Human Error and Risk Taking

Human Error and Risk Taking

When a new ship is built and has a lot of imagination built into it, the quality that is ascribed to the ship is that it is unsinkable. This was said of the Titanic: "The captain can, by simply moving an electric switch, instantly close the doors throughout, practically making the vessel unsinkable." (They Said It. Some Memorable Lines) This was reported in Irish News and Belfast Morning News, June 1st, 1911, on the incomplete Titanic. (They Said It. Some Memorable Lines)

It is very difficult to say why accidents are found to occur as the definition of accidents itself is that they are events out of the ordinary and dictionary alternatives for accident are considered to be disaster, catastrophe, misfortune, calamity, mishap and mistake. At the same time, it is to be understood that people have their own minds and have their judgments, and when they are not in a position to understand a situation, they try to evolve some other causes for it and the easiest reasons that are denoted by them are with regard to what they already know well -- their specialties. 1987 was considered as a bad year for the ferries. In July of that year 390 people died when a barge capsized in the process of crossing a crocodile infested African river. Another ferry capsized after that, and that occurred in the Philippines, killing 38. The Dona Paz was yet another ferry which met with an accident. On the whole, during that year shipping tragedies reached its height. Figures that were later released by Lloyd's Underwriters demonstrated that more people died at sea during the year 1987 in comparison to any other year since the keeping of records had begun. (An astrological warning of trouble at sea)

The accident that we are referring to is one that caused 193 deaths when the roll-on roll-off ferry 'Herald of Free Enterprise' capsized off Zeebrugge, Belgium on 6 March in the year 1987. The bow doors had not been closed after departure, and water filled the car decks. While the accident is gruesome, it led to the recognition of flaws in company systems of operations and finally, the tragedy led to new safety rules in the British ferry industry. This had been followed up by the sinking of the Estonia in the year 1994 for causes which were found to be similar and the death of 850 people. This led to new regulations in international ferry safety being brought about in the year 1999. As a result of the accident, the Crown Prosecution Service had made charges of corporate manslaughter against the P& O. European Ferries in the year 1989 and seven employees individually with manslaughter. The case did not succeed in the courts, but brought about a precedence for corporate manslaughter to be made being legally permissible in an English court. (Herald of Free Enterprise 1987: Zeebrugge disaster was no accident)

It was on the evening of Friday 6 March 1987, that the Townsend Thoresen car ferry Herald of Free Enterprise was making it ready to leave Zeebrugge, Belgium, for its usual trip of crossing over to Dover. This was a usual journey for the ship and it took about four hours. This was not a very old ship and it was only seven-year-old. As a ship it was a ferry of the roll-on-roll-off type, and cars were able to get on to the ship and move out. In order for the cars to be able to get on the Herald, the ship had to flood the forward ballast tanks. This let extra water in the ballast tanks and made the ship low in the water. However, the entire process of the cars getting on and getting off was speeded up by this process and the operation of loading the ship was over and shortly after 6pm the ship was leaving the port. Then she backed off from the terminal and turned around. By this point of time, it was assumed that the checks had been finished and the ship was ready to plunge into the sea. But this assumption was incorrect and something was considered to be wrong. The bow doors were kept open even when the ship was leaving the port as the person who was to check them had slept off in his cabin. (Herald of Free Enterprise: Shipwreck Data Office)

The problem was not known and it was assumed that everything was in order. The Herald gathered its speed as per the usual manner made out to the sea. But this did not continue and just half a mile outside the harbor, the ship began to list violently. The captain tried to correct the problem and swung the ship round. This made the ship roll onto her port side, and only a sandbank prevented the ship from rolling completely over. The ship did not get enough time to issue a signal of distress, but capsize of the ship had been seen by the dredger Sanderus, and this ship sent a radio message that the Herald had capsized immediately at the outside of the harbor. (Herald of Free Enterprise: Shipwreck Data Office) There were many passengers on board and most of the ship's passengers who were more than 500 in number were in the restaurant or buying duty-free goods at the time Herald of Free Enterprise began to list to port as she was in the process of leaving Zeebrugge, Belgium, on the evening of 6th March 1987. The accident happened very fast and within 90 seconds, the British car ferry had settled at the bottom of the sea. (Accidents and the lessons learned)

As there were more than 500 people on board, the rescue missions plunged into activity. Rescuers worked throughout the night and dragged people out of the capsized ship and through this process, many bodies were recovered. In total 193 people had lost their lives. (Herald of Free Enterprise: Shipwreck Data Office) The accident was gruesome and it is important to know why this happened. We have seen that this was an accident and certainly it is now known that at least one employee did not complete his duties. At the same time, let us remember that there are always individuals involved in accidents and definitely the responsibility can be pasted on somebody, but the correct procedure should be to look at procedures so that such accidents do not occur again.

