Press Summary (English) Press Summary (Chinese) CCDI 346-354/2013 (PW) IN THE CORONER’S COURT THE HONG KONG SPECIAL ADMINSTRATIVE REGION (Case No. CCDI 346-354 of 2013) HO Oi-hing HO Oi-ying HO Oi-ming TANG Yuk-ling SIU Chi-man KWAN Pui-man Eleni POON Lau-tim TO Sau-ching POON Tak-sze Coram: June Cheung, Coroner Dates of hearing: 15-26 Feb, 2 March, 9 March, 31 March and 23 May 2016 Date of delivery of inquisition: 7 June 2016 I N Q U I S I T I O N Introduction 1. I have mentioned at the commencement of and during this inquest, but I will reiterate here: that the purpose of this Inquest is to inquire into the cause of the death and the circumstances connected with the death. We are not concerned with the fault, civil liability or compensation here. Although we have looked into matters concerning travel insurance as well as responsibility of travel agent at different locality, those, as I have mentioned more than once, were to facilitate me in making practicable recommendation to prevent future tragedy. In fact, the law expressly prohibits any conclusion being framed in such a way as to determine any question of civil liability. Therefore the question as to whether or not there was negligence such as to give rise to an action for damages or compensation is not a matter for this court; - that is a matter for the civil courts. My role here is to determine simply: what happened and what did not happen as well as making practicable recommendation having the hard lesson learnt. 2. The standard of proof I apply in this inquest, unless I specify otherwise, when deciding upon all matters is what known is as “on a balance of probabilities”. In other words, is it more likely than not that a fact existed or an event occurred. 3. Despite the difficulties encountered during the investigation, namely the fact that all eye witnesses of incident were not available, the court was not able to examine the real exhibits and that Hong Kong itself does not have experience or expertise in hot-air ballooning, this court has fortunately obtained two detailed reports from the Egyptian authority which were admitted as evidence, namely, 1) the investigation report issued by the Egyptian Ministry of Civil Aviation in December 2013 (“AAIC report”) governed by Annex 13 to the Convention on International Civil Aviation and 2) the Public prosecution report signed by the “President of the Appeals, Acting Chairman of the Technical Officer to the Officer of the Attorney General of the Arab Republic of Egypt (“Prosecution report”) containing the transcript and memorandum from the General Prosecutor’s office. The two reports are in my view thorough, detailed and professionally produced by persons with the necessary skills, knowledge and expertise. We also have the benefit of having Mr. Chadwick, General Aviation Flight Standard Officer (Balloon Operations) from the UK Civil Aviation Authority, to assist this court to understand the two reports and operation of hot air balloon (“HAB”) in general. I consider Mr. Chadwick’s expert evidence was most helpful, impartial and professional. 4. During the inquest, we have called 9 witnesses: they were Mr Wilson AU (CW1) (“AU”) and LAU Tak ping (CW3) (“LAU”) from Kuoni Travel (“Kuoni”); Mr Wong Kong Sing (CW2), one of the tour member who did not join the optional hot air balloon ride; Mr Joseph Tung, Chairman of the Travel Industry Council (“TIC”) (CW4), Mr Chin Shing (CW5) who was responsible for making the HAB model for the purpose of this inquest and two Arabic translators for clarification of some of the contents of the reports (CW6 and CW7); Mr Chadwick (CW8), the HAB expert mentioned above and finally Miss Scarlett SO Lai-kuen (CW9), person in charge in Hong Kong of Paradise Travel (“Paradise”) which was the Destination Management Company (“DMC”) engaged by Kuoni for this Egypt tour. Their evidence covered a number of issues in great details that apparently might not be strictly relevant to the findings at inquest set out in Form 12 but essential for this court to understand the background of the case and finally making recommendation to prevent future similar tragedy. General course of event leading to the deaths 5. The present case may be one of the most tragic incidents happened while Hong Kong citizens were travelling abroad. As a matter of fact, it was the deadliest hot air ballooning disaster in history resulted in 19 deaths, 9 of which were the deceased in the present inquest. The general course of event was largely undisputed. All the nine deceased, together with 6 other tour members who did not join the HAB ride, were joining a 10 days’ tour to Egypt departing on 22 February 2013 organized by Kuoni. The HAB ride in question took place in Luxor city and was one of the self-pay optional activities offered in the tour. Kuoni has engaged Paradise as their DMC responsible for the arrangement in Egypt and Paradise has chosen Egyptian Airship and Balloon-Sky Cruise Company (“Sky Cruise”) as the local HAB service provider. 