Herald of Free Enterprise

UK registered Ro-Ro ferry ‘The Herald of Free Enterprise’ capsized only a few minutes after leaving the Belgian port of Zeebrugge on the night of 6th March 1987, killing 193 people onboard and is considered as one of the deadliest casualties involving a UK-registered ship, since 1919.

One of the root causes of this incident was that the bow door was left open; the failure of the assistant boatswain to close the bow door (who slept through the alarm) before dropping moorings. The bow door remained open as the ferry set sail into the waters, soon waves washed though the lower car decks, and due to the top-heavy design of the vessel, water quickly filled the boat and it capsized minutes later. The ship turned on to its side and rested on the sidebar in the shallow water.

Actions that could have reduced the likelihood of the incident’s occurrence

• Negligence: The ship went to sea with its inner and outer bow doors open.
  • Assistant bosun Mr. Mark Victor Stanley fell asleep in his cabin and failed to hear the call to sail.
  • Bosun, Mr. Terence Ayling, saw the open doors but because it was never part of his dutues, he just assumed that someone else would do it, even though there was no one in the vicinity.
  • There was no foolproof system to ensure the doors were closed irrespective of the failure of an individual.
  • There was miscommunication between two officers, about who was in charge of loading, because of which the assistant bosun was not reminded/chased for securing the doors
  • A general instruction prescribed the officer loading the main vehicle deck to ensure the bow doors were “secure when leaving port”. However, the instructions were interpreted as a duty to check that the assistant bosun was at the controls, and not to check that the doors were actually closed.
  • The “Bridge and Navigational Procedures” guide issued by the Company included the following:
    Departure from Port:
    a) O.O.W./Master should be on the Bridge approximately 15 minutes before the ship’s sailing time. This guideline did not make it clear whether the O.O.W. or the Master had to be on the bridge 15 minutes before sailing, which created confusion. This conflict was brought to the attention of the management who chose to ignore it.
  • Before the disaster, at least on five occasions, the Company’s ships set for sail with bow or stern doors open. Despite the management neing aware of the issue, no action was ever taken to rectify the issue.

• Pressure to leave the berth: The officers were always under pressure to leave the berth immediately after the completion of loading. On that fateful day, the loading officer did not remain on the G deck to check if the doors were closed (even though it would have taken just under three minutes) and rushed instead to his harbour station on the bridge; they had to rely on another person to close the doors in time before the ship set for sail. This sense of urgency to sail as quickly as possible was demonstrated by an internal memorandum sent to assistant managers by the operations manager at Zeebrugge.

• No Indicator lights: The captains were obviously unhappy with this procedure (depending on another person to close the doors) and had asked the management to setup indicators that would display (at the bridge) that the doors had been closed. However, the management rejected this demand as it was considered an unnecessary expense.

  The captain (master) of the ship on that fateful day had no view of the bow door and there were no indicator lights or other means for him to confirm that the doors were closed. The absence of a communication channel with deck crew meant that the captain just assumed that the door was shut and set for sail.

  This had previously been raised as an issue by a captain of a similar vessel, which had also gone to sea with bow doors open; however, the warning was ignored by the shore-based managers of the operating company, Townsend Thoresen.

• Overloading: The company’s ships also frequently carried many more passengers than what as permitted, and there were no serious attempts by the officers to read the draught to see if the shup was overloaded. Also, when a ship sails, the movement under it creates low pressure, which sucks the bow downwards, and this effect becomes more greater in shallow water dragging the bow down more. This was also one of the factors in the capsizing of the boat.

• Poor communication: Poor communication and lack of uniformity in the manner in which the crew and officers operated; there was a lot of ambiguity over each one’s duties and responsibilities.

So, there are several things that could have been done that would have prevented the disaster:

• Ensuring that the closure of the doors was properly checked. Mechanical interlocks that provide visual signals about the bow doors in the control room, TV cameras that showed the bow door’s status, and many other methodologies. These things should have been thought of during the design of the ship itself.
• Updating the Bridge and Navigation Procedures Guide to include instruction that the doors should be closed. Introduced a monitoring or checking system.

A general culture of poor communication in the owner company was deemed responsible for the accident. Several fatalities would have been avoided if safety culture had been built into routine operational procedures.

This incident is a clear example of what can happen when a culture of carelessness contaminates an entire organization. “From top to bottom the body corporate was infected with the disease of sloppiness,” this quotation from the official report sums up the issues that led to the incident.

Industry wide reaction and subsequent actions to prevent re-occurrence

Criminal charges of negligence were pressed against the crew and the owners, but the cases collapsed; however, this incident set a precedent as it was the first time that the courts had agreed that such a charge against a corporation was feasible.

The formal investigation into the accident was appreciated for its findings and also for its recommendations that were meant to enhance future maritime safety.

There was a detailed enquiry and several recommendations were made.

• Beginning April 1988, the MSC adopted SOLAS amendments, including among others:
  A new regulation requiring indicators on the navigating bridge for doors which, if left open, could lead to major flooding
  A new regulation requiring cargo loading doors to be locked before the ship proceeds on any voyage and to remain closed until the ship is at its next berth.
• In order to satisfy the general public about the transparency of formal investigations, it was felt that a body that was not related to the Department in any way should be setup.
  The investigation of the accident resulted in the formation of UK MAIB (Marine Accident Investigation Branch) in 1989. MAIB was setup in Southampton, London. The sole objective of MAIB is to improve safety at sea by periodically announcing and spreading safety lessons learnt from marine accidents. Today, the MAIB is one of the oldest maritime investigation units in the world.

References

Herald of Free Enterprise: A wake-up call for Ro-Ro safety

MS Herald of Free Enterprise

Review of common human vulnerabilities and contributions to past accidents

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