At the same time, the management of the ship owners was very proud of their system and just 9 days before the accident P& O. had stated that their procedures were designed 'to deal with the unexpected from whatever quarter'. (An astrological warning of trouble at sea) Yet the ship, the Herald of Free Enterprise, capsized at Zeebrugge with the loss of 193 lives. The large number of deaths and unexpectedness of the tragedy got it compared to the Titanic incident. (An astrological warning of trouble at sea) There was a formal investigation/enquiry and that mentioned that the company management had to be blamed for failing in their mission to give clear instructions in relation to the safety procedures to be followed. But even then the company management did not take them seriously and implement any new safety measures or techniques and new safety measures were at the last brought into effect in the year 1999 when another ferry disaster had taken its place. The disaster that is being referred to over here is that of 'The Estonia' which sank in the year 1994 which took the lives of 850 people. (Herald of Free Enterprise 1987: Zeebrugge disaster was no accident)

At the same time, it should have been realized by the operators of roll-on roll-off car ferries had large and open decks and these decks made them relatively unstable. When even a small amount of water gets into the open deck area, the water will pour into from side to side of the ship. This will cause the ship to capsize very quickly even when only a gentle swell is going on. In this case there were significant human errors. These can be listed as the assistant boatswain, who had the duty of closing the doors, was sleeping in his cabin. It should be remembered that he had just been removed from the maintenance and cleaning responsibilities. The second point is that the boatswain, the direct boss of the assistant boatswain had noticed the bow doors as being still open, but did not close the doors as he did not feel that closing doors was part of his duties.

The third point is for the captain, and he was expected to assume that the doors were safely kept closed till he was informed otherwise, and at the same time, it was nobody's particular responsibility to inform him. The written procedures were unclear regarding this matter. The fourth point is regarding the chief officer. He also had the duty of closing the door, but he testified during investigations that he thought he had seen the assistant boatswain going towards the door to close it. He also had other duties and had to be on the bridge for 15 minutes before the sailing time. (Herald of Free Enterprise Sinking) Thus it is clear that the line of command on the vessel was not clear and the responsibility was not being taken up by superiors in the event of failures of the juniors. It should be remembered that in management the chief always has the ultimate responsibility, and it is his duty to check everything before he institutes a change. Let us take a very simple and primary example of a guard starting off a train. He clearly checks everything on the platform before he blows his whistle for the train to start.

The incident was followed by a coroner's inquest and the jury into the capsizing of the Herald of Free Enterprise returned decisions of unlawful killing. The result of the ferry disaster in March, which killed 193 people, then started the likeability of a criminal prosecution by the Director of Public Prosecutions -- DPP. In concluding of the incident, coroner Richard Stuart mentioned that decisions could be returned only if the jury believed a criminal act had been performed and whether there had been any negligence. The coroner had further mentioned that the purpose of the inquest was to declare facts and not blame. At the same time, he mentioned that only the activities of three crewmen might have led to the deaths. However this did not satisfy most of the families of the victims and they wished to see the Townsend-Thoresen company directors who are now part of the P& O. To face prosecution, and not employees of the company. Immediately after the public inquiry done into the disaster, Lord Justice Sheen recognized a disease consisting of sloppiness, and negligence at each and every phase of the hierarchy relating to the company. (Herald of Free Enterprise 1987: Zeebrugge disaster was no accident)

The captain could not know if the bow doors were open as there were no signals for him. Two years before, the captain of a similar vessel which was owned by the same company had informed that a warning light need to be installed, as there had been a similar incident when he had gone to sea by keeping his bow doors open. Company management had not accepted the request. After this accident, bow door warning lights were made compulsory on roll-on roll-off car ferries. At the same time, let us remember that the top heavy design of roll on, roll off ships is inherently unsafe. It can also be seen that a several human mistakes inclusive of problems relating to management, design and those which were individual related resulted in the loss of 193 lives. At the same time, it is such errors that are significant for disasters to take place. (Herald of Free Enterprise Sinking)

To prevent such problems in future, in April 1997 the new international maritime safety regulations were agreed to. The regulations try to take care of the latent design errors and have been made to ensure that a roll-on, roll-off ship can promote and maintain stability with the car deck flooded to a depth of 50.8 cm. This will be done through installation of internal partitions or additional flotation devices within the hull. The motive is to avoid disasters such as the Herald of Free Enterprise and more then the Estonia. These changes are expected to make the ships safe for the evacuation of several passengers. This is also the rule for cruise ships and they are expected to remain afloat for duration of at least half an hour after being found to be irreparably holed. About two thirds of the 107 car ferries available on UK routes are close to the new standard. (Herald of Free Enterprise Sinking)