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Capsizing of Herald Free Enterprise (People (individual factors) (Captain…
Capsizing of Herald Free Enterprise
People (individual factors)
Captain was trying to speed things up to make up for lost time when loading cars
Lack of attention from crew of the bow doors being left open
Captain expectation that crew had the doors closed
Crew were stress from trying to get all cars on deck
The crew were fatigue
Workplaces
Workplace Environment
Freezing cold temperature
Calm conditions
Poor visibility due to night conditions
Equipment Design
Captain could not see if the bow door were closed or not
No warning system to alert the bridge
No indicator or displays that bows door were left open
Feedback was poor
Workplace Factors
Harbour loading deck didn't reach upper car deck
ship sat low in water
Ballast tank had very little capacity
Technology on the ship was limited which meant no indicators or displays to show that bow door were open or closed
Management
Organisational system factors
Captain complacency
Commercial pressure
Increase speed when leaving the harbour
LTA crew procedures
LTA emergency procedures
Previous issue of bow door been left open of Townsend Thoresen ship were ignored
Job design
Supervision of crew was poor
Heavy workloads
Roles of crew weren't clear
Crew relied on people to do their job and wouldn't follow up to see if it had been done
Information Transfer
Faulty communication equipment
Lack of communication between crew