Please enable JavaScript.
Coggle requires JavaScript to display documents.
Herald of Free Enterprise Disaster - Coggle Diagram
Herald of Free Enterprise Disaster
PEOPLE
Fatigue
Mark Stanley failed to notify his chief officer or the captain of his tired state and inability to continue working without rest
Investigation tool - Antecedents, Behaviour and Consequences Analysis
All of the ships sailors were working large hours under time constraints
Investigation tool - Workload Analysis Tool
Age
Age was not a factor in this incident
Health
Health was not a factor in this incident
Culture
TT had a poor safety culture and proritised trip times and company profit
Investigation tool - Safety Through Organisational Learning
A previous incident had occured with the bow door months prior and the company (TT) failed to learn from this NM
Investigation tool - Safety Through Organisational Learning
Harbour Master see leaving the doors open as normal practise and chooses not to notify captain Lewry
Investigation tool - Incident Cause and Analysis Method
the crew only preformed tasks which were assigned to them and did not assist with other jobs that needed to be completed
Investigation tool - Safety Through Organisational Learning
Goals
Goals were not a factor in this incident
Bodysize
Body size was not a factor in this incident
Attention
None of the crew paid attention to the state of Mark Stanley or if he was in fact at his post completing his role
Overloading of work was viewed as the norm and apart of the job role
Investigation tool - Management Oversight and Risk Tree
leslie sable failed to realise that Mark Stanley had not left his cabin and was therefore not at his post
Investigation tool - Procedural Event Analysis Tool
The captain did not know that the speed he had set for travel in the open ocean would produce a bow wave that would rise above the bow spade and be capable of even putting pressure on a closed bow door.
Investigation tool - Incident Cause and Analysis Method
The crew on G deck failed to notice that the assistant Bosun did not return to close the bow doors after his regular rest period
Investigation tool - Procedural Event Analysis Tool
Strength
Strength was not a factor in this incident
Expectations
Captain Lewry expected that Mark Stanley would have completed his job and shut the doors and at very least Leslie Sable would have carried out his checks with the Bosuns and alerted him to the fact that the bow doors were open
Investigation tool - Procedural Event Analysis Tool
Leslie Sable expected that Mark Stanley would have been at his post and carried out his duties and closed the bow doors
Investigation tool - Incident Cause and Analysis Method
The bosun saw that the bow doors were open but did not close them as it was not apart of his job, he also didnt alert the others of them being open
Investigation tool - Incident Cause and Analysis Method
The second officer failed to alert the Captain when the bow wave raised above the bow spade
Investigation tool - Procedural Event Analysis Tool
Stress
Workers onboard were under a lot of stress to ensure that trips were on time and the sheduale met. This meant long work hours and short breaks - stress from fatigue
Investigation tool - Workload Analysis Tool
Knowledge
Captain David Lewry failed to verify with Leslie sable that the bow doors were shut Before he left Port. Leslie Sable failed to verify this with Mark Stanley. The captain knew that the bow doors being open would present a major risk to the boat in the open ocean despite the ballast tanks being full and the ships speed.
Investigation tool - Procedural Event Analysis Tool
WORKPLACES
Employment design
Interface
The ships interface does not appear to have played a role in the causation of this incident
Feedback
Feedback did not appear to play a role in the causation of this incident
Controls
there were no controls fitted to the vessel that would allow the bow door to be closed from the ships control room
Knowing this and the lowered position of the ship in the water due to the ballast pump inadequacies and the requirements of the berth at Zeeburrgge. TT management, Captain Lewry and his crew should have understood the risks for operation and factored this into procedures. The bow door being shut prior to entering open water would have comprised a major part of this. As such pre sail checks and confirmation of such behaviors should have taken place. This made up part of captain lewrys responsibilities as well as Leslie Sables
Investigation tool - Procedural Event Analysis Tool
Displays
Captain Lewry did not have a bow door indicator on the ship to inform him if it was shut or open
Knowing this and the lowered position of the ship in the water due to the ballast pump inadequacies and the requirements of the berth at Zeeburrgge. TT management, Captain Lewry and his crew should have understood the risks for operation and factored this into procedures. The bow door being shut prior to entering open water would have comprised a major part of this. As such pre sail checks and confirmation of such behaviors should have taken place. This made up part of captain lewrys responsibilities as well as Leslie Sables
Investigation tool - Procedural Event Analysis Tool
Warning Systems
There was no warninig system fitted to annouce that the bow doors were still open when the ships speed was increased
Knowing this and the lowered position of the ship in the water due to the ballast pump inadequacies and the requirements of the berth at Zeeburrgge. TT management, Captain Lewry and his crew should have understood the risks for operation and factored this into procedures. The bow door being shut prior to entering open water would have comprised a major part of this. As such pre sail checks and confirmation of such behaviors should have taken place. This made up part of captain lewrys responsibilities as well as Leslie Sables
Investigation tool - Procedural Event Analysis Tool
There was no warning system fitted on the ship to announce the ingress of water into the ships hull or bulkheads
Knowing this and the lowered position of the ship in the water due to the ballast pump inadequacies and the requirements of the berth at Zeeburrgge. TT management, Captain Lewry and his crew should have understood the risks for operation and factored this into procedures. The bow door being shut prior to entering open water would have comprised a major part of this. As such pre sail checks and confirmation of such behaviors should have taken place. This made up part of captain lewrys responsibilities as well as Leslie Sables
