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.
At 1805 (GMT) on 6 March 1987, the Herald of Free Enterprise (“Herald”), a roll-on/roll-off passenger and cargo ferry, departed berth 12 in the inner harbour of Zeebrugge, Belgium. The Herald had 459 passengers, 80 crew members, 81 cars, 47 cargo trucks and three other vehicles. The weather was good.
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.
Reference Documents
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