6. At small hours on 26 Feb 2013, the 9 deceased, AU, tour escort of Kuoni, and Mostafa, assistant from Paradise, set off from hotel to the place where the balloon would take off. It was around 0615 hours local time when the balloon took off with 20 passengers. When the balloon had flown for more than 35 minutes, the pilot instructed the ground crew to receive the drop line starting the landing procedure. The HAB suddenly caught fire in the air which caused major injury to the pilot who exited the basket followed by a few passengers. While the balloon was still burning with less weight on the basket, it kept ascending until the envelope was so badly damaged, incapable of supporting the basket and fell on the field. As a result of the incident, 19 passengers were dead, 9 of which were the deceased of the present inquest. The pathologists found that the injury causing each of their death to be multiple injuries and burns. Cause of the accident 7. The HAB in question was manufactured in 2004 by a Spanish balloon company called Ultramagic and registered as SU 283. The balloon type was “Ultramagic N425” and Sky Cruise bought it in 2005 from a Sweden operator. The balloon was operated by wind action effects for horizontal movements while vertical movements control was made through the control of the burners by the balloon pilot. 8. On the evidence, the take-off procedures seemed to be normal and the balloon had flown for about 35 minutes before the fire started in the course of landing. Evidence from the Pilot 9. The only surviving eye-witness of the event who has given evidence to the Egyptian authority was the pilot of the HAB in question, Mr Momen Murad Ali Hussein, Egyptian, aged 29. The other surviving passenger was not willing to give evidence. The pilot has held a balloon pilot commercial licence issued by the Egyptian Civil Aviation Authority since 2006. He was firstly interrogated by the authority when he was badly injured in bed after the accident. He was further taxed for the purpose of prosecution in April 2013 and he gave a statement to the investigation authority again on 17 June 2013[1]. The prosecution was not proceeded with finally[2]. His evidence was contained in the AAIC report[3] and prosecution report[4]. 10. He stated that because there was no maintenance manager available at the time, he took a look at the balloon and ensured the hoses were safely installed using sense of smell before taking off. At the time of taking off, he contacted the control tower but no one was there to answer him. He said however the take-off procedures went smoothly and the balloon kept flying like usual until it started to land at around 10 meters height from the ground. At the beginning of the landing, the fuel quantity for both aft cylinders showed ¼ capacity, whilst the forward burners were not used except for the “pilot light”. After about 35 minutes, the pilot used the forward cylinders. All of a sudden, a fire hit him on his back and ejected him from the balloon. He was not able to take any measures to control the fire, neither using the extinguisher nor turning off the valve of the gas cylinder. 11. The pilot also stated that at the beginning of the landing, he dropped the rope out of the basket before he heard a loud sound of a fire flame. He did not notice any interference between the rope and any of the hoses. The location of the drop line rope is far from the hoses, he believed it cannot be scrambled around them. Neither did he smell any gas nor hear any explosion sound of any part. All he heard was the sound of a fire flame. The fire sound was similar to the spraying sound coming out of an “insect repellant pressurized can”. He said the fire came from the forward burners but was not able to identify the exact location of the fire source. The fire was from left side and his injuries mainly on the left side. The fire was in one direction of yellow color. 12. He could not conclusively identify the source of the flame. He believed that the cause of accident could be as a result of defect of [5]one of the hoses connecting the cylinder to the burner. 13. The Egyptian investigation[6] also showed that the surviving pilot was suffering from burn wounds scattered on his head, his face, his back, his left upper limb and right upper arm, and upper chest and abdomen and lower limbs. Skin grafting operations were conducted. Maintenance of the hoses 14. The maintenance manual states the need for a special inspection of the hoses every ten years and to check if there are any cuts or damage.[7] It is said that the maintenance manager conducted a 100 hour annual inspection dated 5 October 2012 under the supervision of Egyptian Civil Aviation Authority and the Validity Certificate was renewed for the period of 13 October 2012 until 12 October 2013[8]. 15. Within the AAIC analysis[9], it is stated that maintenance carried out by Sky Cruise did not always refer to the appropriate part number or serial number, as per the full maintenance procedures.[10] 16. On the other hand, Hasan Muhammad Kinnawi, the assistant of the Ground Team Head for the HAB who was responsible for supervising the workers in taking off and landing, stated that gas leakage was a usual occurrence in his job, and they usually noticed the leakage by smell it and would change it without mentioning of any reporting system. He also said that the operation manager (ground team head) and the maintenance engineer were both absent on the day of the incident for unknown reasons[11]. The operation manager of Viking Company, another HAB company in Luxor, also said that gas leakage of HAB happened a lot.