but was clearly visible from theother parts of the bay. Th e sudden deve lopm ent of the fi re oc curred at 00.40appro xima tely. N o explosions were observed b y those watch ing the ship and jet tydurin g the first phase of the disaster, other than the initial sound like distant thunderwhich was heard a t the comm encem ent of the casual ty .

(b ) Th e Second Phase lasted from 00.40 hours un t i l 01.06-01.08 hours, at which t ime amassive explosion occurre d. D urin g the second phase a num ber of smallerexplosions too k place, the first at about 00.50 hours a pprox imate ly. T he fire at the


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beginning of the second phase was, for a t ime, som ewh at l imited in intensi ty but i tlater expanded considerably in s ize,(c) Garda F lynn, w ho was on duty in the Garda Stat ion in Ban try tow n, w as alerted tothe disaster at 00.45 hours appro xima tely. He saw the fi re from the entrance to theS tat ion and imm ediate ly t r ied to t e lephone Gul f Cont ro l a t W hid dy but he wastold by the operator in the Bantry Exchange that al l l ines were busy and that GulfCo ntrol was awar e of the disaster. He rad ioed for the patrol car which w as then atthe W est L odge Ho tel , outside the tow n. T he fire had been observed at 00.45 hoursby C ar da jo y and Garda Byrne wh o were on duty a t the hotel . As they were aboutto make contact with the Stat ion, Garda Flynn came through to them. Theyreturned immediately to the Stat ion.(d) Superintendent McMahon was alerted to the emergency at 00.50 hours andimmediately gave instruct ions that the major accident plan be put into operat ion.Th e local fire officer was alerted, and the Ba ntry tow n fire-siren was sounded justat the t ime of the major ex plosion. This occurred at betw een 01.06-01,08 hours.The outside f ire serv ices a t Dunm anw ay and Skibbereen were a ler ted .(e) A considerable num ber of persons gave evidence as to wh at they ha d seen andheard on the n ight of the d i sas ter . Al though a few, indeed a very few, wereinaccurate or confused abou t some of the events or the t ime at which they

occurred, nearly al l the individual versions were consistent with each other and i twas possible to cross-check and confirm impo rtant matters of detai l f rom more thanone source. As a result, the Tribunal has been able to establish, with a considerabledegree of accuracy, the t ime the disaster comm enced , i ts nature, and i tsd ev e l o p m en t .(f) Shor t ly after midnight the pos t -mis tress on Wh iddy Island saw the "D on em ar k"leave the pier at Bantr y. This evidence assists in establishing that the "D on em ar k"did not leave the pier at 00.15 hours as its crew claimed. At 00.50 hours she receiveda telephon e cal l from the dispatcher at Gulf Contro l tel l ing her that the tanker wason fire an d asking her h usban d to get he lp. This assists in show ing tha t thedispatcher w as aw are of the disaster before 00,55 hours.

(3) Th e ev en t s o f the d is a st er a s e s ta b l is hed by G ul f em pl o y ee s o n d uty o n theIs land and by other ev idence (Chapter 6 )(a) Mr. Harris and M r. Ball (cargo inspectors) left the "Bete lgeu se" at about 18.35hours on the Evening of the 7th Janua ry and returned to the W est Lo dge Ho tel . M r.Harris wa nted to return to the vessel before bal lasting was completed and anarran gem ent was made before the y left the ship by which he w oul d be picked up atBant ry P ier a t midnight . This ar rangement was communicated to Mr. Connol ly ,wh o re layed it to Mr. Tessyman, the act ing coxswain of the "Do ne m ark " . The"D on em ar k" f inally ber thed a t Bant ry P ier some t ime before 19.00 hours andwaited there to bring Mr. Harris back to the ship. Mr. Harris and Mr. Ball haddinner together in the West Lodge Hotel and then played a game of snooker unt i li t was t ime to go back to the ship. At no t ime during the evening did Mr. Harriscontact Mr, Connol ly andcont rary to Mr. Connol ly 's ev idenceno change wasmade in the or ig inal ar rang ement for h is journey back to the "Betelgeuse" . Mr.Ball broug ht Mr. Harris by car to Bantry Pier. He left the hotel at 23.55 hours, andarr ived a t the P ier just before midnight . T he " D on em ar k" left immed iate ly . Mr.Tessyman and Mr, Hurley (the deck-hand) are wrong in s tat ing that the"D on em ark " left a t 00 ,15 hours . In a ll p robabil i ty the "Do ne m ar k" took the backroute to the jet ty i .e. around W hi dd y Po int East (see: Appendix 7 part 1). T h ejou rne y took a bout 25 minutes and they arrived at Dolph in 22 at 00.25 hoursapproximately. There was no delay there and they then sai led immediately forAscon Jet ty where it was in tended that the "Do ne m ar k" would be moore d for thenight . The "D on em ar k" arr ived a t Ascon Jet ty a t approximately 00 .35 hours .

