REYES EARL JETHRO DC MANAGEMENT 2

3C ALPHA MT CAPT. CRISTOBAL, PAULINO

HERALD OF FREE ENTERPRISE

Introduction

This tragic accident is of particular importance as it was the main reason for the creation
of the ISM Code (International Safety Management). The capsize of the Herald of Free
Enterprise revealed the negligence of the ship's crew and the serious responsibility of the ship's
operator's management for the accident. Therefore, this accident clearly shows that a sound
safety management process is necessary for safe operation.

On March 6, 1987, at 18:05 (GMT), the roll-on/roll-off passenger and freight ferry
Herald of Free Enterprise ("Herald") departed from Berth 12 in the inner harbor of Zeebrugge,
Belgium. The Herald had 459 passengers, 80 crew, 81 cars, 47 trucks and 3 other vehicles. The
weather was nice.

Gerardo she passed the outer breakwater at 18:24 and capsized about four minutes later.
The ferry suddenly struck her starboard and ran aground on her port side in shallow water just
before capsizing. The ferry landed sideways with her starboard side out of the water. The
submerged section of her ferry quickly filled with water. The accident resulted in a tragic
accident that killed 191 passengers and crew. The Herald capsized only about seven cables
(about 1.3 km) from the harbor entrance.

Analysis

The immediate cause of this accident was the failure to close the bow door to load the
vehicle prior to departure. As a result, the activities of the crew in charge of Baudor were
investigated.
 Normally the assistant skipper was responsible for closing the forward door before
sailing, but in this case he did not. He reportedly went to his cabin to rest after the ferry arrived
in Zeebrugge and went to sleep. The announcement to call the crew to the departure station
apparently did not wake him up, and he slept until the ship began to capsize. This leads us to the
next question.

Why did no one notice that the boatswain did not report his departure from the station?
Moreover, despite the possibility of human error, the important task of closing the bow doors
was not carried out. Why wasn't there a procedure to confirm that the flight was completed? Why
wasn't there a foolproof system to prevent this important step from being overlooked prior to
departure?

Investigations have revealed that this is not the first time such incidents have occurred on
similar vessels operated by the Company. In October 1983, Pride's Auxiliary Boatwain
apparently fell asleep and did not hear the call to the departure station. As a result, the ferry left
Dover with its bow and stern doors open.

A company order of July 1984 stated that it was the responsibility of the officer in charge
of the main wagon deck (G deck) to check the safety of the forward doors before departure.
However, we have found that this policy is regularly overlooked.

The bosun was the last crew member to exit the deck where the bow door was located.
He worked near the door, but no one in the area tried to close it. When asked why he had not
closed the door, Boatsun explained that it was not his duty, nor his duty, to see who was on deck
to close the door. They were at the station, carrying out their respective duties.

The second officer went out on deck to save the first officer who was loading cargo. He
met with the chief mate, but did not receive a proper handover from the chief mate. After
spending some time on G deck, the chief officer entrusted the second officer to supervise the
loading operation. About 10 or 15 minutes before the scheduled departure time, a problem
occurred on the G deck and the chief officer returned. The second officer, hearing the chief
officer giving instructions to the crew, assumed that the chief officer had taken over loading of
the cargo. Therefore, the second officer headed for the stern of the ferry, the starting point,
without telling the first officer how to close the bow door.

At a critical time, the chief mate had to go to the station of departure and was clearly
under pressure to go to the bridge. The chief officer confirmed that the boatswain had arrived on
Deck G. However, the chief officer did not confirm that the bow door was closed.

It is clear that there have been many instances of negligence that directly or indirectly
contributed to this tragedy. However, court proceedings concluded that the chief officer's
negligence in ensuring that the forward door was securely closed was the primary direct cause.
 It took three minutes to close the front door. Why didn't the officer in charge of the line
stay on deck G to close the door before continuing to his duty post? It was reported that the
Herald officers were still pressured to leave as soon as they were empty. On the Herald, crew
members are usually ordered to the departure station before all cargo is loaded.

