Risk 2.

New events happen.

Foreword.                                                                                                                                              As i write today, and its the 3rd time that i have started this post, it’s a very wet and ‘slack’ Sunday.  As i look outside there is a curtain of fine rain and it doesn’t look very appealing to get outside and crank out my daily hundred.

This is the second in a series of posts in which i am attempting to write about much harder subjects within the genre of seamanship and the sea.  In the first post i talked about 3 similar accidents/incidents that left 3 highly experienced sailing seamen dead in cold water and i have a personal connection with one of those events.  Some might say that we sailors take on that degree of risk as a natural consequence of what we do, to a small extent i agree in that : “live by the sword-die by the sword” but in a larger sense i do not.  In the first post i tried to explain how one formal tool ie risk management might help and inform us sailors to understand and manage the hazards and risks that are exposed to out there and thus live to fight another day.  As a leisure sailor who primarily sails solo i have a duty of responsibility to myself first and then to the other water users that i might interact with.  That changes when i am at sea with my partner at which point i acquire a duty of care towards her and that can be demonstrated as a principle in law.  As mate, then skipper, of a small commercial sailing vessel at one time i clearly had a 24 hour responsibility for that boat, its crew and passengers and a clear duty of care towards them.   In this post i will be showing what happens when a duty of care breaks down and where concerns of efficiency and expediency over-ride that duty of care.

Secondly in that post i tried to introduce my readers to the idea of not dismissing risk management as merely the dead hand of petty power seeking low-end council beaurocrats endlessly parroting ‘elf-n-safety’ but as a genuine subject worth due consideration. With that in mind i gently introduced some of the key concepts, one of those being the idea of basing our work around evidence ie things that actually have happened.  Furthermore in that post i also pointed out that i was trying to avoid some of what can be very often the pitfalls for example being wise after the event.  In this post i am doing nearly the opposite in that i am going to talk about an event that really hadn’t happened before, was in the professional world of seamanship where a duty of care really did exist, which was catastrophic in its scope and in which i am going to delve into the causes and failures.  Later in the post i am going to try to make some connections between the organisational and cultural failures in the ferry company and similar ones in another large organisation.

Limitations.

Once again in a post i need to explain my limits of competence.  I am a sailor and seaman and i have been a professional one.  I can and do read widely and in this case have done the work of at least reading the actual accident report rather than just repeating media versions.   Despite having a basic understanding of concepts such as duty of care and negligence i am not competent to comment on the legal side of this event, particularly in the decision not to hold the company responsible for corporate manslaughter.

What happened ?….introduction.

In March 1987 a car/passenger ferry sailed out of the harbour at Zeebrugge and within 4 minutes of leaving the outer mole around 18.30 that evening had capsized and settled on a shallow sandbank.  During the rescue operation which went into action almost immediately 193 passengers died , mainly due to hypothermia.   The article link below is well worth a read if you have any interest in at-sea disasters or a more general interest in adverse incidents and human error.

http://www.ship-disasters.com/passenger-ship-disasters/herald-of-free-enterprise/

 

In this piece i want to do the opposite thing to the first post and actually comment on the causes of event that was really a new event : almost a ‘black swan‘        I don’t know of anything similar that had occurred before in the world of sea transport although the sinking of 3 other ferry’s before that time may have had some similar features.    Both the MV Larne and the TEV Wahine sailed into extreme weather such that just about any vessel could have got into difficulty in the same place at the same time.   For anyone wants to look at these for comparison here are the links .  There is a significant 4th ferry sinking also in heavy weather : the Estonia in the Baltic in 1994 which i will mention at the end of the post which as i understand is the worst maritime disaster of the 20th century.

1.TEV Wahine. https://en.wikipedia.org/wiki/TEV_Wahine

2.SS Heraklion : https://en.wikipedia.org/wiki/SS_Heraklion

3.MV Princess Victoria : https://en.wikipedia.org/wiki/MV_Princess_Victoria

I have a small personal connection with the Herald of Free Enterprise capsize in that i was involved in organising a specialist nursing conference i think the year after the accident  when the psychologist who dealt with many of the survivors was one of our speakers.   During his lecture he talked briefly about how badly he had been affected by the survivors stories, something he didn’t realise until he made a cross-channel trip on of Heralds sisterships.  I remember that he spoke about his own emotional reaction when, sat inside the ferry, he looked at his seat number and realised that had he been sat in the same place on the Herald that he would most likely not have survived the capsize.

First lets see an original BBC clip.

In the first few hours reporting is very direct and almost visceral in its initial impact especially for anyone who knows even a small amount about the sea.  Now it annoys me when reporters and BBC presenters talk about a ‘freezing’ sea…..it isn’t just merely very cold.  Knowing though that this is March and that the sea temperature in that part of the north sea is usually between 6 and 9 degrees C this is about the same temperature water that both Rob James and Peter Phillips fell into fully suited up.  Survival time at that water temperature can be as low as 20 minutes : my bunk-mate Bart Van den Dwey reported loss of consciousness at about 25 minutes in a similar situation.   Add to the low water temperature the march air temperature and that it was just getting dark, that the vessel quickly lost all power and lighting and was on its side and we have a disaster actually happening.