[12] 17. Mr Chadwick commented[13]that the hose that was attached to the burner that was made in 2005 and may have accumulated high flight hours may not necessarily be directly a contributing factor to the accident. Hoses with many more confirmed flying hours and much older are being regularly used in the world hot air balloon fleet. At the time of this report, the UK CAA are unaware of another hot air balloon accident that is attributed to an in-flight hose failure of the nature specified in the report, this being largely due to the stringent inspection and maintenance requirements in of HAB activities in UK and the implementation of it. Conclusions from the Egyptian authority 18. It is stated in AAIC report (Exhibit C30), at page 147, that: “The probable cause for the accident as seen by the investigation committee is due to a (1) hose fuel leak at the upper portion of the forward right hose connected to burner number 193 capturing its ignition source from burner’s fire causing a fire that caused a major and direct injury to the (2) balloon captain” (my emphasis) 19. Nevertheless, it could not be ascertained from the investigation carried out by the Egyptian authority if the hose fuel leak was as a result of internal malfunction of the hose due to lack of inspection and/or maintenance or if there was an outer force pulling off the hose from the burner, e.g. tangling by drop line at the time of landing. 20. The AAIC report also considered two contributing factors to the accident at page 147 of the report: “1. Maintenance actions that were carried out on the hoses could not indicate the need to replace the hose that was the cause of the accident” 2. The part number of the hose connected to the burner 193 was for a hose made in 2005 and therefore it has accumulated high flight hours and sometimes under adverse conditions” 21. On the other hand, the Spanish Civil Aviation Commission of Accidents (CIAIAC) made their point in their letter[14], as the accredited representative from Spain in the Egyptian investigation, that: “the simultaneity or coincidence in time of the action of pulling down the balloon by the ground crew through the drop line rope (handling line) and the start of the gas leak and a further fire should be considered as a significant condition for the accident scenario under which the fire broke out” 22. Further conclusion by CIAIAC[15] was that: “- Operator maintenance discrepancy issues and certain lack of maintenance control were evident during the AAIC investigation; - With regard to this particular flight, the pre-departure check had not been fully completed by the balloon pilot.” Finding at inquest in Form 12 23. Having heard all the evidence I accept and find that: Injury causing death The medical causes of death for all of the deceased were multiple injuries and burns. Time, place and circumstances at or in which injury was sustained All nine deceased died in the morning of 26 Feb 2013 during a hot-air balloon ride over Luxor City when the balloon caught fire during the flight after the landing procedure had started. The fire was due to hose fuel leak at the upper portion of the forward right hose connected to the burner number 193. Such fire also caused serious and direct injury to the balloon pilot who was unable to do anything to control the fire. Conclusion as to the deaths I find the conclusion as to the deaths of all deceased to be deaths by accident. 24. I now also read out the Particulars for the time being of each deceased required by the Birth and Deaths Registration Ordinance (Cap 174) to be registered concerning the death (See form 12 attached for each deceased). Consideration of recommendation 25. Under section 44(2) of the Coroners Ordinance (Cap 504), the coroner at an inquest may make recommendation designed: (a) to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held; (b) to prevent other hazards to life disclosed by the evidence at the inquest; (c) to bring to the attention of a person who may have power to take appropriate action any deficiencies in a system or method of work which are disclosed by the evidence at the inquest and which are of public concern. 26. The following are some features of the evidence which are helpful to me in considering recommendations to be made after the inquest. Risk involved in HAB ride in Egypt 27. HAB is an activity not available in Hong Kong and has become a popular activity around the world and welcomed by Hong Kong tourists travelling abroad. As HAB was operated under apparently simple mechanics and the speed of the same is generally quite slow and steady for commercial/tourism purpose, the risk of the same was generally not recognized by tourists. Although Mr LAU of Kuoni testified that he, as a member of senior management responsible for designing tour, viewed that HAB ride involved moderate degree of risk, Kuoni has not conducted any risk assessment on this activity before offering them and there was no particular attention, guidelines or information concerning risk of taking part in this activity provided to their employees, including front desk receptionists or tour escorts nor their customers. LAU said that they basically relied on the fact that other companies were also offering HAB activities and they were aware that HAB was offered in many other countries and considered to be safe in general. 