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(b) The dispatcher was on duty in the Con tro l bui lding from 20.00 hours. He is wron gwhen he states that he never left the Co ntrol Roo m from 22.00 hours unt il after thedisaster. He is wrong when he states that he saw i ts commencement. Thedescript ion he gave of t he co m m en cem en t of the disaster was a fabricated o ne. T hedisaster did not commence at 00,55 hours, as stated by him, but at some time before00.35 hours, and p robab ly at 00.31-00.32 hours as s tated by inde pende nt eye-witnesses to the disaster.(c) T he dispatcher had left the Contr ol Room and did not becom e awa re of the fire

unti l just before 00.45 hours. I t is highly probab le that he was then im mediately inradio contact with Mr . Kingston (the Pollut ion Co ntro l Officer) w ho was on thejet ty and Ca ptain W ar ne r (the Pi lot) w ho was on the ship. He tried to contact M r.Ash (Gulfs G eneral Ma nage r in Bantry to wn ) using the eme rgenc y telephone toBantry Exchange, and he succeeded in reaching Mr. Wil l iam Flynn, Operat ionsManager . H e contacted the "D on em ar k" on Channel 14 probably a t about 00.48hours. His first message was: " G o to the je t ty w e h ave a fi re". This message wasoverhe ard on the "S na ve ", the l ine-boat then moo red at Ascon Jet ty. At 00.50hours he contacted the duty tug , the "Ba nt ry Bay " (moored out of s ight of thejet ty a round W hi dd v P oint East) using; Chan nel 16, and was overheard by M r.W on g, the second mate of the "Bi lb ao" anchored 8y mi les (14 km) d own Bant ryBay. He said "C om e qu ick we have a f ire" . H e te lephoned M r. Dow ney at 00.50hours in the office of the pow er-ho use and told him-. "T he ship is on fi redo wha tyou can to help". About one and half m in ut ^ af ter h is f irst cal l to the "D on em ark "he made a second call to her saying "G o as fast as you can, Br uce , to Dolph in 22and take the lads off". He m ade a second cal l to the "Ba ntry Ba y" about 2\minutes after the firs t. He said "A re you coining? She has broken her back. She ison fire al l ov er" . H e telephone d Mrs. Desm ond the post-mistress on Wh iddy Islandand asked her to get help.He received a cal l from Garda F lynn from the Garda Stat ion in Bantry enquiring ifhe wanted help to which he repl ied: "Send al l the help you can". This was at about00.50 hours, and not after 00.55 hours, as Mr. C onn olly claimed.

(d) At about 00.48 hour s Mr. C on nol ly activa ted the fire-pumps at Ascon Jetty. Beforethis there wo uld have been no water-pressure in the fi re-fight ing equipm ent on theoffshore jet ty. A t the same t ime he at tempted to close the emergenc y block valvesto cut off any supply of o i l to or f rom the je t ty . W heth er the mechanism workedor not will be considered in a later chapter. He did not sound the siren either on theGulf bui lding or on the jet ty, as he claimed he d id.

(e) Short ly after 00.50 M r. Co nno lly w as sti ll in touch on Ch ann el 90 with Mr .Kingston. At this t ime, Mr. Kingston radioed to him to send out the "Donemark"and M r. Co nno lly repl ied: "she is on her wa y" . Short ly after this Mr . K ingstonradioed again: "John, you are on Channel 90" and Mr. Connolly repl ied "I know,turn on C hann el 90 and Chan nel 14". Som e t ime later M r. Kingston cal led for thelast t ime "quic k, Joh n, quic k".Captain Warner also contacted Mr. Connolly by radio. In his last cal l he said hewas on the poop deck with three or four of the crew, and added "I am going over.Ask the boats to be on the look-ou t for us ' . This message was sent before the majo rexplosion at 01.06-01.08 hours, and Mr. Connolly is wrong in s tat ing that i toccurred after the m ajor explosion and at about 01.20 hours.