Investigation tool - Procedural Event Analysis Tool
Ease of Use
Ease of use did not appear to play a role in the causation of this incident
Equipment
The ballast pumps were poorly designed for the task in which they had to preform
The parent company TT was aware of the pump issue due to a letter from the captain and engineers expressing concern over the pumps lack of efficeiency - which in turn meant that captain lewry knew the importance of the bow doors being shut due to the boats nose down position in the water. Yet this did not form part of any procedure to manage the risk as it stood, until an engineering solution was offered and fitted
Failure by management, captain and crew to recognise risk and plan for it within actions and procedures
Investigation tool - Management Oversight and Risk Tree
Work Environment
Lighting
Lighting was not a factor in the causation of this incident
It should be noted that it was nightitme when the incident occured and this may have contributed to poor visability after the fact
Temperature
Temperature was not a factor in the causation of this incidet
Vibration
Vibration was not a factor in the causation of this incident
Chemical exposure
Chemical exposure was not a factor in the causation of this incident
Noise
Noise was not a factor in the causation of this incident
Workplace Design
Workstatation configuration
There were no indicators in the ships control room to inform the captain or crew that the bow doors were open
Knowing this and the lowered position of the ship in the water due to the ballast pump inadequacies and the requirements of the berth at Zeeburrgge. TT management, Captain Lewry and his crew should have understood the risks for operation and factored this into procedures. The bow door being shut prior to entering open water would have comprised a major part of this. As such pre sail checks and confirmation of such behaviors should have taken place. This made up part of captain lewrys responsibilities as well as Leslie Sables
Investigation tool - Procedural Event Analysis Tool
Accessibility
Accessibility did not appear to play a role in the causation of this incident
Facility Layout
The layout of the ship did not allow captain Lewry direct line of sight with the bow door
Knowing this and the lowered position of the ship in the water due to the ballast pump inadequacies and the requirements of the berth at Zeeburrgge. TT management, Captain Lewry and his crew should have understood the risks for operation and factored this into procedures. The bow door being shut prior to entering open water would have comprised a major part of this. As such pre sail checks and confirmation of such behaviors should have taken place. This made up part of captain lewrys responsibilities as well as Leslie Sables
Investigation tool - Procedural Event Analysis Tool
The bulkheads in the ship were not sealed and allowed water into the belly of the ship. If these had of been sealed then the water would have simply retured to the ocean
This may have been able to be looked at as part of the pumping system failure. As this would have arrived at the conclusion that the ship would be sitting much lower in the water and thus the bow wave be higher, putting pressure on the bow door and its seal. As part of planning for a door failure sealed bulheads would have allowed the ship to stay upright and lessened the risk portfolio for the company
Investigation tool - Incident Cause and Analysis Method
The berth a Zeeburgge was dangerously low and required the HFE to take on much more ballast than was desirable even within the port setting. This also meant that the ship would not finish emptying its load of ballast until near the end of it crossing. leaving it to travel nose down due to the inadequacies of the ballast pumps.
The parent company TT was aware of the pump issue due to a letter from the captain and engineers expressing concern over the pumps lack of efficeiency - which in turn meant that captain lewry knew the importance of the bow doors being shut due to the boats nose down position in the water. Yet this did not form part of any procedure to manage the risk as it stood, until an engineering solution was offered and fitted.
Failure by management, captain and crew to recognise risk and plan for it within actions and procedures
Investigation tool - Management Oversight and Risk Tree
There were no engineering controls designed in to the ship to prevent the free movement of water should water ingress occur. this meant that the water was able to freely shift and overcome the ships balance
This may have been able to be looked at as part of the pumping system failure. As this would have arrived at the conclusion that the ship would be sitting much lower in the water and thus the bow wave be higher, putting pressure on the bow door and its seal. As part of planning for a door failure sealed bulheads would have allowed the ship to stay upright and lessened the risk portfolio for the company
Investigation tool - Incident Cause and Analysis Method
MANAGEMENT
Job Design
Workload
Mark stanley had already done an 18hr shift when he fell asleep the work shedule was very demanding of the ships crew
Investigation tool - Workload Analysis Tool
The workload for the crew was excessive and relentless between ports - need to work large shifts
Investigation tool - Workload Analysis Tool
All crew members had a substancial workload when entering and exiting port - Mark Stanley and Leslie Sable - factors contributing to fatigue and overlooking task duties
Investigation tool - Workload Analysis Tool
Management failed to adequalty maintain staffing levels appropriate to the needs of the ship and the task that were required to safely sail and maintain it. thus maintaining crew fatigue
Investigation tool - Management Oversight and Risk Tree
Officers felt pressured to leave the berth immediatly after the completion of loading and this may have led to the chief officer not waiting on G deck to see that the bow doors were closed prior to being called to quarter
Investigation tool - Management Oversight and Risk Tree
Task Design
The job of closing the bow door was not given enough criticality in the process of leaving port
Investigation tool - Management Oversight and Risk Tree
No pre departure check practises in place because the time restrictions varied from port to port and meant that they could not be strictly adopted and were there for practised on the fly in no real structured way.
