Capsize of the
Roll on Roll off Car ferry,
“Herald of Free Enterprise”
THE ACCIDENT:
At
about
WHAT
HAPPENED:
The Herald
of Free Enterprise, like her sister ships Pride of Free Enterprise
and Spirit of Free Enterprise, was a modern ro-ro
passenger/vehicle ferry designed for use on the high-volume short Dover-Calais
ferry route. She could accelerate rapidly to her service speed of 22 knots. She
was certificated to carry a maximum of 1,400 persons.
At
433 feet long and 7,950 gross tons, the Herald was of record size at her
launching in 1980 and was one of the prides of the 22-ship Townsend Thoresen fleet. She had two main vehicle decks and at
When
the Herald left Zeebrugge on
The
bosun left the car deck at the “harbour stations” call to go to his assigned
station. He later said, “It has never been part of my duties to close the doors
or make sure that anyone is there to close the doors.” The chief officer, Mr
Leslie Sabel, was in charge of loading vehicles. He
stated that he remained on the car deck until he saw – or thought he saw
– Mr Stanley threading his way through the parked cars toward the door control
panel. He then went to the bridge, his assigned position for departure from
dock.
The Herald
backed out of the berth stern first. The Herald had a new design of
clamshell doors which opened and closed horizontally. This design made it
impossible for the ship’s master, Captain David Lewry,
to see from the bridge if the doors were opened or closed. As the ship
increased speed, a bow wave began to build up under her prow. At 15 knots, with
the bow down 3 feet lower than normal, water began to break over the main car
deck through the open doors at the rate of 200 tons per minute.
In
common with other ro-ro vessels, the Herald’s main
vehicle deck lacked subdividing bulkheads. If water entered the deck, it
could flow from end to end or from side to side with ease. The flood of water
through the bow doors quickly caused the vessel to become unstable. The Herald
listed 30 degrees to port almost instantaneously. Large quantities of water
continued to pour in and fill the port wing of the vehicle deck, causing a capsize to port 40 seconds later. The Herald settled
on the sea bed at slightly more than ninety degrees with the starboard half of
her hull above water. There had been no chance to launch any of the ship’s
lifeboats.
THE
COURT OF INVESTIGATION:
Under
the 1894 Merchant Shipping Act, a Court of Formal Investigation of the capsize
of the Herald of Free Enterprise was held in London between April and
June 1987 before the Wreck Commissioner, the Hon. Mr Justice Sheen, a respected
judge. The court had investigative powers, the power to suspend or remove a
Merchant Officer’s Certificate of Competency, and the power to determine who
should contribute to payment of the investigation’s costs. The court had no
other powers.
THE
IMMEDIATE CAUSES OF THE ACCIDENT:
The
most important factor was that roll-on roll-off car ferries, with their large
open decks, are inherently unstable. A small amount of water pouring into the
open deck area will swill from side to side and cause the ship to capsize very
quickly even in a gentle swell. The significant human errors included the
following:
·
The assistant bosun, who was directly responsible for
closing the doors, was asleep in his cabin, having just been relieved from
maintenance and cleaning duties.
·
The bosun noticed that the bow doors were still open, but
did not close them as he did not see that as part of his duties.
·
It seems that the captain was to assume that the doors
were safely closed unless told otherwise, but it was nobody's particular duty
to tell him. The written procedures were unclear.
·
The chief officer, responsible for ensuring door closure,
testified that he thought he saw the assistant bosun going to close the door.
The chief officer was also required to be on the bridge 15 minutes before
sailing time.
SIGNIFICANT LATENT ERRORS:
However,
Justice Sheen's report into the disaster found 'At first sight, the faults
which led to this disaster were the aforesaid errors of omission on the part of
the Master, the Chief Officer and the assistant Bosun, and also the failure by
Captain Kirk to issue and enforce clear orders. But.....the underlying or
cardinal faults lay higher up in the Company. The Board of
Directors.........did not apply their minds to the question: What orders should
be given to the safety of our ships?........From top to bottom the body
corporate was infected with the disease of sloppiness......The failure on the
part of the shore management to give proper and clear directions was a
contributory cause of the disaster '.