(f) Th e "D on em ar k" left Ascon Jet ty to render assistance at 00.51 hoursapp rox ima tely . It arrived too late at the scene of the disaster to save the life ofanyo ne w ho ha d been on the jet ty or the ship.(g) T he "B ant ry Ba y" left i ts moorings as quickly as i t could after i t was alerted at00.50 hours. '(h ) The "Sn ave " fo llowed the "Do ne ma rk" out from Ascon Jet ty af ter an in terval of


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abou t four m inutes. As it left the Jet ty M r. Co nnolly contacted i t and before hecould del iver any message was told "W e are on our w ay ". By the time the"S na ve " reached the scene of the disaster there was nothing i ts crew could d o tosave life.(i ) Mr. Downey, the pumpman, and Mr. McGee, the assis tant pumpman, were in theoffice of the power- house wh en contacted by Mr. Conno l ly . Mr. McG ee hadarrived first to the pow er-ho use. Mr. D ow ne y arrived just seconds before 00.30 andlogged the commencement of his t ime for check ing the pow er-ho use gene rators andother eq uipm ent at 00.30 hours. T he fi re had not s tarted whe n he entered thepow er-ho use. He had finished these duties and was seated in the office wh en the cal l

came from M r. C onn olly. He checked the t ime: it was 00.50 hours. He and M r.Mc Ge e imm ediately went to Ascon Jet ty. Th ere they ascertained that the electricfire-pumps we re wo rkin g (the diesel pump was not work ing) , and called to thecrew of the "D on em ar k" to go as quickly as they could to the "offshore" . Theythen travel led back by Land Rover to the Control Room. In the Control Room Mr.Downey helped Mr. Connolly by making one, or perhaps two, telephone cal ls tothe mainland, using the emergenc y telepho ne for this purpose. Mr, Do wn ey andMr. McG ee left just prior to 01.08 hours to go to the fi re s tat ion. As they were ontheir wa y they he ard the m ajor explosion and imme diately after i t there was apow er fai lure. The y we nt to the pow er-hou se and restored pow er in a very shortt ime. The y w ent to Ascon Jet ty and picked up M r. Kearns and Mr . O'D on ne ll andthen took steps to preven t the fire igni t ing the storage tanks. They overhead M r.Kingston's message on Channel 90 to Mr. Connolly in which he requested that the"D on em ar k" be sent out and was told that it was on i ts way. The y heard this forthe first t ime as they were on their way to Ascon Jet ty. The y ov erheard Cap tainWarner 's last message. This was prior to the major explosion and probably whilstthey were in the Cont ro l Room.

(j) M r. Kearns and Mr. O 'D on ne ll had been together in the securi ty hut from aboutmidn ight , Mr . O 'D on ne ll left i t at 00.25 to go on a tour of inspect ion. H e w ent firs tto Harris 's Gate, then to the bunker t reatment plant , and then to the warehouse. Heentered the w arehouse before 00.30 hours, at which t ime the fire had not s tarted.He checked into the clocking-point at the rear of the w arehouse at 00.37 hours, andleft some t ime later. C ontra ry to wh at he stated, he must have seen the fire w hen heleft the wa rehouse and i t is probable (but a fi rm conclusion on the point is notpossible) that he ran up the nearby steps to the Control Room to render assistance tothe dispatcher.* It seems likely from the evidenc e of the telephonist in the Ba ntryExchange that jh er e were tw o persons in the Cont ro l R oom when h e te lephoned itjust before 0(?.45 hours; proba bly on e of these was Mr. O 'D on ne ll . M r. K earnsrema ined at Asc on Jet ty in the securi ty hut .

(k) Mr. D ow ney saw the "B etelge use" after leaving the powe r-hous e at 00.50 hours.Th e ship had by the n b roke n its back am idships and the fire on the vessel was acrossi ts centre. There was no fire on the jet ty, b ut there was on the w ater be low thejet ty, and i t was not reaching to the height of the catwalk or Do lphin 22 at thatt ime. The dimensions of the fire we re such that, at that time, the witness con sideredthat the personnel on the jet ty could be saved.By 00.54 appro xima tely, on his return from Ascon Jet ty and his arrival at theCo ntrol R oom , the fire had developed drama tical ly. There we re then very largeflames rising 200 feet (61 m) or so in the sky ove r the centr e platform . Th e jetty eastof the centre platform and the ent ire ship aft of amidships were enveloped inflames. The flames w ere on the w ater spreading in towa rds the shore of the Island.

(4 ) The rescue operat ions (Chapter 7 )(a) The "Donemark" and the "Snave" were a ler ted to the d i sas ter a t approximately00.48 hours. The "Donemark" arrived in the vicini ty of the offshore jet ty at ab out00.58 hours, and the " Sn av e" some four or five minutes later. By this t ime there

