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Herald of Free Enterprise - Coggle Diagram
Herald of Free Enterprise
People
Attention
All crew failed to realise Mark Stanley was missing from the lower deck near the bow doors, and was alseep in his cabin
CREAM
Sky Brary, 2012
Stress or fatigue
Mark Stanley was asleep due to fatigue from his current 18 hours he had worked that day
Workers were working harder as they had more cars and people to load compared to a regular day. Had fallen behind due to these conditions
Pressure to complete tasks in given time frame
Time Base Analysis
Kirwan, B & Ainsworth, LK 1992
Expectations
Captain Lewry should not have left the port without confirmation that the bow doors were closed, with confirmation coming from a worker at the bow doors
Captain should have confirmed with Mark that the doors were closed before disembarking
Competency
Mark Stanley failed to imform any crew or the captain that he was going to his cabin
I Mark had of told the captain, another crew member would have been assigned and the disaster could have likely been avoided
MORT
Safety Corner,2010
Workplace
site design
poor ballast design
slow release time for the ballasts to become empty
feedback
Lack of feedback from the system to alert of doors being open or closed
No feed back to show crew members whereabouts- if they have a key notification system
warning system
Lack of indicators on the bridge or in the captains station to alert faults or incorrect position of items for voyage e.g indicator to show bow doors down when they should be up for the voyage
Indicators of sandbank below
Warnings or signals in the occurrence of the ship tilting
visibility
Lack of visibility from the captains station to the bow doors for visual confirmation
Management
Leadership
Staff level management
staff are required to conduct more than one task area e.g- cleaning, loading, in charge of the doors, etc
Lack of worry or acknowledgement of the tilting of the ships
SCAT
ISRS, 2020
procedures
No known fatigue management plan
Lack of system management of way to sail the ship and rulings in regards to the bow doors
Hierarchical task analysis
Science Direct, 2006
workload
Had pressure on crew to complete tasks in the assigned time to ensure cash flow and good business reputation
long working days
Workload Analysis Tool
BAW Architecture, 2020
communication
Lack of communication between crew members as well as with the Captain
insections
No staff members double checked to ensure Mark completed the job with the doors