Herald of Free Enterprise
By: John Kirk, Mercy Flight Central
Ships and Planes and Managers who don’t know!
Have you ever wondered if a pilot in command can learn safety lessons from a ship's captain? The answer is unreservedly yes because the similarities between the two professions are remarkable. Both are in command. Both are ultimately responsible for the safety of their vessel, their crew, and to their passengers. And strangely enough in many cases they are working for people who are not experts in their profession. One of the requirements of a Safety Management System (SMS) is to define an accountable executive, he who controls the purse strings. How many pilots are working for pilots? For that matter, how many sea captains are working for sea captains? In both cases not many.
The historical lesson we can take from previous accidents in either field, whether in the air or on the sea, cannot be more clearly highlighted than by a study of the Herald of Free Enterprise Disaster. This was a roll-on roll-off ferry that capsized on 6 March 1987 causing the deaths of some 188
Figure 1 Herald of Free Enterprise http://www.mirror.co.uk/news/uk-news/zeebrugge-disaster-25-years-on-752501
persons because it left port with the bow doors open. This was, as are many transportation accidents, a human error accident. The report into this accident (UK Department of Transport MV Herald of Free Enterprise Report of Court No. 8074, MV Herald of Free Enterprise) said, “At first sight the faults which led to this disaster with the aforesaid errors of omission on part of the master, the chief officer, and the assistant boatswain…" (Report paragraph 14.1) As usual, this is not the whole picture. Somewhat controversial for the time, the report's authors created somewhat of a precedent of adding the cause, "Failure of Management", to the list of causes. The most damning piece of the report is, "…all concerned in management, from the members of the board of directors down to the junior superintendents, were guilty of fault in that all must be regarded as sharing responsibility for the failure of management. From top to bottom the body corporate was infected with the disease of sloppiness."
To best illustrate this failure of management the report examined in detail the consideration that had been given, at the request of the sea captains, to fitting an indicator system to show whether the bow doors were open or closed. The captain's concerns were repeatedly documented and yet rejected for the reasons of costs or even trivial, sarcastic, and frankly incredible statements such as, “do not we pay somebody to close the doors?" Another management failure was the lack of clear orders for the crews and their officers. In short, nobody was actually ordered to close the doors. There was evidence that on many occasions the ships had been overloaded, that they sailed incorrectly ballasted and therefore unstable, and that these shortcomings had been drawn to the attention of management on many occasions by the captains.
So who were these captains working for? The report states, "… those charged with the management of the company's fleet were not qualified to deal with many nautical matters and were unwilling to listen to their masters, who were well qualified." Does this sound familiar to many a pilot? How many pilots work for management qualified to deal with aviation matters? Are not many aviation companies run by those with degrees in business, or accountancy, or almost anything except aviation? Surely this must lead to the same frustrations the ferry captains must have felt at the lack of action on serious concerns and other safety issues they had raised with management?
So is there a possible way to solve the issue of specialists working for layman? This whole story of the Herald of Free Enterprise was actually a pivotal point in the history of safety management. The introduction of safety management systems to the transportation industry in particular has many attractive features. Perhaps the most important has already been mentioned; the identification of the accountable executive. This defines, perhaps for the first time, the desk upon which Harry S Truman's sign, “the Buck Stops Here,” must sit. Part of the measure of a safety culture is the attitudes and commitment of management toward safety; having committed to adopting SMS that attitude is by design subject to change.
So if we are truly to learn from this tragedy management must listen to those who are experts in their appropriate field, react to hazards identified by their experts, and prove that they really are committed to safety by their actions not by their words. Pilots can learn from this too, for they are in the best position to find hazards both in the air and on the ground. They only have themselves to blame if they do not report these hazards.
So has your organization recently adopted SMS? Have you had your Herald of Free Enterprise moment? Have you noticed your management responding more positively to your concerns than before?