describe seven contributing condition and state what kind of latent failures for each of the condition

herald of free enterprise

list 10 factors according to reason 1990 that caused the accident of herald of free enterprise ferry
essay

the most significant factor that lead to the accident of Herald of free Enterprise Ferry was the
top-heavy design roll- on roll off car ferries, with their large open decks, which were
imminently unstable and unsafe. The outer and inter doors where left open and badly
constructed bow doors was the main reason as to why the Herald of Free Enterprise capsized.
If small amount if water enters open desk area will cause the ship to capsize quick even in a
gentle swell. It was therefore a combination of human errors ie management, design and
individual that combined resulted in the loss of 188 lives. The following highlight reason that
cause the accident of Herald of Free Enterprise Ferry:

1. Ship’s Design: In the case of the Herald of Free Enterprise, the master should have
confirmed with the person in charge that the bow doors were closed. The design of the
ship made it difficult for the master to see if the bow doors were open or close.
Therefore, in both cases the bow doors were the cause of the accident. However, in
the case if MS Estonia the wreck showed that the locks on the bow door had failed
and that it had separated from the rest of the vessel. In the official report it indicated
that the bow visor and ramp had been torn off at some point that would have caused it
to open or unlatched. The direct cause of the accident was the failure of locks on the
bow visor, that broke under the strain of the waves. The construction of the bow door
was not good.
2. Lack of Communication is also a main factor for this cause. The lack of
communication between the master and officer in charge of the stations to verify the
status of the doors, everything was based on the assumptions to which should have
not been the case for an effective working environment. There are no definite report
system as to confirm the closure of the doors and it was all based on assumption.
3. Exhaustion of personnel : The Herald of free enterprise assistant officer , who was
directly responsible for closing the doors, was asleep in his cabin, having just been
discharged from maintenance and cleaning duties, as no record of rest hours of
personnel were being monitored and did not hear the station signal being called out.
4. Responsibility of Officers, the chief officer, responsible for ensuring door closure,
testified that he thought he saw the assistant close the door. Towards the last moments
 of loading the chief officer took over from the second officer at the loading deck and
later proceeded to the bridge not confirming the doors were shut . The chief officer
showed lack of expertise in ensuring the safety of the vessel again assuming that all
was in order .The second officer being at stations did not realise that he was short of a
person and it was not reported to the master. The chief officer was also required to be
on the bridge 15 minutes before sailing time.
5. Stability the chief officer sailed the ship three feet down at the bow which made the
bow doors more close to the waterline and thus easily vulnerable. The loading ramp at
Zeebrugge was too short to reach the upper car deck. To clear the gap, the captain put
sea water into the ballast tanks to lower the ship, but forgot to release the water
afterwards. There was one more factor: when a ship sails, the movement under it
creates low pressure, which sucks the bow downwards. In deep water the effect is
small and in shallow water it is greater, because as the water passes underhull, it
moves faster dragging the bow down more. This reduced the clearance betwen the
bow doors and water line to 1.5 metres. Although the bow doors were open and they
were 1.5 metres above the water.
6. Overload of work as the cargo duties were shared between two officers , managing
time and work pressure had taken a toll on them . Fatigue must have set into them and
duties were misunderstood as to who was responsible for being at the loading deck to
check the loading was completed and all was in order.
7. Standing Instructions : 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 There was no written instructions about the
responsibility of closure of the doors and duties were not properly understood , this
being the reason for the bosun after seeing the bow doors open assumed that the
closing of the doors was the responsibility of the able seaman.
8. Pre-Departure Checklist : There was no brief checklist verifying the closure of the
bow doors ,if there was one in place , this wouldn’t have gone unnoticed .
9. Pressure to leave the berth : Due to the commercial pressure and the vessel was to sail
immediately , the chief officer had to go to the bridge without confirming the doors
were shut and the vessel was ready to sail , assuming the task would be carried out .
10. Bridge and Navigational Procedures, the conflict in duty reflects the poor thought by
the management ashore. These procedures laid down by the company was not
transparent and had doubt in its guidelines as to whether, the master was to be on the
 bridge 15 minutes prior to departure. As the chief officer or second officer was in
charge of loading at the final stage and then report to bridge was impractical as he
couldn’t be at two places at the same time.
11. Indicator Lights there was no information demonstrating that there was any warning
light to advise the captain that the doors where properly shut. Research search advise
that two years earlier, the captain of a similar vessel similar vessel owned by the same
company to install warning light to indicate any safety issue to the vessel as a similar
incident occurred and the company management treated the request with contempt.
12. Company Management did not accept its responsibility for safe management of the
vessel. The management failed to give precise orders for safety of the ships. The
expert was to assume that if no flaws have been reported that the vessel was ready in
all respects to proceed to sea and leave the berth in the absence of any reports done. .
This was a very hazardous assumption which lead to this disaster.