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was nothin g that the crew of ei ther vessel could do to save the l ives of those trappedin the disaster.(b) The stand-by tug-boat , the "Bantry Bay", was alerted to the disaster at 00.50hours. I ts crew responded to the emergency with alacri ty. I t arrived in the vicini tyof the offshore jet ty at 01.10 hours approxim ately. T here was nothing that it couldthen do eithe r to save lives or to dim inish the scale of the disaster. A second tu garrived in the vicini ty of the jetty at about 01.50 hours, a third at 03.20 hours and afourth at 04.10 hour s. The se vessels cou ld o nly assist in the search for bodies.(c) The two pumpmen and the two Plant Protect ion Operators on the Island actedprope rly in taking act ion to cool the tanks on the tank farm. T hey acted w ithcom me ndab le co urage in a potent ial ly dangerous si tuat ion, as did the crews of th e"Do n em ark " , t h e "S n av e" an d t h e "B an t ry B ay " wh o , n o t wi t h s t an d i n g t h eexistence of a very real risk to their l ives, t ravel led close to a fire of enormo usprop ort ion s in their efforts to save those t rapped in i t .(d) Th e members of the Bantry Fire Brigade and the members of t h e Du n m an way an dSkibbereen fire brigades reacted p rom ptly an d efficiently to the emergen cy. T heywere delayed in get t ing to the Island owing to lack of proper t ransportat ion fromthe Pier and they w ere further delayed on arrival at Ascon Jet ty because of thebre ak dow n o f vehicles on the Island. Tj lere was, how eve r, noth ing the brigades

could have done to minimise the disaster had transportat ion been avai lable. Theyacted properly in taking steps to cool ' the tanks on the tank farm.(e) T he m ajor accident plan was init iated by Supe rintend ent M cM aho n at 00.55 hoursappro xima tely. It wo rked efficient ly and well .

(5) Steps taken to suppress the truth (Chapter 8)Active steps were taken by some G ulf personnel to suppress the fact that the dispatcherwas not in the Control Room when the disaster began. False entries were made in logs,false accounts wer e given of the disaster both to the Tribunal and in investigations heldbefore the public hearings, and efforts we re mad e to avoid ma king statements to theGarda i w ho we re invest igat ing i t ( including the ma king of false accusations againstthem for the purpose of em ployin g a sol icitor so as to justi fy a refusal to be interview edby the Gardai), Incorrect t imes at which they were alerted were knowingly given tothe Tribu nal by both Gulfs Op erat io ns Ma nage r and its General M anag er as well as bythe telephonist in the Bantry Exchange. This was del iberately done to lend support tothe dispatcher 's evidence,

(6) Al legat io ns m ade b y G ul f aga ins t the Gardai in the course o f the hearings(Chapter 9 )Du rin g the course of the hearings serious charges were m ade against one part icularmem ber of the Gardai . They were wi tho ut foundat ion and should never have beenmade. Fur therm ore, i t was submi tted on G ul f s behalf that the invest igat ion carried outby the Gardai into the disaster had been inadequate and improper. This submission wasequal ly wi thou t foundation . The inves t igat ion was carr ied out wi th co mme ndableeff ic iency and com plete p ropr ie ty .

(7) The ev i dence re l a t i ng to the v i c t i m s (C ha pter 1 0 )Th e b o d ies o f f iv e m em b ers of the crew of the "Betelgeus e" were found on the je t ty a tDo lphin 22. It is extremely unlikely that refuge on the jet ty wo uld ha ve been sought bymem bers of the ship 's crew had the ini t iat ing e vent of the disaster been a fire on thecent re p la t form, as suggested by To tal . Th e bodies of the o ther members of the crewwe re found in the sea and had been clothed w hen they died. Th e vict ims w hose bodieswere recovered f rom the sea had d ied f rom drow ning and not f rom explosion or f iredam age. Th is evidence confirms the fact that the init ial phase of the disaster was such as


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to permit at least some of the members of the crew to get dressed and escape from theacco mm odatio n area of the vessel.An at tem pt to launch the inflatable l ife-raft at Do lphin 22 had been m ade. Th e lastcerti ficates of service and testing of the t w o l i fe-rafts on the offshore jet ty were datedOc tobe r and N ov em be r, 1976. It is not possible to determine wh ethe r the fai lure toescape in the life-raft arose because it was not serviceable, or because of inadeq uatetraining of the jet ty crew , or because of the fi re on the water wh en i t was launch ed.The a deq ua cy o f the pre -d i s a s ter m ea s ures ta ken by Gu l f t o prev en t o rm i n i m i s e an em erg e ncy (C ha p ter 12 )(a) The original ire-f ight ing acil i t ies

Th e fire-fight ing system at the terminal and offshore jet ty wh en first comm issionedwas of goo d internat ional s tandard.(b ) Th e modifications to the original ire-fighting systems

A nu mb er of modifications o ver the years impro ved the system, but three had theeffect of down-gra ding i t. How eve r , a t the t ime of the disaster the rate of deliveryof water at the jet ty was good and so we re the num ber, s ize and elevat ion of thefoam monitors in the system.In 1970 a decision w as taken no t to keep th e fire-mains pressurised. This resulted inthe jet ty crew being una ble to act ivate the system w ithou t the intervention of thedispatcher at Gulf Contr ol . This decision was taken with an inadequateappreciat ion of its consequences.Th e pre-m ix fixed foam system on the jet ty was also modified in 1970. As a result i tceased to be an autom atic one. It wo uld have been preferable to have im prov edmain tenanc e techniques rather than to modify the system in the way i t was done.In 1971 a decision w as taken to decom mission the remote co ntrol bu t ton si tuated inthe Co ntro l Roo m which was designed to s tart the foam on the four m onitors onthe centre platform. The original system was superior to the modified o ne and noteno ugh c onsiderat ion w as given to the re-design of the system.