28. HAB is a type of aircraft and a highly regulated industry. Of course, each jurisdiction has its own civil authority to regulate this activity. It was emphasized at times by Mr Ozorio, SC, representing Kuoni, that HAB ride is a safe activity by quoting Mr Chadwick’s report: “the advancement in fabric technology and envelope rapid deflation systems has facilitated larger balloons to be operated with a high degree of safety and reliability.”[16] However, since HAB ride is taken place in the air with considerable height, it undoubtedly involves a certain degree of risk. By giving a simple click in the internet will show a number of serious fatal HAB accidents occurred in the past around the world. That is why hot air ballooning needs stringent regulation on the airworthiness and operation of the balloon and pilot licensing scheme. In fact, as testified by Mr Chadwick, UK has developed a set of stringent regulations to ensure safety of air ballooning activities especially the commercial passenger carrying balloon has been vastly developed over the years around the world[17]. The safety of and risk involved in this activity actually depend on how stringent such regulations are and how well the same are implemented. 29. It is of note that AAIC report did make a recommendation, at p.149 of the report,[18] that: “Issue necessary instructions to balloon companies to assure informing passengers when they reserve their flights that this kind of sports included some degree of risk and for the purpose of adventure in order that passengers would make their decisions from the beginning .” (my emphasis) 30. In relation to that, Mr Chadwick responded in his report[19] that: “Many hot-air balloon passenger flights are bought by a third party as a present, with the actual passenger not finding out about their flight until the day of the flight. However, it is accepted that flying as a passenger in a hot-air balloon involves certain different threats to that of flying on a commercial airliner, and the AAIC is correct that information as to the physical requirements of flying in a hot-air balloon needs to be given at the point of reservation. This would therefore have implications to tour operators and local representatives at resorts, etc.” (my emphasis) Information about HAB ride provided by Kuoni to its staff 31. The present tour was the fifth Egypt tour Mr AU led as he testified. He started escorting Egypt tour since Sept 2012. He testified that before he led the first Egypt tour it was the experienced colleagues sharing to him local information about Egypt and he has not received any formal training or briefing relating to safety of leading tour in Egypt or taking part in hot air balloon activities. About half to one month prior to the 1st Egypt tour escorted by him in Sept 2012, experienced colleagues did mention to him briefly and casually in office how HAB was operated by wind, the flight distance and landing posture. Apart from that, no other information or training was given to him in respect of the risk of taking HAB ride. He was also told that people who had heart condition, hypertension and fear of height should not take part in HAB. Information about HAB provided to tour members 32. In early 2013, Mr AU was assigned by Kuoni to host the “tea party” on 7 Feb 2013 for the present tour. By then, he did not know if he would be the tour escort of the tour. About a week before the departure, Mr AU was informed by Kuoni to escort the tour in question. 33. There is no dispute that the need for customers to purchase comprehensive travel insurance before departure is generally set out in the tour booking form[20] and the receipts issued by Kuoni to the deceased[21]. It was also reminded in the receipts, though in small prints, under the heading of “Important Notice” that customers are suggested to read carefully the coverage and relevant clauses in their insurance policies to ensure sufficient coverage in case of accident. I am also well aware that Kuoni was not allowed by the TIC[22] nor did they put pressure upon or force customers to purchase Kuoni’s own Generali insurance. The question is whether the customers are provided with clear and sufficient information concerning the activity they are joining and the risk involved in it before they made an informed decision of participation. 34. AU said that during the tea party, among other information, there was a note named “Safety guidance of activities in Middle East and African area”[23], provided to tour members. On which there was a paragraph concerning taking HAB rides which stated to the effect that participants shall follow staff’s safety guidance and rules of activity. Participants shall only leave the balloon as directed by the staff upon landing of the balloon.