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Mv Herald of Free Enterprise: Report of Court No. 8074. Formal Investigation (Merchant Shipping Act 1894 Formal Investigations Department of Transport)

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Publisher: Bernan Press
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DESCRIPTION:

Binding: Paperback
EAN: 9780115508288
ISBN: 0115508287
Label: Bernan Press
Manufacturer: Bernan Press
Number Of Items: 1
Number Of Pages: 75
Publication Date: 1987-09
Publisher: Bernan Press
Studio: Bernan Press


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Customer Rating:
Summary: Focus On Ro-Ro Hydrostatics And Human Factors
Comment: Her Majesty's Stationery Office published this, the official accident report covering the loss of the "Herald of Free Enterprise," an investigation presided over by the Honorable Mr. Justice Sheen, Wreck Commissioner. It is informative, comprehensive, and full of safety lessons applicable to all industries, but particularly to Roll on-Roll off (Ro-Ro) and other slab-sided oceangoing vessels.

The "Herald of Free Enterprise" capsized on March 6, 1987 shortly after departure from the port of Zeebrugge. The proximal cause of the casualty was departing with the large bow doors open to the ocean due to the facts that the Assistant Bosun had overslept and had failed to close them, and the Captain set sail without verifying the doors were closed. The doors of this type of ferry are not visible from the bridge, and no indicator lights were installed on the bridge to verify position of the doors. These lights had been requested by many Captains, but the owners refused to fund this modification.

Ultimately the board of inquiry made numerous important findings both related to the accident specifically, as well as other systemic problems in the Ro-Ro industry. The report contains a thorough analysis of hydrostatic and nautical dynamic issues (such as limiting KGf and GZ curves, stability in varying seas [a huge issue in Ro-Ros], the effects of trim [the "Herald" had to be trimmed by the head by perhaps 1m in Zeebrugge to facilitate loading of vehicles on both decks] on the metacentric height of the vessel, etc.) as well as Human Factors issues such as unclear duty definitions, awkward crew rotations, inattention of management to the concerns of Captains, etc. Most of these Human factors lessons transfer easily to other industries.

The board's approach is interesting to contrast with similar NTSB investigations in the US. In this case the board made many valid recommendations (though unlike in the US, they are distributed throughout the report) such as "There is clearly a need for a good standardised industry approach to escape windows. These should be reliable and uncomplicated and openable from either side." The board also incorporates lessons learned and recommendations from other ferry casualties such as the loss of the "European Gateway" and the "Wahine." Many of these are very specific findings of interest only to naval architects ("There should be a requirement in the PSC&S Regulations for standard KGf envelope curves, at least for level keel and trims by the stern and by the head of, say 0.4% and 0.8% of the length of the ship."), but many recommendations are prudent for any serious student of system safety in any industry, the best illustration of which is found on page 58:

This Court need say no more than stress the need for:

(a) Clear and concise orders.

(b) Strict discipline.

(c) Attention at all times to all matters affecting the safety of the ship and those on board. There must be no "cutting of corners."

(d) The maintenance of proper channels of communication between ship and shore for the receipt and dissemination of information.

(e) A clear and firm management and command structure.

The board found many managerial shortcomings and deep roots in this accident. The report is an eminently readable and important safety document, and I highly recommend it to safety professionals and students in any industry.

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