(c) Th e modifications to escape facilities from the offshore jettyTh e original operat ional plan made adequate provisions for an em ergen cyevacuat ion of the je t ty .Inadequa te considerat ion, h ow eve r, was given to the means of escape from theoffshore jet ty; both when the tug moor ings we re al tered and wh en the personneltransfer faci li ties from Do lphin I were re mo ved. Gulf should have appreciated that ,as there was no direct m eans of access from the jet ty to the Island, the provision ofinfla tab le l ife- raf t spart icu lar ly in v iew of the danger f rom the escape of burningoil on to the sea was an inadequa te safeguard. Prope r rescue boats or escapecapsules should have been p rovided at each end of the jet ty.

(d ) Pressurised Personnel Building on the offshore jettyA pressurised system wa s intro du ced in 1972 into the personne l buildin g on thecentre platform of the offshore jet ty . I t was considerably extended in 1978. Th esystem was a highly undesirable and potent ial ly dangerous one. It did not ,however, contribute in any way to the disaster,

(e ) Hazardous Area ClassificationIt is good practice to re-assess a plant not less than twelve months afterco m m en cem en t of operat ions and review i t at intervals of one to three years . Gulffailed to do this. Re-assessment was und erta ken in 1976 wi tho ut any pr op er studyhavin g first bee n unde rtaken . Th e re-classification as printed in Gulfs "Po licy and

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Procedures" Manual was ignored in pract ice and was admit ted in evidence as beinginaccurate.() Maintenance Standards

Some impo rtan t i t ems of f ire-f ighting equipment were a l lowed to remaininoperable for a t ime muc h long er than is desirable. Standards of maintenance hadbeen low ered for some t ime prior to the disaster. This resulted from econ om ymeasures and not through lack of ski l l or dedicat ion by the maintenance personnel .This lowe ring of s tandards, ho we ve r, did not con tribute to the ini t iat ion of thedisaster or i ts development.

(g ) Emergency ProceduresT w o ma jor defects in the emergen cy procedures de veloped over the years . Th efirst arose from the fact that the duty tug was perm it ted to m oor out of sight of th ejet ty an d at a considerable distance from i t ; the second from the fact that ini t iationof the procedures depe nded ent irely on the constant presence of the dispatcher inthe Con t ro l Roo m.

(h) Training and 'Escape PlanA decline in safety standards had tak en place. Th e fact that employees designated" tem pora ry emplo yees" got no formal t ra in ing in f ire-f ighting techniques wasundesirable. Th e failure to ut i lise the? fi re-fight ing system o n the night of thedisaster was not , however, due to lack of t raining, but to the nature of the casualtywhich occurred on the vessel .N o escape plan to evacu ate the jet ty had been formalised and no training inevacuation had been given. Had proper t raining been given and had a properescape craft been supplied at Do lphin 1, then i t is possible although this cannot beconcluded wi th any great degree of cer ta in ty that the l ives of most of the je t tycrew would have been saved .

(9) Th e ro l e o f the du ty tu g (C ha pter 1 3)The duty tug was moore d out of s ight of the "B etelgeuse" and a t a d i stance of about2.8 miles (4.5 km) from it. It took abo ut 20 min utes to rea ch the scene of the disasterafter i t was alerted at 00.50 hours. H ad i t been m oore d in s ight of the "Betelgeuse" andin i ts vicini ty i t wo uld have ob served the fire and i t is probab le that , notw ithstandingthe absence of the dispatcher from the Con trol R oom , the l ives of those on board theship and the crew of the jet ty wo uld ha ve been saved.Th e posi t ion of the duty tug on the night of the disaster was not that contemplated inthe original operat ional design of the terminal . Gulf altered the original position of th eduty tug as a resul t of pressure from the com pany opera t ing the tugs, and in thekno wle dge that that al terat ion w as undesirable from the po int of view of safety.Gu lfs "Po licy and Pro cedu res" Man ual , up-dated in 1976, gave a who lly misleadingdescript ion of the role of the tugs in an emerg ency a nd w as not complied w ith inpract ice. Th e reasons given at the hearing for the removal of the duty tug from thevicini ty of berthe d vessels were no t convinc ing. T he al terat ion in the original planseriously weakened the emergency services.