[24] 35. At the tea party, tour members were also provided with a Price list of Self-pay Activities in Middle East and Africa [25] on which it was said relating to HAB ride: “Go on a hot air balloon ride in Luxor to view the beauty of Nile and Luxor. This activity includes breakfast and insurance. An aviation certificate will be issued: Approx. 45 minutes (the entire trip takes approx. 2.5 hrs: USD 190 for all age group” (my emphasis) 36. The information given to customers in the above price list: “this activity includes insurance” was ambiguous. When Senior Manager LAU was asked as to what it exactly meant, he said vaguely that might mean this activity included flying insurance taken by Sky Cruise and customers were covered by insurance when they take part in this HAB activity. LAU said they in fact just translated and copied the information stated on the Sky Cruise’s leaflet[26]. In my view, this clause may let the customers misunderstand that their joining of this activity was covered by insurance which turned out to be not the case, as revealed from the evidence of this inquest. Should the members be warned more clearly and specifically that their insurance may not cover this HAB activity, their decision to join the activity may be changed. 37. This court is well aware of its limited jurisdiction. I am not concerned about why 6 deceased out of 9 did not buy Kuoni’s travel insurance but bought their own Comprehensive Travel Insurance from China Merchants Insurance Company Limited. Nor is this court attempting to explore the reasons why they were not insured. My concern is whether practicable recommendation could be made to prevent recurrence of similar fatalities. The ambiguous wording on the above optional self-pay activity price list[27] about the HAB ride and the lack of sufficient information provided to the customers joining the HAB ride so that they could make better assessment of the risk may affect their choices of participating the activity. 38. On AU’s evidence, he said that when tour members were paying the fees the day before the ride, he had told them briefly information about the duration of the flight, what scenery to be seen and advised them not to join if they have heart condition, hypertension and fear of height. He has also shown pictures taken about the ride before to the tour members. Upon arrival at the taking-off place before they were approaching the balloon in question, he gave his group of 9 members some information as to the duration of the flight and landing posture. He also told them he would be taking pictures for them and taking care of their belongings. While the pilot of the HAB from Sky Cruise was conducting briefing session in English to 20 passengers before taking off, no instant interpretation was given by AU because he saw no need as his had given his own briefing to the deceased earlier on. Information concerning HAB ride acquired by Kuoni 39. In fact, after hearing the evidence, it was not surprising why not much information relating to HAB ride was given to the employees and customers by Kuoni. On LAU’s evidence, even the senior management designing the tour did not have much information about the HAB ride. Apart from having been told by Paradise that Sky Cruise was licensed, insured and experienced, Lau basically told the court that he had never discussed the HAB ride among the senior management before offering this activity. Neither did he nor Kuoni as far as he knew conduct any formal evaluation after this incident. 40. It was submitted by Mr Ozorio, SC for Kuoni that there were no discussion nor query raised among tour members concerning risk of HAB ride and that they could easily do researches on their own should they wish so. That, as submitted, showed that the deceased were not concerned with the risk of HAB ride. I am afraid I cannot agree with that. It is not hard to observe that people who tend to join travel tour, as opposed to planning their own trip, are those who are either more senior in age or do not prefer to plan by their own. Participants of travel tours tend to leave the planning and entrust all the arrangement to the travel agent company and the tour escort. That may require higher responsibility from the travel company to conduct sufficient risk assessment before offering the activities and to provide sufficient information to the customers. 41. It is of note that this case happened in Egypt which is not a developed and advanced country like the United Kingdom, Australia or New Zealand where HAB industry is long established and governed by stringent regulatory system. It is common sense that an activity is considered to be safe in one country does not necessarily mean that it is safely operated in another. 