I don’t want to dwell too much on this stage but to say that most of the deaths would have occurred within that first half-hour either through having been trapped underwater and drowned, through the early mechanism of cold shock or slightly later due to cold water immersion hypothermia.  Relevant to all persons that are rapidly immersed in cold water that the cold shock response does occur but also that most people become rapidly and progressively unable to help themselves in water that cold….most will lose consciousness before the half-hour.

First analysis.

The initial reporting seemed to suggest 2 possibilities : first that the ferry had hit the harbour wall and secondly that the bow doors had somehow come open allowing waves to wash in over the bow ramp.  Neither was true : this is in fact the ferry that sank itself.

If you can get past the awful ‘seconds to disaster format’ watch this :

Full investigation, research and later analysis.

For those that haven’t already read the actual investigation above i will now cut and paste the relevant sections.

1.Human error.      “Mark Stanley was the bosun’s assistant on the vessel and it was his job to close the bow doors. At the time the vessel sailed from port he was asleep in his cabin and didn’t hear the harbour stations sounding.  This was the que for the bow doors to be closed and all crew members to report to their harbour stations.  Chief Officer Leslie Sabel recalls seeing a man in orange overalls whilst he made his rounds, he assumed this man to be Mark Stanley and therefore that the bow doors had been closed.  The Chief Officer returned to the bridge, which was his harbour station and reported that they were ready to sail. Captain Lewry could not see the bow doors from the bridge and as there was no other way to substantiate they were closed relied upon the chief Officers report being accurate.  Captain Lewry then dismissed the second officer and told Chief Officer Sabel to take his dinner break.”

2.Design error and expediency.     “This meant that upon sailing the Herald’s bow doors were open.  To compound matters, due to the incompatibility of the design of the ferry and the linkspan at Zeebrugge the ferry’s vehicle decks could not be loaded simultaneously as they could at Dover and Calais.  The loading ramp at Zeebrugge could not be raised high enough to reach E deck which was the upper vehicle deck.  To combat this the ferry was lowered by filling the bow ballast tanks, allowing vehicles to be driven on to E deck. This meant that when the ferry sailed from Zeebrugge in addition to the bow doors being open, she was also 3 feet lower in the water than usual.

Normal experience with this design of ferry which included a sister ship sailing and surviving with her bow doors open didn’t indicate that a catastrophic flooding and free surface effect could occur.  This was only discovered later on in the accident investigation by doing a complete replay with a sister ship, fully laden and leaving Zeebrugge exactly as the Herald had done.  What the replay demonstrated is that when trimmed bow-down the ferry would still be relatively safe in flat water up to a critical speed….just over that speed and the combination of shallow water ‘squat’ at speed and the design of the bow critically changed the shape and size of the bow wave such that the vessels own bow wave then flooded the open car deck.  The free surface effect then destabilised and capsized the ferry.

Thus far and sticking with the accident investigation and subsequent coroners court hearing we can say that a combination of several human errors did occur aboard the ferry but that also the ferry’s design, its sailing trim that evening, the shallow water and a critical increase in the vessels speed were all factors that came together to capsize the ferry.      There is however another layer of cause here once we start to dig a little deeper.

3. Management failure to listen to warnings.  “The investigation found that the Herald was overloaded on weight and that this was a regular occurrence which Masters had alerted shore side management of, however found that this ‘was not in any way causative of the casualty’.

Failure in the reporting/command structure specifically that although it was normally the bo’sun’s mate whose job it was to actually close the doors that there was no system in place to ensure that this had been done : for example that there was no ‘pre-flight’ style check of the doors.

4.         “Judge Sheen questioned why the failing of one member of staff could lead to such a catastrophe and why systems had not been implemented to ensure that the doors had been closed, particularly as this was not the first time a spirit class ferry had sailed with the bow doors open.

5.  (Its not my job !)         “The report criticised the attitude of Mr. Terence Ayling who was serving as bosun on the Herald.  He left G deck for his harbour station knowing that the bow doors were open and the assistant bosun was not present to close them.  When questioned regarding his actions he advised the enquiry that he did nothing about it because it had never been part of his duties.

It is at this stage that i am going to leave the strictly factual and the dramatised version in the documentary and take a sideways look at some comparisons with other transportation industries specifically with their ‘culture of safety’ (or not) in mind.

Reading through the full report it becomes apparent that the ferry’s officers and crew had some ‘normal ways of doing things’ : not exactly ‘standard procedures’ for example written up in a formal document say and adhered to by all parties.  What it and its parent company certainly did not have was a ‘safety culture’ that mandated safe practices aboard its ships.   The direct comparison here is with the air transportation industry that has a very strong, very overt and very visible culture of safety almost throughout that entire industry.

