Capsize of MS Herald of Free Enterprise (Management (Job design…
Capsize of MS Herald of Free Enterprise
Captain Lewry's did not know for certain that the bow doors were closed (DoT 1987).
No equipment in place to identify whether the doors were closed
Stanley fell asleep after 18 hour working
Stanley Failed to notify his supervisor of his condition for someone to take over his responsibilities (DoT 1987)
Fatigue Risk Management tool (Lerman & et al. 2012)
First officer Sabel was pressured to make it to his habor station quickly so he failed to stay around long enough to witness stanley arrive or the bow doors close (DoT 1987)
There were no procedures in place in the form of physical or electronic check-lists to make sure every factor if completed before departing (Mosier, Palmer & Degani 1992)
No Fatigue Management System
Requests for maintenance or updating of equipment were dismissed by management (DoT 1987).
Lack of Safety Culture
Poor Communication between on board management and on-shore (DoT 1987).
Conflicting orders from management
officers- 12 hours on, 24 off
Shift Work roster design tool (Sier, et al. 2004)
crew - 24 hours on, 48 off.
Shift Work roster design tool (Sier, et al. 2004).
High demand due to dismissal if ferry was late departing or arriving (Dot 1987)
Kessler Psychological Distree Scale tool (Burgess, Slade, Grove 2011)
NASA Task Load Index tool (Hart, S 2006)
The other Bosun, witnessed the ferry departing without the bow doors being closed but failed to notify anyone
No Indicator Light in the Bridge for position of bow doors
Design allows ferry to operator when bow doors are open
Common practise to leave door open while leaving to let vehicle fumes out
Bow doors are located underneath bridge so impossible to view the position of the doors
Draught marks difficult to read
Poor design of ballast tank
Calm whether and ocean
The Zeebrugge linkspan was not designed for Spirit class vessles like HFE (DoT 1987)