42. As a matter of fact, it was not the first HAB accident occurred in Luxor. It is not disputed that there was a major HAB accident happened in Luxor as a result of which 16 passengers were injured which caused temporary suspension of the activity. I consider that Hong Kong travel companies apart from designating a DMC to appoint and liaise with the local service providers should also acquire sufficient information of such activity before offering the activities that involved a certain degree of risk. 43. Instead of relying on the fact that other companies are also providing the same activity, travel companies should acquire sufficient information for its own risk assessment before providing such activity. The information is also essential for training the frontline staff. More importantly, customers should be well informed of the information before taking part in such activity involving certain degree of risk. In my view, the list of basic information about the HAB ride that should be acquired by the travel company and provided to the customers includes but not limited to: - Height and duration of the HAB flight; - Pictures of HAB showing the envelope, basket and burners of the HAB; - Size of the HAB; - Brief information about material and mechanics of operation of the HAB; -Information about experience and reputation of the company providing the HAB ride; - Any HAB accidents happened before in the destination and any of such related to the service provider; - The licensing system in the country as compared with other worldly recognized country. 44. In fact, it is stated at paragraph 9.3 of Code of Conduct for Outbound Tour Escort issued by TIC in October 2007[28] that: “Prior to arranging self-pay activities, tour escort shall explain clearly to tour participants the content, duration, fee, safety and responsibility of such activities.” Checklist 4.2 attached to the same Code also provides a few items for checking in respect of optional activities. Selecting and supervising the local destination management company and/or service provider 45. From the evidence of LAU, Senior manager of Kuoni responsible for product designing and tour planning, Kuoni started to offer HAB ride in 2008. Kuoni stopped offering HAB immediately after this accident, but still offer Egypt tour until June 2013. He said that Kuoni relied upon the fact that other Hong Kong travel companies were also offering HAB ride before they were offering the same. He was aware that HAB ride was also provided in other countries around the world and was considered to be safe by other companies. He said that some of their colleagues also had the experience of HAB ride in other companies before they joined Kuoni. 46. When asked if there was any risk assessment of HAB ride in Egypt done by him or Kuoni as far as he knew before the accident, LAU replied negative and said that they usually relied on the local licensing system and if the company was insured. He was informed by Paradise that Sky Cruise was licensed and insured (being one of criteria of obtaining license). Surprisingly, Kuoni has not even obtained a copy of those documents but just relied on Paradise words until the accident occurred. He was told by Paradise that Sky Cruise was an experienced operator of HAB and started to operate HAB activities in 90s. Kuoni basically relied on the choice and information given by Paradise. LAU said that they also relied on feedback from tour escorts and customers when considering the quality of service provided by local company. 47. Despite the absence of any risk assessment done by LAU/Kuoni before offering HAB ride, he agreed that HAB contained certain degree of risk. He considered HAB ride as an activity having moderate degree of risk. As to what training, if any, was given to tour escort or front desk staff, he said there would only be casual sharing given by experienced colleagues to junior ones. Kuoni did not have particular safety guidelines or briefing of HAB ride provided to staff. During the tour in Egypt, AU basically was responsible for liaisoning with the local guide/assistant there called Mostafa and relied on him for all the local arrangements. 48. Miss Scarlet So, the person in charge of Paradise in Hong Kong testified that she had not received any training on travel industry. She worked for Osama, founder of Paradise in Egypt, since 2005 through an introduction by a common friend. She did not have any travel or working experience in Egypt. She, although being the person in charge of Paradise in Hong Kong and having the title as Regional Manager, basically said that she was not more than a mail box transferring message between Kuoni and Osama. In relation to the choosing Sky Cruise, she said it was Osama’s choice and she had no idea why it was chosen. She said there was no discussion between Kuoni and her on HAB activities. Before the accident, she has never given any copy of Sky Cruise’s license or insurance but just told Kuoni that Sky Cruise was chosen as the HAB service provider upon Osama’s instruction. 49. A Risk Solutions Manual for Travel Industry in Hong Kong was issued by TIC in February 2008[29]. Paragraph A1.1.1 of the Manual provided a Supplier selection criteria checklist. However, the checklist does not cover present situation in which the Hong Kong travel company has engaged a DMC to select and arrange with the local service providers. 