(10) Th e po s t -d i s a s t er co nd i t i o n o f the o ff s hore j e t t y (C ha pter 14)(a) Th e structure of the jet ty from the west breast ing do lphin to Do lphin 22 wascom pletely devastated in the disaster. There was, how eve r, n o fire or explosivedam age west of the west breast ing dolphin . H ad an y person from the crew of th ejet ty or of the ship been able to reach D olphin 1 he wou ld, in al l proba bil i ty, ha vebeen saved.(b) N o explosion occurred inside any of the buildings on the centre platform including


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the pressurised personnel bui lding, al though al l were extensively damaged by fi re.The air inlet to the pressurised system of the personnel bui lding was not da ma gedby an explosive force.(c) The crude oi l valves on the centre platform we re closed, indicat ing that there wasno transfer operat ion betw een the ship and the terminal taking place when thedisaster occurred, and that there could not have been a run-back of oil into the sloptank or the slop tank pi t w hen the disaster occur red. T he closed posi tion of thevalves also establ ished that n o bun kerin g or bal last ing operat ions from the jet ty was

taking place,(d) The re was noth ing to indicate that the specified fi re-fighting equip men t was not onthe jet ty on the night of the disaster. The fi re-fight ing system was capable ofoperat ion provided (a) the fire-mains had been pressurised and (b) there wassufficient t ime to operate them. T he fire-pumps could have provide d sufficientpressure and volum e of wate r to fight the fi re had they been started. The foam onthe jet ty was prope r and the quanti ty adequ ate.(e) The status of the valves of the fi re-fight ing system establ ished that no at tem pt tofight the fire was made by the jet ty crew .(f) The re w as no eviden ce to suggest that any i tem of equ ipm ent on the jet ty was

defective so as to cause an escape of oil o r in flammable vapour f rom the je t ty . (Theevidence in relation to the slop tank is separately considered later).(g) The maintenance of some of the explos ion-proof e lect rical equipment was notadequa te, and v iolat ions of the original certi ficates for use in hazardous areas hadoccurred .

Items of equ ipm ent whic h were not sui table for use in Class 1, Division 1hazardous areas classificat ion had been instal led. How eve r, the violat ion of theoriginal cert ificates did not m ean that the equipm ent w as defective or that i tconst i tuted a source of igni t ion on the night of the disaster. Similarly, there was noevidence to suggest that the equipm ent wh ich was unsuitable for a Class 1, Division1 area was defective or that i t had const i tuted a source of igni t ion on the night ofthe disaster. Ther e w as no indicat ion from the cond it ion of the electrical apparatusthat fire or e xplosion was init iated at any part icular spot .(h) Th e tw o 42" (1,067 m) crude oi l eme rgenc y block valves on the jet ty w ere foundto be op en after the disaster. The dispatcher had stated in evidence that he hadpressed the btftton in the Contr ol Room whic h should have closed them. It isprobab le that they failed to close because the fire h ad dam aged the wiring at thecentre platform at that tune . It is probable that damag e was also done at the sametime to the wires at the centre platform leading to the telephone kiosk on D olph in22 and that this caused a short which was observed by the telephonist in the BantryExc hang e and caused him to telephone Gulf Con trol just before 00.45 hours.C o n c l us i o ns f ro m the ev i denc e re l a t i ng to the pre -d i s a s ter h i s to ry o f the"Bete l g eus e" (C ha pter 1 5 )(a) It is no w virtual ly s tandard pract ice for large tankers to have supplied on them anelectronic computer kno wn as a " load icato r" or o ther mechanical means for thecalculation of stresses. The "Betelgeuse" had no loadicator or other s imilar type ofequipment . In taking on interm edia te ballast (as the ship did on the 7th /8thJanuary) the Mas ter and C hief Off icer had availab le to them o r ly a do cume ntknows as the "Condi t ions de Chargement" , which , had they consul ted i t , wouldhave bee n of l i t tle or no assistance to them . To tal was aw are that the absence of aloadicator (an effective model of which wou ld have cost on ly a few thousandpounds) caused problem s for i ts Chief Officers . N o adequate e xplanat ion for thisomission was given to the Tribunal . I t had most serious consequences.

