Public Law — Jeffrey Tam represented the families of seven deceased in the Lamma IV tragedy death inquest
Mr Jeffrey Tam and Mr Colman Li (instructed by Messrs. Ho Tse Wai & Partners, assigned by the Director of Legal Aid) represented the families of seven deceased in the Lamma IV tragedy death inquest, after successfully persuading the Court of Appeal to order the Coroner’s Court to hold the inquest (Leung Shuk Ling & Others v Coroner [2023] 4 HKLRD 264).
Background
On 1 October 2012, the passenger vessel Lamma IV, owned by The Hongkong Electric Company Limited, collided with the ferry Sea Smooth off Lamma Island. The collision resulted in the rapid sinking of Lamma IV and the tragic loss of 39 lives.
Following an initial decision not to hold an inquest, the families of the deceased successfully appealed to the Court of Appeal, which ordered an inquest to be held to examine the cause of death and six specific issues relating to the vessel’s design, construction, and regulation.
Unlawful Killing
On 22 January 2026, the Coroner returned a verdict of unlawful killing for all 39 deceased. The Coroner found that the collision was caused by negligent navigation of the coxswain of both vessels. The failure of coxswain constituted a gross departure from the standard of care reasonably expected, amounting to gross negligence.
Key Findings on Remitted Issues
The inquest examined six specific issues identified by the Court of Appeal. The Coroner’s primary findings were as follows:
1. Design intent of the Frame ½ Bulkhead
The Coroner rejected the suggestion that Ken Lo’s evidence was fabricated, finding him to be a truthful and credible witness. The Coroner found that the omission of a watertight door at the Frame ½ bulkhead was a deliberate design decision. The design intent was for the watertight subdivision to be located at Frame 4 rather than Frame ½ . This decision was made to comply with the “0.1L Rule”
2. Responsibility for Damage Stability Calculations
The Coroner found that Mr Cheung did not consciously seek to shift the blame. Instead, the failure to detect the errors was attributed to a systemic lack of oversight and undefined responsibility within the shipyard. The Coroner found that Mr Cheung operated under a mistaken assumption that his work would be verified by the Marine Department of his superiors.
3. Port Hull Plating of Sea Smooth
The Coroner partially accepted thatlegally there is no breach of specific regulations because the plate was cosmetic and did not constitute “equipment”. However, the Coroner accepted the substance of the next of kin’s argument about the safety culture, ruling that “as a matter of prudence and proper practice,” Cheoy Lee should have informed the Marine Department of the installation to allow them to assess any potential risk.
4. Coaming Height of the Internal Door
The Coroner accepted the expert evidence that “deck openings” referred only to openings exposed to the weather. Since the external doors leading to the deck had compliant 300mm coamings and weathertight closures, the entrances to the internal door were protected by the external doors and the internal door did not require a 300mm coaming. The Coroner was also of the opinion that the Internal Door’s coaming height neither contributed to the sinking nor had any material connection with loss of life.
5. Inspection of the Frame ½ Bulkhead
The Coroner opined that the purpose of a periodical survey is to assess the vessel’s ongoing condition, not to re-verify the correctness of the original construction or design. The Coroner held that expecting inspectors to re-check the vessel against structural drawings at every survey was “impractical, unrealistic, and inconsistent” with the survey’s purpose.
6. Working Hours of Seafarers
While the Coroner acknowledged the difficult working conditions, it found no evidence that fatigue caused the collision. The Coroner concluded that the issue is driven by severe manpower shortages and cannot be resolved by judicial recommendation alone. The Coroner preferred a collaborative approach between the Department, operators, and unions rather than unilateral regulation.
Systemic Deficiencies in the Marine Department
Significantly, the Coroner identified that the “real systemic deficiency” of the Marine Department was the “mistaken assurance it gave, namely that Lamma IV continued to comply with the one-compartment flooding standard after 1998”
The Coroner found a pattern of “approval based on assumptions rather than verification”. When 8.25 tonnes of ballast were added to the vessel in 1998, the vessel became non-compliant with the applicable flooding standard. This critical safety failure went undetected because the Marine Department failed to identify that the mandatory 0.1 Rule had not been applied in the stability calculations.
Referral to the DOJ
During the inquest, a senior surveyor of ships, Mr Leung Wai Hok gave evidence that contradicted his previous testimony before the COI regarding his knowledge of the 0.1 Rule.
The Coroner held that this inconsistency raised a serious question as to whether the evidence he gave under affirmation at the inquest was truthful and had referred Mr Leung to the Department of Justice for consideration.
Please view the verdict here: https://legalref.judiciary.hk/lrs/common/ju/ju_frame.jsp?DIS=176538&currpage=T
Jeffrey Tam
“He has effective advocacy and what most impresses me is that he can advise clients in a very practical way, not just on winning or losing but on what the best outcome is for them.”
Chambers and Partners Greater China Region Guide 2026
Commercial Dispute Resolution, Administrative & Public Law (Band 1)
Jeffrey Tam, FHKIArb, attended St. Anne’s College at the University of Oxford for a Bachelor of Civil Law (BCL) on a scholarship after reading law at the City University of Hong Kong. In Legal 500 Asia-Pacific 2026 edition, he is recognised as a “Tier 1 Leading Junior” in Administrative and Public Law, and “Leading Junior” in Commercial disputes and Construction and property.
Visit Jeffrey’s profile for more details.
This article was first published on 2 February 2026.
Disclaimer: This article does not constitute legal advice and seeks to set out the general principles of the law. Detailed advice should therefore be sought from a legal professional relating to the individual merits and facts of a particular case. The photographs which appear in this article are included for decorative purposes only and should not be taken as a depiction of any matter to which the case is related. The views and opinions expressed in this article/material are solely those of the members authoring it and do not necessarily reflect the official policy or position of Denis Chang’s Chambers, or of any other member or members of Denis Chang’s Chambers.