The Herald of Free Enterprise capsized on March 6, 1987, killing ~200 people. It sank because its inner and outer bow doors had been left open on sailing due to a combination of factors and decisions. The subsequent investigation found that all of these could have been avoided or ameliorated. Management failures set up a culture that compromised safety and allowed individual human errors to occur. The disaster could have been avoided if management had addressed safety in a more informed and committed way.
Management Failures
Management pressured crews to sail early by sending memos to staff demanding that ships leave 15 minutes early. To speed up sailing times, the chief officer, who was responsible for ensuring the bow doors were closed, was required to be on the bridge before sailing rather than on the car loading deck. He was thus on the bridge before the cars had finished being loaded. It was the management’s responsibility to ensure that a safe procedure was in place to prevent this type of omission. Another failure included orders that only ‘negative reporting’ should be employed; officers on board the ship were to assume that all was well unless they heard otherwise.
Supervisory and Organizational Failure
The assistant boson, whose job was to close the doors, was asleep in his cabin after a maintenance and cleaning shift. This would not have occurred if more attention had been paid to rostering and monitoring staff. The boson left the deck without checking either that his assistant was on duty or that the doors had been closed.
System Design Failure
Ship masters had repeatedly requested that bow door warning indicators be installed on the bridge, but management did not act on these requests. For an estimated $400, the equipment could have been installed, and the ship’s master would have known about the state of the doors before he left port. Other design failures
included the top-heavy design of the ferry and inadequate equipment to remove water from the flooded deck.
Sources: Reason, J (1989): Human error. Cambridge, CUP. Sheen, B. (1987): Herald of Free Enterprise, Report of Court no. 8074 formal investigation. London.