The deck and navigation procedures issued by the Herald operating company include the
following statement:

"Operating Officer (OOW)/Captain must be on deck no later than 15 minutes prior to departure."

When OOW is responsible for loading, this 15-minute requirement is not suitable for
loading duties. In previous years, captains of similar ships have reported this problem.

The Herald operator said the crash could have been avoided had the first officer stayed on
deck G for three more minutes. While this is true, the company did not provide appropriate
measures to allow the first officer to remain on the G deck until the forward doors were closed.

The captain saw the first officer arriving at the bridge before departing. However, the
captain did not ask the mate if all preparations for departure were complete. Furthermore, the
first officer did not report anything to the captain.

Prior to this accident, ferries operated by this company had left the port with the front or
back doors open at least five times. Some of these incidents were reported to management but
not to the captains of other ferries.

The court investigation revealed that there were fundamental and serious flaws in the
company that ran the Herald. The managers and employees of this company were not aware of
their responsibility for the safe management of their ships. In fact, no one involved in
management, from managers to junior supervisors, has a sense of responsibility in managing
their own ships.

Meetings between senior staff and senior captains took place from time to time. Several
complaints and requests, such as those listed below, were raised at these meetings.

As previously noted, ferries operated by this company have departed multiple times with
the front and/or back doors open. In 1985, a captain made the following request to the company:

“The most important thing is that the doors are watertight, i.e. the front and back doors. No
indicator is displayed when these doors are open or closed. The canal is narrow with a
breakwater on one side and the open sea on the other. There can be problems if vessel operations
are delayed or if there are problems with the closures… The overview board (indicator) is useful
to allow the jetty crew to confirm the condition of the doors.
Recommendations

The Court has submitted multiple recommendations in the following three categories.
This section includes some of those recommendations.

1. Short-term action

a) Boat safety:

Install door indicators and video link showing doors; wharf renovation;

b) Load and stability:

Set draft, weigh cargo, make bill of weight;

c) Rescue means:

Take action on problems (not enough lights, difficult to put on life jackets, not enough exits and
difficult to use these routes), install emergency lights, provide life jackets, plan preliminary
methods canopy for 'emergency'.

2. Medium-term action

Provides information on stability (leakage stability angle), KG curve limit setting, responsibility
for stowage stability leak angle.

3. Long-term action

Ship design, calculation of stability when ship is damaged, survival at sea, sinking, air ducts,
vehicle deck drainage system.

Lessons From This Accident

This accident was one of the main reasons for the establishment of the ISM code in 1993.
In 1994, the code became mandatory due to the addition of Chapter IX to the SOLAS annex. The
Code was enacted in 1998. This section lists the lessons learned from this accident in relation to
the following three causes and cases of negligence and in relation to the ISM Code.
<ISM Code 7> Development of plans for shipboard operations (Summary)

“The company should establish procedures, plans and instructions, including checklists as
appropriate, for key shipboard operations. The various tasks should be defined and assigned to
qualified personnel.”

Companies operating ships are required to prepare manuals for key shipboard operations,
but simply preparing these manuals does not fulfill this obligation. Actions are needed to ensure
that the crew members of this ship follow these procedures. Implementing these actions is a
major role of companies operating ships and of ship’s crew (their captains). Numerous measures
are required to ensure that proper procedures are used, such as management reviews, internal
audits and shipboard meetings.

<ISM Code 3> Company responsibilities and authority

“3.2 The company should define and document the responsibility, authority and interrelation of
all personnel who manage, perform and verify work relating to and affecting safety and pollution
prevention.”

This provision is the basis of the ISM code and differs from the previous approach to
responsibilities and authority. The ownership and management of ships requires a constant
awareness by managers of the obligation to fulfill these responsibilities.

<ISM Code 9> Reports and analysis of non-conformities, accidents and hazardous occurrences

“The Safety Management System should include procedures ensuring that non-conformities,
accidents and hazardous situations are reported to the company, investigated and analyzed.”

Companies operating ships are required to establish procedures for responding to