50. Despite the fact that Kuoni was told by Paradise that Sky Cruise was an experienced service provider with reputation, it was revealed from the Egyptian investigation that the maintenance carried out at Sky cruise did not always refer to the appropriate part numbers or serial numbers, as per the full maintenance procedures[30]; for example: absence of record of the 5th tank (for inflating the balloon) and unclear basket number[31]. Further, gas leakage appeared to be a common problem as testified by the staff of balloon companies, which did not appear to cause serious concern by the company, which seemed to be quite contrary to the stringent UK reporting system as testified by Mr. Chadwick. 51. Regarding operation of the present HAB, it was also revealed that the pilot was allowed to take off, despite absence of the maintenance engineer and the operation manager and that he was not able to contact the control tower until 10 minutes after taking off[32]. When the pilot was asked by the investigation team about the dissimilarity between his pre-departure check signature and his previous signature, he claimed that he would use several signatures in order not to be imitated! Mr. Chadwick could not help expressing his concern as to why anyone would want to imitate a pre-departure check signature during normal operation.[33] Also, no summary or translation of pilot briefing was supplied to the passengers before taking off. It was however recommended by Mr. Chadwick that the use of laminated passenger safety briefing cards should complement the pilot’s briefing to passengers. The use of diagrams and briefing cards in major world language should be provided.[34] 52. My pointing out the above observation made after Egyptian investigation was not because I wanted to discuss or determine the fault or liability, but to show the danger of Hong Kong travel companies simply replying on words of DMC without conducting its own risk assessment. It is equally important for Hong Kong travel companies to properly select and supervise the service providers even after a DMC has been engaged. 53. Given the highly technical nature of HAB operation and the fact that the inquest does not have the advantage of hearing direct evidence, this court is not in the best position to make any conclusion or comments on the requirement of a safe HAB maintenance or operation. 54. Upon hearing this inquest, I reckon that there is at present a lacuna in TIC’s guidance on Hong Kong travel companies’ duty and responsibility on local service providers when DMC is engaged. I note that there is quite a detailed list for TIC members to select local service providers[35], however such manual does not cover situation when travel agent companies have entrusted a local DMC. 55. Apart from telling me that we should trust the licensing system of each country and it is very difficult for Hong Kong travel company to monitor local service providers as well as it is a worldwide common practice to engage a DMC to do the work for travel companies, Mr. Tung of TIC basically gave me no suggestion nor assistance as to how the service of Hong Kong travel companies can be improved and safety of Hong Kong customers be better safeguarded. 56. To my surprise, both Kuoni and TIC have never conducted any evaluation of the case until the present inquest. Neither has TIC done anything to review the existing guidelines. More than three years have lapsed since the date of this tragic event. It is disappointing to learn that not only the travel company and TIC were not able to realize the risk involved in this particular activity showed by the lack of risk assessment, they were also not alerted after loss of nine precious lives. That in a way shows how insensitive the Hong Kong travel industry is to the well-being of customers. Regardless of whether this tragedy could possibly be avoided, the cursory attitude in assessing risk and reflecting after the accident as showed from the testimony given by LAU being senior management of Kuoni, given its reputation as one of the most high-end travel companies in Hong Kong, was unsatisfactory in my view. Similarly, I consider TIC’s reaction after the accident to be too slow and attitude too passive. The AAIC report was issued in December 2013 and I expect TIC should have looked into the matter thoroughly and reviewed the present guidelines on outbound activities involving risk much earlier instead of waiting for the result of this inquest. 57. Further, I consider that information or assistance currently provided by TIC to travel companies and more importantly to customers as to risks involved in various activities operated at various countries to be insufficient. Recommendations to Travel Industry Council (TIC) 58. Analyzed as the above, I now recommend: 1) TIC to conduct a thorough research and collect data from the industry so as to list out popular activities operated in different countries offered by travel companies involving certain degree of risk. TIC to categorize the degree of risk in respect of different activities provided in different countries for industry as reference. Such list should be updated from time to time; 2) TIC to set out clear guidelines for travel companies as to the necessary information of activities involving certain degree of risk to be provided to customers before taking part in such activities; 3) TIC to set out clear and specific guidelines for travel companies that customers should be reminded that their travel insurance may not cover activities involving