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(b) The ship 's fi re-fighting system was a good o ne, and the crew were well trained inits use.(c) Th e ship's Seco nd Special Surv ey too k place in Singa pore in the summe r of 1977, Aconscious and del iberate decision was taken by Total not to renew certain of thelongitudinals and other parts of the perm anent ballast tanks which were kno wn tobe seriously wasted. In addition, a deliberate decision not to renew the tanks'cathod ic protect ion was taken at the same t ime. These decisions were taken becauseit was then considere d tha t the ship would be sold in the near future, and in the

interests of eco nom y. Ina dequate considerat ion was given to the effect they wo uldhave on the safety of the vessel. They had most serious consequences, as theycon tribu ted to the fact that on the 8th Janu ary, 1979, the vessel was in a seriouslycorroded and was ted condi t ion .(d) Th e weld ing of certain of the longitudinals which were renewed in Singapore wasimproperly carried out and contributed to the potent ial ly dangerous condit ion thevessel w as in on the 8th Ja nu ar y, 1979.(e) The rep airs to the port pe rman ent bal last tank which were carried ou t at feddah inNo vem ber , 1978, were prop erly carried out and it is prob able that no leakage ofcargo into this tank occu rrcd prior to the disaster. Dur ing the li fet ime of the shipthere had never been a leak into the starboard permanent bal last tank and the

Tri bun al conc ludes that it is hig hly un^ kely that one existed in that tank prior tothe disaster. ?(f) Th e vessel was superficially inspected o n\th e 7th Jan ua ry, 1979, by tw o surveyors onbehalf of potent ial purchasers of the vessel . Neither inspected the perman ent bal lasttanks or the carg o tanks an d n either was in a position to assist as to the internalcond it ion of any of the tanks. Th e Tribu nal is satisfied that the ship 's cargo pum pswe re w or kin g satisfactorily and that the ven t lines, insofar as a superficialexaminat ion could determine, were not corroded . However , the pain t -work on thedeck was in poor and rusted con dit ion, the deck's s team l ine was in a poor condit ionnear the cargo room, the electric cable duct ing was in a poor condit ion andconsiderable sections of the small-bore piping duct ing required renew al . O therw ise,from a superficial exam ination, the vessel appeared to be in reasonably good order.

(12) C o n c l us i o n s f ro m the ev i denc e re l a t ing to s urv ey s a nd ex a m i na t i o ns o f the"Betelgeuse" carried out a f ter the di sas ter (Chapter 16)(a) Th ere was no explosion in the N o. 4 centre tank. Explosions took place in both theport and the starboard permanent bal last tanks.(b) A massive explosion to ok place simultan eously in the N o, 5 cen tre tank and in allthree of the N o. 6 tanks. This was the explosion that was observed by eve-witnessesat 01,06-01.08 hours.(c) The only explosions which took place on the ship were those in the permanentballast tanks, the No . 5 centre tank and in way o f the No . 6 tanks.(d) The ship broke i ts back in tw o places: (a) at frame 11\ w here the explosion in theperm anen t bal last tanks occurred and (b) in way of the No . 6 tanks where thesecond explosions occurred.(e) The N o. 2 wi ng tanks we re und am aged b y the disaster and retained their cargo.Th e N o. 1 tanks after the disaster were em pty of fluid and contained an over-richgas mix ture. T hey w ere und am aged in the disaster,(f) The photograph ic ev idence of the deck longitudinals of the permanent ballast tanksin wa y of the forward bulkhe ad is s t rongly persuasive evidence that the decklongitudinals buckled before the explosions in the PBT s occ urred.


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(g) Th e fire-marks on the ship, caused by oil bu rn ing alongside the ship and across it ,establish that the explosions in the perm an en t ballast tanks took place before thosein way of the N o. 6 tanks. Th ey also establish tha t, after the ship broke its back forthe first tim e, it assumed a position wi th its deck aw ash forw ard of the manifo ld butwith the top of the manifold above the water. T he first e xplosion on the ship (inthe pe rman ent bal last tanks) had taken place before the ship took u p this posi t ion.(h) It is proba ble that the m ajor port ion of the fractures of the uppe r part o f the side-shell of the por t perm ane nt ballast tank was caused by the exp losion in that tank,and not by the buckling of the side-plates, but the metallurgical evidence does notpre clud e the possibility that some cracks had occur red in the side of the tankfol lowing buck ling of the deck or sheer s trake longitudinals and before theexplosions occurred.(i) Th e metal lurgical evidence relat ing to the side-shel l of the starboard perma nentballast tank is equ ally consistent w ith the fractures h avi ng be en caused (a) by anexplosive force or (b) by buckling wh ich fol lowed an explosion in the portpermanent bal last tank. Other non-metal lurgical evidence establ ishes that theexplosions in the two tanks were probably simultaneous and so i t is probable thatmost of the fractures w ere caused by an explosion rather than by buc kling. Aga in,ho we ve r, the metal lurgical evidence is not inconsistent with the fact that somecracks might have occurred in the starboard PBT as a resul t of buckl ing of the deckor sheer strake longitudinals prior to an explosion in the tank.(j) It is probable that the bottom plates would not have fractured if the explosion in thePBTs had not occurred.(k) Th e fractures in both the low er starboard and p ort s ides of the PBT s w ereconsistent with explosions having fractured the bottom plates and the fractureshav ing prop agated throug h the bi lge plates as a result .(1) It is possible that at least some of the fatigue cracks in the vessel's side-plating we represent prior to the disaster but , because of doubt in the matter, no conclusions onhow the disaster occurred will be based on this possibility.(m) O n the nigh t of the disaster the structure of the vessel was abno rma lly, seriouslyand significant ly wasted due to corrosion, and w astage was part icularly m arked inw ay of the permanent bal last tanks. An important cause of the excessive corrosionwas Total 's decision not to renew the cathodic protect ion in the permanent bal lastt anks and/or i i ts fai lure to ha ve the tanks coated w ith a protect ive coat ing.(n) The vessel was especially weak in way of strakes R and Q of the permanent bal lasttanks owin g to Total 's failure to rene w at Singapore in 1977 longitudinals 43 and44 which, at that t ime, w ere seriously wasted. It was further wea kened by the no n-renew al of other wasted parts of the vessel.(o) A further factor w hich w eaken ed the vessel 's s t ructure and its abi l i ty to w ithstandcompressive stresses was the defective ma nner in w hich some of the weldin g was

