Thirty years ago... http://www.bbc.co.uk/news/uk-england-39116394

Another tragedy so typical of that time which could easily have been avoided with only a small intervention like a pilot light and/or interlock to the engines disabling them if the bow doors were not fully shut.

A spate of incidents in the 1980s and 90s accelerated health and safety management (i.e. Kings Cross fire, Marchioness sinking, Clapham Common train crash, Bradford fire, Hillsborough, etc). Let us not forget.  

I still refer to the 'Herald of Free Enterprise syndrome' - everything is ok unless we tell you otherwise.

Edited by user 06 March 2017 16:35:28(UTC)  | Reason: Not specified

John please remember this is one of the incidents that lead to the Corporate Manslaughter Act (much frusttration by the authorities that they could not hold those at the top accountable) under which..... 30 years on and how many prosecutions of these large body corporates?

To mind I can think of two prosecutions both classed as SME.

When i was watching the report on the BBC yesterday morning, I was thinking there were many lessons learned from this incident.

My concern is these get forgotten over time and we (society) make the mistakes all over again.

 Hi folks

If you check out the case studies in James Reason's book on human error [which some of our number think is uninteresting!!/useless]  #5 deals with the sinking

Key issues

1 Berth's ramp could not be elevated enough due to high tides so the ship was trimmed down at the bows-System failure

2. Ship proceeds with both inner/outer bow doors open as assistant bosun asleep in his cabin-having just been relieved of other duties-supervisory failure/poor rostering

3. Bosun, noticed doors open and did nothing-not his job. management filure

4. Chief Officer, checking deck thinks he sees assist bosun but is confused-he is responsible for ensuring doors closed-and also is required on the bridge 15 mins before sailing-mgt failure again

5. Because of delays at Dover great pressure to sail early-memo from Ops Mgr " put pressure on First Officer to sail early, sailing out of Zeebrugge isn't on-its 15 minutes early for us" -mgt failure

6. No report made by Chief Officer-Master assummes all is well-mgt failure

7. On leaving harbour, Captain increases speed, water floods G deck, and at around 1827 ship capsizes-Despite many earlier requests from Captains to Management no bow door indicators were made available  [cost £400-600] and the Captain was unaware that he had sailed with the doors open [Always wondered about this?] Mgt failure

8. Ship had chronic list to port, Mgt/technical failures

9. Scuppers inadequate to void the flood-water-Design and maintenance failure

10. Top heavy design of the RO-RO ferries inherently unsafe-design failure.

Latent failures in action and it's the same with the other case studies

Sorry it's a long one but I've precised it

Regards

Mike 

Looking at the spate of disasters at that time, you could level the same criticisms about poor design and practices at most of them - Challenger, King's Cross, Piper Alpha, Flixborough, Bhopal to name but a few.

Have we learned lessons from all of them? Challenger - not convinced, King's Cross - probably, although the smoking ban sidestepped the problem, Piper Alpha - probably, but unsure on some aspects, Bhopal - not convinced at all (we simply don't hear the name Union Carbide these days re the last one).

As the old saying goes - those who don't learn from mistakes are doomed to repeat them.

Originally Posted by: biker1

Looking at the spate of disasters at that time, you could level the same criticisms about poor design and practices at most of them - Challenger, King's Cross, Piper Alpha, Flixborough, Bhopal to name but a few.

Have we learned lessons from all of them? Challenger - not convinced, King's Cross - probably, although the smoking ban sidestepped the problem, Piper Alpha - probably, but unsure on some aspects, Bhopal - not convinced at all (we simply don't hear the name Union Carbide these days re the last one).

As the old saying goes - those who don't learn from mistakes are doomed to repeat them.

What these accidents have in common is that they were ultimately caused by people who were not experts (by that I mean those that really understood the systems involved eg naval architects) taking major decisions based on assumptions, gut feeling and in some cases a prayer. When RO-RO ferries were first developed I can’t imagine the designers saying: “Of course the ships will leave port with the bow doors opens, we included this in our calculations”.

An interesting discussion. I would comment on a couple of points.

Firstly most ferries of that generation had bow visors, not clam doors. From the bridge these were obviously open or closed as they raised upwards. The Dover routes were peculiar in the the shore infrastructure required clam doors which are not obviously open.

Again, most ferries of that era did have sensors fitted showing if doors were open or closed. However, the technology of the day resulted in these being mechanical switches which, in a salt laden atmosphere, were highly unreliable and could not be relied upon. Modern ferries use sealed proximity switches, far more reliable.

The comment in respect of the military requiring transverse bulkheads I cannot directly comment on, but some ferries of the Herald's era were retrofitted with these. However, they were not popular as they delayed loading and discharge and not acceptable to the paying public. Alternate stability arrangements now apply.

Rayrapp correctly mentions that leaving the berth with doors open was not unusual. UK ro-ros of that era had two doors fwd, one the watertight inner door and the outer door (visor or clam doors). A visor often could not be closed until after the vessels moves off the berth as the visor lowering fouled the shore ramp. Even after the Herald, the MCA did not require closure before leaving the berth, but to be closed "within a ship's length of the berth". Same for opening on arrival.

As mentioned there were changes after the Herald. stability reqirements were changed significantly, especially for new builds. Secondly there is now a mandatory requirement for a formal safety management system to be in place under the ISM Code, this being a fully externally audited system (in the case of UK passenger vessels audited by the MCA).

Post Herald, departure routines were changed with the Chief Officer being required to physically sight doors closed (or to sight the tell-tale lights to ensure the outer door was closed and locked), the operating cabinet locked and then the C/O goes to the bridge, the keys are locked into a cabinet, the power supply to the hydralics isolated and that key also being put in the key cabinet. the cabinet is locked and the key is kept by the Master until the next port. Once all this is done, the departure check list can be completed.

Colin