This tragic accident is of particular significance because it was a major reason for the creation of the ISM (International Safety Management) Code. The capsizing of the Herald of Free Enterprise revealed negligence involving the ship’s crew as well as the significant responsibility of the management of the company operating the ship for the accident. Consequently, this accident clearly demonstrates that safe navigation requires sound safety management processes.
The Herald passed
the outer breakwater at 1824 and, about four minutes later, capsized.
Immediately prior to capsizing, the ferry suddenly listed to starboard and the
port side ran aground on a shoal. The ferry ended up on its side with the
starboard side above water. Submerged sections of the ferry quickly filled with
water. The accident resulted in the tragic loss of life of 191 passengers and
crew. The Herald capsized only about seven cables (approximately
1.3km) from the harbour entrance.
Analysis
1. Direct cause
The
direct cause of this accident was the failure to close the bow doors used for
loading vehicles prior to departure. As a result, the activities of crew
members responsible for the bow doors were examined.
a) Assistant bosun
The
assistant bosun was normally responsible for closing the bow doors prior to
departure but on this occasion failed to do so. He reportedly went to his cabin
for a break after the ferry arrived in Zeebrugge and fell asleep. The
announcement calling crew members to departure stations apparently did not wake
him up and he remained asleep until the ship started to capsize.
This
leads to the question: why did no one notice that the assistant bosun had not
reported to his duty station for departure? Additionally, why, despite the
possibility of human error, was there no procedure in place to confirm that the
critical task of closing the bow doors had been performed? Why was there no
foolproof system for preventing the oversight of this vital step prior to
departure?
During
the investigation it was discovered that this was not the first time that this
incident had occurred on board a similar ship operated by the company. In
October 1983, the assistant bosun of the Pride apparently fell
asleep and did not hear the call to departure stations. As a result, the ferry
departed Dover with the bow and stern doors open.
A
company directive issued in July 1984 stated that confirming the safety of the
bow doors prior to departure is the duty of the officer responsible for the
main deck for vehicles (G deck). However, this directive was found to have been
regularly overlooked.
b) Bosun
The
bosun was the last crew member to leave the deck where the bow doors are
located. He was working near the doors, but no one in that area made any move
to close them. When asked why he did not close the doors, the boatswain stated
that it was not one of his duties, nor was it his duty to confirm who was on
the deck to close the doors. Fellow crew members were at their departure
stations performing their own duties.
c) Second officer
The
second officer went to the deck to relieve the chief officer who was handling
the loading of cargo. He met the chief officer but did not receive a proper
handover from the chief officer. After remaining on G deck for a while,
the chief officer entrusted the second officer with supervising cargo loading
operations.
About
10 or 15 minutes before the scheduled departure, there was a problem on G deck
and the chief officer returned. The second officer heard the chief officer
giving instructions to the crew and assumed that the chief officer had taken
over responsibility for cargo loading. Consequently, the second officer went to
the stern of the ferry, which was his departure duty station, without talking
to the chief officer about closing the bow doors.
d) Chief Officer
At
the material time, the chief officer was required to go to his departure
station and apparently felt under pressure to go to the bridge. The chief officer
is believed to have confirmed that the assistant bosun had arrived on G deck.
However, the chief officer did not make sure that the bow doors were closed.
It
is clear there were many instances of negligence that contributed directly, or
indirectly, to this tragedy. The legal proceedings, however, concluded that the
chief officer’s negligence to ensure that the bow doors were closed was the
primary direct cause.
2. Pressure to depart
Three
minutes are needed to close the bow doors. Why did the officer responsible for
loading cargo not stay on G deck to close the bow doors before going to his
departure duty station? It is reported that the Herald’s officers
were always under pressure to depart immediately after all cargo was loaded. On
the Herald, crew members were often ordered to departure stations
before all cargo had been loaded.
Bridge
and Navigational Procedures issued by the company operating the Herald include
the following statement:
“The
officer on watch (OOW)/ captain must be on the bridge by no later than 15
minutes before departure.”
When
the OOW is responsible for loading cargo, this 15-minute requirement is
contradictory to cargo loading duties. In prior years, captains of similar
ships have pointed out this problem.
The
company operating the Herald stated that this accident could
have been prevented if the chief officer had remained on G deck for three more
minutes. Although this is true, the company did not provide suitable measures
that allowed the chief officer to remain on G deck until the bow doors were
closed.
3. Captain
The
captain saw the chief officer arrive on the bridge prior to departure. However,
the captain did not ask the chief officer if all departure preparations had
been completed. In addition, the chief officer did not report anything to the
captain.
