The findings of the Formal Investigation ordered by the Department of Trade into the loss on December 19, 1981, of the coaster Union Star with her eight people and of Penlee lifeboat Solomon Browne with her crew of eight lifeboatmen. THE FINDINGS of the Wreck Commissioner, Richard Stone, QC, at the Formal Investigation into the loss of the coaster Union Star and the Penlee lifeboat Solomon Browne were announced in Penzance on Wednesday May 18. The Commissioner found: '. . . that the loss of the Union Star and those on board was caused by: (i) the irreparable failure of the ship's engines due to contamination of fuel by sea water while off a dangerous lee shore, (ii) the extreme severity of the weather, wind and sea, and (Hi) the capsize of the vessel on or shortly after stranding.

'The loss of the Solomon Browne and her crew was caused in the aforesaid circumstances in consequence of the persistent and heroic endeavours by the coxswain and his crew to save the lives of all from the Union Star. Such heroism enhances the highest traditions of the Royal National Lifeboat Institution in whose service they gave their lives.' The Investigation took 29 days between March 14 and April 27 and considered written and oral evidence from more than 50 witnesses. In addition the court made visits to Penlee lifeboat station, Falmouth and Gwennap Head Coastguard Stations, Land's End Radio Station, Sennen Coast Rescue Company store and the Union Mars (a sister ship of the Union Star) and studied timed transcripts of tape recordings made by Falmouth Coastguard of VHP radio traffic on channels 0 and 16.

From all the evidence, the Commissioner, who was assisted by three expert Assessors, was able to prepare a detailed timetable of events on the night of December 19, 1981, when the tragedy took place.

The purposes of the Investigation were defined as ascertaining the causes of the tragedy, establishing whether any wrongful act or default of any person caused or contributed to the loss of the vessels or their crews, having examined the facts, seeing what lessons can be learned so that such disasters may, if humanly possible, be avoided in the future.

During the hearing it was repeatedly stressed that assessments could only be made on the basis of knowledge which was available at the time and in his report the Commissioner stated: 'We must all avoid judging anyone else's conduct with the benefit of hindsight, but when actions have been so closely analysed, as during an Investigation, it is of value to note those actions which could have been done differently.' The report pointed out that an earlier launch of the lifeboat would have been advantageous, but cautioned that it could not be proved that it would have prevented the losses. The absence of a Mayday broadcast may also have led to restraint in asking for the lifeboat to launch.

A great deal of evidence related to Coastguard actions and the recent re-organisation in Cornwall and these aspects received much attention in the press. The report stated: 'It is not the purpose of this Investigation nor are we competent to act as a review body of Coastguard policy. But what we can do is to consider whether and if so to what extent the transfer to Falmouth may have affected the events of this one particular night.' The report reflected that the Coastguard's national reorganisation, which was started in 1978, aimed to improve their role in initiation and co-ordination of search and rescue.

Looking at this particular incident, when Land's End Coastguard station was passing information to the Falmouth centre which was co-ordinating operations, the report did not find fault with the system but recommended closer liaison between the Coastguard and the lifeboat launching authorities and stations.

The final moments of the Union Star and the Solomon Browne were studied in detail. A Sea King helicopter and the lifeboat made repeated rescue attempts, but the Commissioner made the point that the experience of successful rescues by helicopter masks the fact that, for helicopters, there are limitations. He noted the factors which in this instance combined to defeat success: (i) Turbulence of the wind created by a severe gale with gusts reaching hurricane force.

(ii) The small after deck restricting the area free of obstructions, (iii) The very high seas in marked contrast to a casualty aground; and (iv) the presence of a woman and children and at least their probable debility in the severe conditions.

Eventually the lifeboat took off four people when both vessels were only yards from the rocky shore. The Union Star capsized, the lifeboat was overwhelmed and efforts by coast rescue teams and other lifeboats to find survivors were in vain.

The final recommendations of the report are: 1. That the Department of Trade should consider the inclusion under the Merchant Shipping (Cargo Ship Construction and Survey) Regulations a requirement that vent pipe heights for bunker tanks carrying fuel oil for the ship's engines should be such as to ensure that the head of the air vent is clear of the level of water likely to be retained on deck.

2. That the Department of Trade should consider the issuing of an Instruction to Surveyors that self-closing drain cocks capable of indicating the presence of water or similar contaminants should be fitted to all fuel bunker tanks unless a water separator is permanently connected into the supply line(s) to the daily service or settling tank(s).

3. That the Department of Trade should consider drawing the attention of Masters and others in charge afloat to the importance of making a distress call when a ship is in grave and imminent danger even if immediate assistance has already been assured.

4. That the Department of Trade should consider issuing a notice to Shipowners and Masters that Owners Standing Instructions to Masters should clearly state that there is no inhibition on the responsibility of a Master to engage salvage assistance when in his judgment as Master that assistance is needed.

5. That the Department of Trade should consider publicising the advantage of Shipowners of coastal vessels providing Coast Radio Stations with a list of their management representatives, their addresses and telephone numbers.

6. That HM Coastguard and the RNLI consider jointly— (i) the phraseology and procedures for requesting a lifeboat to launch or anticipate: (ii) further improving liaison between the personnel of the two organisations and between HM Coastguard and others with local knowledge.

7. That HM Coastguard consider amending their Regulations in respect of the circumstances in which the Co-ordinating Officer may request the launch of a lifeboat and the title and definition of 'Distress Phase'.

The Formal Investigation was lengthy and detailed and the Wreck Commissioner conscientiously listened to all the evidence which people wished to put, much of which was not fully reported by the press.

The RNLI will consider the report in full and has already held preliminary meetings with the Marine Division of the Department of Trade and HM Coastguard in order to pursue recommendations 6 and 7 as swiftly as possible.

During his summing up the Commissioner said: 'The heroism of the coxswain and crew of the Solomon Browne in their selfless endeavours to save those from the Union Star is an episode in the nation's maritime history which will never be forgotten. It is right also to record the skill and courage displayed by Lt-Cdr Russell Smith and his crew in the helicopter Rescue 80 who made repeated attempts to effect a rescue in extreme conditions of wind and sea. Mr Buckfie Id fully deserves his commendation for his descent over the cliffs near Tater-du and we should not forget the dangers faced by the lifeboatmen of St Mary's, Sennen and the Lizard who put to sea that night in search of survivors from the Union Star and for their comrades from Penlee.'.