certain degree of risk; 4) TIC to look into travel companies’ duty and responsibility in selecting and supervising the local service providers and review the existing guidelines when destination management companies are engaged; 5) TIC to set out new guidelines on travel companies’ duty and responsibility to supervise destination management companies; 6) TIC to set out safety guidance and advertise to customers as to the importance of obtaining details of travel policy insurance and information on activities involving risk before enrolment. Recommendations to Kuoni 59. I also recommend: 1) Kuoni to obtain sufficient information from local service providers and conduct thorough risk assessment on activities involving certain degree of risk provided to customers before offering the same; 2) Kuoni to conduct thorough evaluation after every major accident taking place during tours provided by them so as to find out the cause of the accident and consider if there is anything that can be done to improve the quality and safety of service provided to customers. 3) Kuoni to provide sufficient information to customers about activities involving certain risk and remind them in more specific and clear terms that activities involving risk may not be covered by their travel insurance; 4) Kuoni to provide more training and information to front desk staff, including receptionists and tour escorts, so that they can be better equipped to explain the risk involved in activities provided by the company; 5) Kuoni to set out clear criteria for selecting destination management companies and local service providers with first hand information and to closely monitor the service provided by destination management companies and local service providers. 60. Both TIC and Kuoni need to reply the Coroner in writing in three months’ time as to 1) whether the above recommendations are accepted and if yes 2) what steps have been taken to implement the recommendations and 3) reasons if the recommendations are not accepted. 61. Lastly, let me offer my deepest condolence again to the next of kin for their loss of loved ones and also thank you all for attending this inquest. I cannot even try to imagine the difficult journey you have gone through and dare not expect that by having this inquest you will be soothed in anyway. What I sincerely hope is that you will find this inquest helpful in some way having been informed of more details about the incident. I am indebted to the Hong Kong police, Mr Brook and Mr IP, SPP of Department of Justice, for their unfailing support in this investigation despite all the difficulties. I also thank counsel’s assistance from all parties. Lastly, I need to deliver my gratitude to the senior interpreters, Mr Wong and Mr Lai and the Clerk to Coroner, Miss On for their invaluable assistance throughout the hearing. 62. If parties and the press wish, a copy of this inquisition can be obtained from my clerk after the court rises. A press summary is also available for the press. The inquisition and press summary will also be uploaded to the Judiciary website very soon after today’s hearing. The inquest is hereby closed. June CHEUNG	Coroner Representation: Mr Michael Ozorio, SC instructed by Messrs Paul C. K. Tang & Chiu for KUONI Travel (China) LTD. Mr Bernard Murphy of Messrs Howse Williams Bowers for Ultramagic S.A. Mr Foster Yim instructed by Messrs Wan Yeung Hau & Co. for next of kin of Ho Oi Hing, Ho Oi Ying, Ho Oi Ming, Tang Yuk Ling, Siu Chi Man & Kwan Pui Man Eleni Mr Edward Brook and Mr Cliff Ip of Department of Justice as Coroner’s Officer [1] Pp. 17-20 of the AAIC report (Exhibit C30) [2] P.12 of the prosecution report (Exhibit C32A) [3] Paras.1.5.1, pp.16-20, AAIC report (Exhibit C30) [4] Pp.74-84, prosecution report (Exhibit C32A) [5] P.17 of AAIC report (Exhibit C30) [6] P.5 of the investigation report (Exhibit C30) [7] P.6.8 of Maintenance Manual of Ultramagic HAB (Exhibit C50) [8] P.7 of the prosecution report (Exhibit C32A) [9] Paragraph 2.6, page 140 of AAIC report (Exhibit C30) [10] Paragraph 3.4.6 of Chadwick’s report (Exhibit C46a) [11] pp.48-59 of Prosecution report (Exhibit C32A) [12] p.66 of Prosecution report (Exhibit C32A) [13] Page 8 of Chadwick’s report (Exhibit C46a) [14] P.219 of the AAIC report (Exhibit C32a) [15] Page 217 and 218 of AAIC report and page 10, para 3.3.3 of Chadwick’s report (Exhibit C46a) [16] Para.2.12, page 2 of Chadwick’s report (Exhibit C46a) [17] Paragraphs 6.1-6.8 of Chadwick’s report (Exhibit C46a) [18] Paragraph 4.1.4, page 149 of AAIC report (Exhibit C30) [19] Para. 4.14, page 20 of Chadwick’s report (Exhibit C46a) [20] Exhibit C1 [21] Exhibits C8 and C9 [22] Exhibit C35 [23] Exhibit C5 [24] Exhibit C5 [25] Exhibit C6 [26] Sky Cruise HAB leaflet (Exhibit C11) [27] Exhibit C6 [28] Exhibit C34 [29] Exhibit C 36 [30] page 140 of AAIC report, comment 13 of Chadwick report (Exhibit C46a) [31] comments 12 of Chadwick report (Exhibit C46a) [32] pp.75-86 of the prosecution report (Exhibit C32a) [33] Paragraph 3.4.4, p.11 of Chadwick’s report (Exhibit C46a) [34] Paragraph 5(g), pp. 22 and 23 of Chadwick’s report (Exhibit C46a) [35] Paragraph A1.1.1 if Risk Solution Manual (Exhibit C36 and 36A)