The
captain explained that he did not confirm departure preparations because he had
to pay attention to several other matters, as explained below:
·
The Herald’s captain
was simply using the same system that had been used by all previous captains of
this ferry. Additionally, this system had been approved by the company’s senior
captain.
·
The Standard Orders issued by the
company operating the Herald included nothing about opening
and closing the bow and stern doors.
Before
this accident, ferries operated by this company had departed a port with the
bow or stern doors open on at least five occasions. Some of these incidents
were reported to management but were not reported to the captains of other
ferries.
4. Senior management
The
investigation by the court revealed that there were fundamental and grave
shortcomings at the company operating the Herald. The executives
and employees of this company were not aware of their responsibilities
concerning safety management for their ships. In fact, no one involved with
management, from the directors to lower-level supervisors, had a sense of
responsibility about managing their ships.
5. Sharing of information between
managers and senior captains
Meetings
between senior managers and senior captains were held from time to time. A
number of complaints and requests, such as those listed below, were raised at
these meetings. However, the company’s ships operations department did not
fully appreciate the issues raised, which included:
·
Complaints that ships proceeded to sea
carrying passengers in excess of the permitted number;
·
A request to have lights fitted on the
bridge to indicate whether the bow and stern doors were open or closed;
·
Draught marks could not be read. Ships
were not provided with instruments for reading draughts. At times, ships were
required to arrive and sail from Zeebrugge trimmed by the head, without any
relevant stability information;
·
A request to install a high capacity
ballast pump to deal with the Zeebrugge trimming ballast.
6. Bow and stern door indicators
As
was noted earlier, ferries operated by this company had departed on several
occasions with the bow and/or stern doors open. In 1985, a captain made the
following request to the company:
“Most
important of all is watertight doors, meaning the bow and stern doors. There
are no indicators for when these doors are open or closed. The channel is
narrow with the breakwater close on one side and open sea close on the other
side. There could be a problem if ship operations are delayed or there is a
problem closing the doors… Mimic panels (indicator panels) are useful for
allowing the bridge team to confirm the status of the doors.”
Management
rejected these requests.
Recommendations
The
court submitted many recommendations in the following three categories. This
section includes some of these recommendations.
1. Short-term actions
a)
Ship’s safety: Install door indicators and a video link showing the doors; make
improvements to the berth;
b)
Loading and stability: Install a draft gauge, weigh cargo, prepare cargo weight
certificates;
c)
Lifesaving equipment: Take actions concerning problems (insufficient lights,
difficulty of putting on life jackets, inadequate escape routes and difficulty
using these routes), install emergency lights, provide life jackets, provide
emergency evacuation methods.
2. Medium-term actions
Provide
information about stability (angle of vanishing stability), establish KG curve
restrictions, responsibility for the angle of vanishing stability when loading
cargo.
3. Long-term actions
Design
of ships, calculation of stability when a ship is in a damaged condition,
survival at sea, submersion, air pipes, drain system for the vehicle deck.
Lessons from this accident
This
accident was a major reason for the 1993 establishment of the ISM Code. In
1994, this code became mandatory due to the addition of Chapter IX to the
appendix of the SOLAS Convention. The Code was enacted in 1998. This section
lists lessons of this accident concerning the following three causes and
instances of negligence and in relation to the ISM Code.
1) There was no procedure or clear
responsibility for opening and closing the bow doors
<ISM
Code 7> Development of plans for shipboard operations (Summary)
“The
company should establish procedures, plans and instructions, including
checklists as appropriate, for key shipboard operations. The various tasks
should be defined and assigned to qualified personnel.”
Companies
operating ships are required to prepare manuals for key shipboard operations,
but simply preparing these manuals does not fulfill this obligation. Actions
are needed to ensure that the crew members of this ship follow these
procedures. Implementing these actions is a major role of companies operating
ships and of ship’s crew (their captains). Numerous measures are required to
ensure that proper procedures are used, such as management reviews, internal
audits and shipboard meetings.
2) Avoidance of responsibilities by
management
<ISM
Code 3> Company responsibilities and authority
“3.2
The company should define and document the responsibility, authority and
interrelation of all personnel who manage, perform and verify work relating to
and affecting safety and pollution prevention.”
This
provision is the basis of the ISM code and differs from the previous approach
to responsibilities and authority. The ownership and management of ships
requires a constant awareness by managers of the obligation to fulfill these
responsibilities.
3) Responses to complaints and requests
from ships (for example, request for a front door indicator)
<ISM
Code 9> Reports and analysis of non-conformities, accidents and hazardous
occurrences
“The
Safety Management System should include procedures ensuring that
non-conformities, accidents and hazardous situations are reported to the
company, investigated and analyzed.”
Companies operating ships are required to establish procedures for responding to complaints and requests from ships and to follow these procedures.