carried out on the PBTs in 1977.(p) N o part of the deck paint- wo rk in the area of the manifold was affected by fi re,al though the manifold i tself suffered heavy fire dam age. T his excludes thepossibil i ty that the cause of the disaster w as a broken Chiksan arm .(q) N o effort to fight the fire w as made by the ship 's crew , notw ithstand ing the factthat the fi re-fight ing system was a goo d one, that the crew w as prope rly t rained inits use and that the initial fire was in an area close to foam mo nito rs and hyd rants.( r ) It is not possible to con clud e that th e holes in the gas ven t line, wh ich we reobserved after the casualty, existed in the vessel prio r to the 8th Jan ua ry, 1979.

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(13) Poss ible causes o f the di saster (Ch apter 17)Th e Tr ibu nal is satisfied tha t the casualty did not occ ur as a result of the ignition eitheron the ship or on the jet ty of flammable vapours em anating from the ship 's tanks orfrom a possible overflow of oi l from the ship 's tanks. It is sat isfied that i t did not occurbecause of any careless act of a mem ber of the crew of the " Do ne ma rk" , or bvsabotage. The possibi l i ty that i t may have been caused by smoking by a member of thecrew of the "B etelg euse " or of the jet ty is so rem ote that i t can be ignore d.

(14) Poss ible causes o f the di sas tera f ire o n the jet ty (Chapter 18)The ini t iat ing event of the disaster could not have been the igni t ion of flammablevapours from ei ther the slop tank on the jet ty or from the slop tank pi t on the jet tv.All the evidence, both technical and that of the eye-w itnesses, points to the fact that theini tial f ire which was present dur ing the firs t phase of the disaster took place on the shipand not on the jet ty.This evidence is corrobora ted by the fact that some members of the crew of the"Be telgeu se" escaped from the ship on to Do lphin 22. It is highly unlikely that theywo uld hav e sough t refuge on the jet ty had the re been a fire on i t .T he Tri bun al is also quite satisfied that the initiatin g ev ent of the disaster was not oilspi lled on the ship due to a brok en C hiksan ar m. The ini t iat ing event occu rred on theship and not on the jet ty.

^(15) Co nclu s ion s on the hul l fa ilure the ory and the ship' s ba l las t a t the t im e of the

disaster (Chapter 19)This theory of the cause of the disaster suggests that excessive compressive stresses wereset up at deck and sheer-strake level owing to the manner in which the ship wasballasted, and that the ship longitudinals at deck and sheer-strake level buckled, leadingprogressive ly to a total failure of the hull. In considering this possible cause of thedisaster, the Tr ibu na l firstly conside red the stresses to wh ich the vessel was subjec ted atthe t ime of the disaster. Th e am ount of Arabian Light crude on board at the time w askn ow n, and the main inquiry centred o n the amo unt of ballast taken on board on the7th/8th Janu ary. Th e ship had the port and starboard PBT s avai lable for bal last , and asthe Arabian Heavy crude had been discharged i t had avai lable tanks 1 across and tanks 6across and the cen tre tanks 2 to 5; i t was quite clear that the fore peak and forw ard deeptanks were not bal lasted.The Tribu nal conclud ed that bal last ing of the PBTs began at approximately 11,30hours o n the 7th Jan uar y and that they prob ably we re ballasted to

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Disaster at Whiddy Island, Bantry, Co. Cork

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