Examples
of this sloppiness included the following significant latent errors:
·
There was no information display (not even a single
warning light) to tell the captain if the bow doors were open. Two years
earlier, the captain of a similar vessel owned by the same company had
requested that a warning light should be installed, following a similar
incident when he had gone to sea with his bow doors open. Company management
had treated the request with derision. Following the loss of the Herald, bow
door warning lights were made mandatory on roll-on/roll-off car ferries.
·
The top heavy design of roll on, roll off ships in this
class is inherently unsafe.
Once
again it was the combination of human errors (management, design and
individual) that combined to result in the loss of 188 lives. However, it is
the latent errors that are the crucial ones for disaster prevention.
In
April 1997 new international maritime safety regulations were agreed. The
regulations target the latent design errors and are intended to ensure that a
roll-on, roll-off ship can maintain stability with the car deck flooded to a
depth of 50.8 cm (20 inches). This will involve installing internal partitions
(bulkheads) or additional flotation devices within the hull. The aim is to
prevent disasters such as the Herald of Free Enterprise and more
recently the
Two thirds of the 107 car ferries on
EXTRACTS
OF THE COURT OF INVESTIGATION:
The
Management of Townsend Thoresen
“….a
full investigation into the circumstances of the disaster leads inexorably to
the conclusion that the underlying or cardinal faults lay higher up in the
Company. The Board of Directors did not appreciate their responsibility for the
safe management of their ships. They did not apply their minds to the question:
What orders should be given for the safety or our ships?
“The directors did not have any proper
comprehension of what their duties were. There appears to have been a lack of
thought about the way in which the Herald ought to have been organized
for the Dover-Zeebrugge run. All concerned in
management, from the members of the Board of Directors down to the junior
superintendents, were guilty of fault in that all must be regarded as sharing
responsibility for the failure of management. From top to bottom the body
corporate was infected with the disease of sloppiness…It is only necessary to
quote one example of how the standard of management fell short…It reveals a
staggering complacency.
“On
18th March1986 there was a meeting of Senior Masters with
management, at which Mr Develin was in the Chair. One
of the topics raised for discussion concerned the recognition of the Chief Officer.
Mr Develin said, although he was still considering
writing definitions of these different roles, he felt ‘it was more preferable not to
define the roles but to allow them to evolve.’ That attitude was described by
Mr Owen, with justification, as an abject abdication of responsibility. It
demonstrates an inability or unwillingness to give clear orders. Clear
instructions are the foundation of a safe system of operation.
“It
was the failure to give clear instructions about the duties of the Officers on
the Zeebrugge run which contributed so greatly to the
cause of this disaster. Mr Clarke, [counsel] on behalf of the Company,
said it was not the responsibility of Mr Develin to
see that Company orders were properly drafted. In answer to the question, ‘Who
was responsible?’ Mr Clarke said, ‘Well in truth, nobody, though there ought to
have been.’ The Board of Directors must accept a heavy responsibility for their
lamentable lack of directions. Individually and collectively they lacked a
sense of responsibility. This left, what Mr Owen so aptly described as, ‘a
vacuum at the centre.’
“…Mr Develin
[Director and Chief Superintendent] was prepared to accept that he was
responsible for the safe operation of the Company’s ships. Another director,
Mr. Ayers, told the Court that no director was solely responsible for safety.
Mr Develin thought that before he joined the Board,
the safety of ships was a collective Board responsibility.
“… as this investigation progressed, it became
clear that shore management took very little notice of what they were told by
their Masters. The Masters met only intermittently. There was one period of two
and a half years during which there was no formal meeting between Management
and Senior Masters. Latterly there was an improvement. But the real complaint,
which appears to the Court to be fully justified, was that the “Marine
Department” did not listen to the Complaints or suggestions or wishes of their
Masters. The Court heard of four specific areas in which the voice of the Masters
fell on deaf ears ashore.”
ANOTHER BOW DOOR
TRAGETY…THE
The
ferry