Investigation tool - Management Oversight and Risk Tree
Work Shedule
Mark stanley had already done an 18hr shift when he fell asleep the work shedule was very demanding of the ships crew
Investigation tool - Workload Analysis Tool
The work shedule for the ship and its crew was poorly planned to accomodate the real demands of the port sailing shedule
Investigation tool - Management Oversight and Risk Tree
The chief officer was required to be on the bridge 15mins prior to sailing. this placed pressure on leslie Sable due to his other duties and may have contributed to him not noticing Mark Stanley missing or checking on the doors being shut
Investigation tool - Workload Analysis Tool
Commercial pressure to leave the berth as fast as possible due to high demand for docking activities in the areas in which the ferry frequented by other ships etc
Investigation tool - Management Oversight and Risk Tree
Job requirements
The demands of the Job were excessive hours and physical work - it would seem that the crew were always making up a back log of work
Investigation tool - Management Oversight and Risk Tree
Information Transfer
Instructions
Instructions were hard for the ships crew to systematically preform due to the lucid nature of their docking and loading times. They were often short cut or completed as needs be. this meant there was never the adoption of a systematic process on board the HFE
Systematic processes are of benifit when completing tasks in which humans are the last line of defence. It allows for a greater degree of success and a lessening of failure.
Knowing the risk factors associated with not following systems and procedures audit should have been completed by TT to see this shortcoming and correct it. Likewise Captain Lewry and his first officers should have realised the risk involved if certain jobs were missed or done incorrectly and adopted system checks that could ensure that critical elements such as the bow door closure were monitored for quality/completion
Investigation tool -Antecedents, Behaviour and Consequences Analysis
Labels
there was no label present in the ships control room that reminded the crew of the importance of shutting the bow door.
Investigation tool - Safety Through Organisational Learning
Communications
Communications and working practises broke down on the ship due to the complacent actions of the captain and his leaders. There was a high assumption that all parties would complete there working tasks and no checking or supervision was provided. thus the communication broke down as well.
Investigation tool - Incident Cause and Analysis Method
There was no system of communication that was ratified and practised on the HFE prior to or after its arrival from port. Communication could seen to be sporatic at best
Investigation tool - Systematic Cause Analysis Technique
Pressure communicated to captain and crew to maintain good travel figures and thus generate profit for the company through completing more trips during a business year
Investigation tool - Workload Analysis Tool
The communication system used to call the sailors to their harbor stations can be said to be ineffective as it did not rally Mark Stanley from his slumber and into his duties
Investigation tool - Systematic Cause Analysis Technique
The Bosun failed to communicate with other members of the crew and inform them of the bow door being open.
Investigation tool - Task Description Tool
Signs
There were no sign in the control,room that detailed the need to close the ships boor door prior to entering the ocean, this was just expected. However a sign or label my have been able to jog the memory of the bridge crew
Investigation tool - Safety Through Organisational Learning
Systems Organisational Management
Policies
Fatigue management policies were either not in place or not enforced with the crew of the HFE
If a fatigue management policy was in place (no evidence to suggest there was) then it was of an inadequate nature
Investigation tool - Systematic Cause Analysis Technique
Management decisions
Management knew of the fault with the ballast pumps but failed to act on this information
This resulted in the ship travelling in a nose down position and subsequently meant that the ship was able to fill with water in approx 4 mins.
Investigation tool - Incident Cause and Analysis Method
Management knew of the unrealitic work pressures placed on the captain and the crew but failed to act
Investigation tool - Management Oversight and Risk Tree
Organisation of Work
inadequacies present in the organisation of work - no one in the position to check the system (that people have done their duty) as a result key steps to readying the ship to leave the port were missed - bow door left open
Investigation tool - Incident Cause and Analysis Method
Pressures to load and unload the vessel as fast as possible placed on workers by management
Likely to cause errors and fatigue
Investigation tool - Incident Cause and Analysis Method
Cheif mate and the second officer did not follow the same operation pattern when performing cargo duties
Investigation tool - Incident Cause and Analysis Method