Herald of Free Enterprise

[alistairuk]

The reason we have "SMS" and "DPA"s

[chris]

we were just discussing this disaster in class just the other day and attributed some of the blame to the deck department but most to the superintendent and board of directors.

http://www.maib.gov.uk/publications/investigation_reports/herald_of_free_enterprise.cfm

makes for shocking reading

[GuinnessMan]

we were just discussing this disaster in class just the other day and attributed some of the blame to the deck department but most to the superintendent and board of directors.

http://www.maib.gov.uk/publications/investigation_reports/herald_of_free_enterprise.cfm

makes for shocking reading

How did you get to that conclusion?

[alistairuk]

How did you get to that conclusion?

From memory;

While ultimately the cause of the sinking was the deck department forgetting one very fundamental thing (i.e.: not closing the doors);

The ships (since it was a class of ship) had repeatedly advised the office that there was no way to tell if the doors were closed from the bridge (since the way the doors opened meant they couldn't be seen from the bridge) and requested some means of indicating this fact on the bridge - the response from the office went along the lines of "why do you need a light to tell you the doors closed"... needless to say as a result of this all passenger ships now have warning lights and alarms to advise the bridge that one of the shell doors are open! Excellent during bad weather when the movement causes the alarms to go off repeatedly

It was also established company procedure that required the person responsible for checking the doors were closed (Chief Officer) to be on the bridge for departure!

There was no positive reporting of actions being completed - it was just assumed all was done.

The guy responsible went to be bed and didn't wake up in time for sailing .:. couldn't close the doors on departure. Alas if there was a procedure in place for positively checking the doors were shut (or even positively reporting the door as being shut) this probably could of been avoided.

Like everything in this industry, it takes accidents to happen before people take notice and do something about it!

[chris]

thanks alistair, that was the gist of what we said in class

[GuinnessMan]

While ultimately the cause of the sinking was the deck department forgetting one very fundamental thing (i.e.: not closing the doors);

The ships (since it was a class of ship) had repeatedly advised the office that there was no way to tell if the doors were closed from the bridge (since the way the doors opened meant they couldn't be seen from the bridge) and requested some means of indicating this fact on the bridge - the response from the office went along the lines of "why do you need a light to tell you the doors closed"... needless to say as a result of this all passenger ships now have warning lights and alarms to advise the bridge that one of the shell doors are open! Excellent during bad weather when the movement causes the alarms to go off repeatedly

It was also established company procedure that required the person responsible for checking the doors were closed (Chief Officer) to be on the bridge for departure!

There was no positive reporting of actions being completed - it was just assumed all was done.

The guy responsible went to be bed and didn't wake up in time for sailing .:. couldn't close the doors on departure. Alas if there was a procedure in place for positively checking the doors were shut (or even positively reporting the door as being shut) this probably could of been avoided.

Like everything in this industry, it takes accidents to happen before people take notice and do something about it!

From reading the report, I have a few points: -

A) The vessel was manned with two Chief Officers. Surely one would be on the bridge whilst the other would be on the deck?

B) Could the task of telling the bridge the bow doors were shut not have been handled by an AB, OS or Cadet? (This one is Master's Domain).

C) Asst. Bosun admitted he failed to carry out his duty,

D) Bosun worked on the view of "it aint my job to close the doors so I didn't".

E) The court felt that if one of the Ch/Off's had stayed on G deck for three more minutes, disaster could have been averted.

F) There appeared to be a lot of pressure from shoreside management about leaving Zeebrugge 15 mins early. This sort of **** is standard stuff from ferry managers and whilst it can be used to say they were at fault it in effect cannot. Whether to push the crew like this falls to the Master. He makes the decision to follow this or not as it's his bollocks on the fire if it all goes wrong. If I was to go saying this sort of thing to my Captains, they'd tell me to bugger off!

G) This had happened at least 5 times before on other ships. This is a major failing by the shoreside HSE department. It's now common practice to forward particular accident reports to all vessels within the company's fleet. Idea behind it is, learn from others mistakes as well your own.

H) A fairly interesting comment made about crew rotations. However, it was noted in the instructions that the Loading Officer is to ensure that the Bow and Stern doors where closed prior to attending other duties. This was not followed by any of the crew.

I) Consistently throughout the report there are lot of points about the management of the company that is, quite frankly, alarming but did not cause the accident to happen.

From what i've read i'm of a mind that about a blame factor of 75% to the ship and 25% to the shore is what should be applied here. The shoreside where incredibly lax when it came to safety, the on board team were equally as lax and at the end of the day they are the ones with the over-riding safety function. The Master of the vessel can quite legally tell the shore side to bugger off if he felt that the safety of the ship was compromised in any way shape or form.

Accidents never have one singular cause, they are a cascade of events. In this case it was a sleepy Asst. Bosun, Full Bosun with a poor attitude, Lazy Chief Officer and, worst of all, a whole herd of assumptions made by on board staff.

[Chiefy]

The ONLY reason your captains tell you to bugger off, IS because we now have SMS and the likes in place which are rigorously checked, enforced and audited, the Captains now have the back up and the trail of paper if needed.

There was blame all round on this accident so much...would of, could of, should of, my understanding about the 2 Ch Off's is they where (still are) on back to back watches 12on:12off in that case it makes no difference you still only have effectively 1 man trying to be in 2 places (however I stand to be corrected on that point)

Lessons have been learned, hence positive reporting becomes the norm, technology gets added or improved upon....but always after the event, which is a shame....just ask those pour souls mid-atlantic 100 years ago this year,lessons where learned and things changed arguably for the better

[chris]

in hindsight, it seems a bit freaky that this video was posted the day before the cruise ship incident.