Two simple examples immediately come to mind : reporting of safety concerns and the use of checks (checklists) and pauses during pre-flight procedures and while airborne.  Any reader here who has flown will have probably at some point been entertained by the cute hosties doing their arm waving stuff during the pre-flight safety instructions and some may have even heard this (next) over the cabin loudspeakers :

Arm doors and cross check”

Several years ago when i was just getting into patient safety seriously and seeing what i could learn from the aerospace industry i actually made it my concern to find out what was meant by that expression.  What that command refers to is the arming of the doors such that they can be opened in an emergency and that the slides (like liferafts) will then deploy. The command is given usually by the first officer as part of that stage of the pre-flight and usually at the point where the aircraft is being pushed back from its stand.   Notable is that the command is merely one read out from a checklist and that the action is completed and checked by the cabin crew and that the same cabin crew report back that it has been done.   Just imagine now that the Herald Of Free Enterprise had routinely had a checklist procedure during which the skipper or another watch officer HAD to order the closing of the doors and HAD to wait until the bo’sun reported back that the doors were closed.  Later on in this series i will be talking about rank/authority and task loading in safety procedures and commenting on who is best to hold the key responsibility for critical procedures : hint….its not always the driver.

The management.

In the full report of the disaster the factors that i have briefly covered and which appear in the documentary are fully explained, thus the human errors, the shore side problems at Zeebrugge, the technical aspects of loading the ship and so forth.   What the full report then goes on to comment on are the many and serious failures in the management of the company for example that the management were not listening to genuine concerns raised by their most qualified staff ie their ships masters.  Several masters for example stated that their ships had sailed several times over-weight and with far more passengers than the ships were designed for.

“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
Kirby to issue and enforce clear orders. But 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 of 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 organised 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. This became particularly apparent from the evidence
of Mr A. P. Young, who was the Operations Director and Mr. W. J. Ayers, who was
Technical Director. As will become apparent from later passages in this Report, the Court
was singularly unimpressed by both these gentlemen. The failure on the part of the shore
management to give proper and clear directions was a contributory cause of the disaster.

Earlier in the same report the managements attitude of speed and expediency over-riding safe operating procedures is well summed-up in this memo from the then operations manager.

““There seems to be a general tendency of satisfaction if the ship has
sailed two or three minutes early. Where, a full load is present, then
every effort has to be made to sail the ship 15 minutes earlier . . . . .
I expect to read from now onwards, especially where FE8 is
concerned, that the ship left 15 minutes early . . . . . put pressure on
the first officer if you don’t think he is moving fast enough. Have
your load ready when the vessel is in and marshal1 your staff and
machines to work efficiently. Let’s put the record straight, sailing late
out of Zeebrugge isn’t on. It’s 15 minutes early for us.”

And further :
Mr. A. P. Young sought to explain away that memorandum 

Looking at this years after the event and yes with an anti-management hindsight bias it does seem that the real failures weren’t just the human error of for example the bo’sun’s mate  being asleep when he should have been at his station or that the first officer had rushed back to the bridge before checking that the bow doors were shut.  Rather it is that there is a deeper cause here that can only be laid at the feet of the management in that :

1.The management did not listen to its ships masters.

2.The management totally failed to give clear instructions and direction for critical safety procedures.

3.The management was clearly only interested and concerned to maximise efficiency and thus profit.

Thoughts and conclusions.

I want to finish this difficult post by offering some personal insights into this tragic event that i will take forward into the next post.  In this series i am trying to draw out the major themes and common features of accidents and incidents using incidents at sea but ultimately trying to show why these themes re-occur in other places.  In this event what i want to point out is the ‘system culture’ of the ferry’s working practices and that of its parent company.  What the ferry and its sisterships seems to have had is standard or ‘normal’ ways of doing things, for example that each person on board knew what their jobs were and usually did them.  The example is an interesting comment about the Herald’s bosun who was criticized by the judge for his attitude at the hearing ie that “shutting the doors had never been his job”.  I don’t know what his duties were during harbour stations but the impression i get is that he, just like everyone else, was in a rush to get to his station and do his job.     This isn’t actually an uncommon thing ie that in a lot of system ‘cultures’ that this is quite a normal way of working in fact when a system works at high cost efficiency and under time pressure that this is exactly what will happen…each person is on a mission to get ‘their’ tasks done and not to be seen as slacking.   In a future post i will describe how the exact same feature appears again and again in another large system ie the NHS and why then things also go wrong.  My final thought to leave you with along these lines is one taken from the field of clinical/patient safety and is this “that a system that tries or is forced to be maximally efficient it cannot also be maximally safe….something has to give and with management pressures its almost always safety that suffers”

In the next post : risk 3 i am going to pull a whole load of separate threads together and demonstrate how those very same things still apply in large organisations today and how the very same management forces also created a disaster in another large organisation ie the NHS.

 

https://www.gov.uk/maib-reports/flooding-and-subsequent-capsize-of-ro-ro-passenger-ferry-herald-of-free-enterprise-off-the-port-of-zeebrugge-belgium-with-loss-of-193-lives

https://assets.publishing.service.gov.uk/media/54c1704ce5274a15b6000025/FormalInvestigation_HeraldofFreeEnterprise-MSA1894.pdf

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