Daniel S. Parrott - Bridge Resource Management for Small Ships: The Watchkeepers Manual for Limited-Tonnage Vessels

Bridge Resource Management for Small Ships

The salvage operation in full swing after the Herald of Free Enterprise rolled on its side and sank. (Scaldis)

The Watchkeepers Manual for Limited-Tonnage Vessels

Captain Daniel S. Parrott

Copyright 2011 by Daniel S. Parrott. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

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To mariners everywhere who must balance the expectations of the shore against the demands of the sea

ON MARCH 6, 1987, the modern cross-channel ferry Herald of Free Enterprise left its berth at Zeebrugge, Belgium, for the routine 70-mile run across the North Sea to Dover, England. There is, perhaps, no maritime endeavor more prosaic than that of a ferry. Four minutes after passing through the jetties, the Herald rolled over and sank with the loss of 188 lives.

The Herald of Free Enterprise sank because no one was aware its enormous bow doors had been left open, allowing the North Sea to wash in. Because of the tide that day, the bow had been ballasted down to facilitate loading, and the Herald remained trimmed by the head at departure. The assistant boatswain, whose job it was to close the bow doors, had fallen asleep in his bunk during the loading and did not awaken when called to get underway. His immediate supervisor, the boatswain, had been working near the bow doors prior to sailing and noticed that they were open and that nobody was standing by the controls, but he proceeded to his own station without giving it any more thought. He explained later, It has never been part of my duties to close the doors or make sure anybody is there to close the doors.

The salvage operation in full swing after the Herald of Free Enterprise rolled on its side and sank. (Scaldis)

Written operational procedures stated that it was the duty of the loading officer to ensure the doors were secure when leaving port. This was not what usually took place, however. In practice, loading officers frequently left the area once they saw the assistant boatswain standing by the door controls. This enabled loading officers to get to their sailing stations so the ferry could sail on time. Sometimes the loading officer was the second officer (second mate); sometimes it was the first officer (chief or first mate). On this occasion it had been both. The first officer started the loading but the second officer relieved him early in the process. A little while later the first officer took over again without explanation. Subsequent interviews with both men suggested that on this particular day there was some tension between the two officers. When the first officer resumed the loading there was no clear transfer of responsibility; the two men did not meet face to face. The second officer heard the first officer giving loading orders over the radio and concluded that the job had been taken away. When the loading was finished, the first officer headed for the bridge as required, but there was still no one at the door controls. The second officer, who by this time had left the scene, said later, He took over as loading officer so I assumed he took the responsibilities that go with that job.

The first officer told investigators that he thought he had seen a man approaching the bow door controls but was then distracted. Whoever he thought he saw, it was not the assistant boatswain because the assistant boatswain was still asleep in his bunk, and there was no exchange with this other person related to getting the doors closed. It seems more likely that, in his haste, the first officer didnt notice, period.