Good Example Of Report On Herald Of Free Enterprise
1. Summary of various forms of loss, which did occur as well as were likely to have occurred as a result of the event.
Every organization aims to avoid generating a loss; whether it is financial loss, work-related injuries or fatalities, damage to the company image, or actions that negatively impact the environment. In the report on Herald of Free Enterprise where the ship capsized after a little less than 30 minutes from sailing from Number 12 berth at Zeebrugge, Belgium, the various forms of loss that were sustained (and could have been sustained) from the accident are summarized below:
Financial loss, since the accident destroyed the ship, as well as everything contained aboard; and the company has to pay for medical and hospitalization expenses of the injured, death benefits for those who died, as well as any damage to the environment (water pollution, specifically).
Loss of lives of the people onboard;
Loss of good image of the company;
Loss of confidence from the public who knew of the accident
Loss of business license to continue operating without first addressing intensified adherence to safety and health standards.
The accident could be effectively evaluated using the ILCI Loss Causation Model where different sequences that ensued prior to the accident and loss were explicitly proposed to be undertaken, such as: lack of management control, basic causes, immediate causes, accident, and loss. Under the loss component, the following provided an in-depth analysis accordingly:
People: physical and mental injuries, as well as fatalities of passengers or staff.
Property: the ship, per se; including all equipment listed as assets of the company.
Product: the service of ferrying passengers and vehicles.
Legal: legal expenses sustained from passengers who filed complaints, as well as
penalties that the company has to pay for damages sustained from the accident.
Material: the belongings of the passenger which were disclosed in their manifesto of
travel; the movable items that were owned by the company onboard.
Public: loss of confidence to contract services of the Herald
2. Brief description of the loss-producing event with focus on “Accident/Near hit”
The ILCI Loss Causation Model effectively traces the events that transpired prior to the accident, using the above-mentioned phases. In this particular requirement, the accident/near hit phase is briefly described according to the report. The immediate cause of the disaster was presented as number 8 of the report and disclosed the accident to have happened due Herald’s travelling in the sea with the inner and outer bow doors irresponsibly left open. All other factors could be deemed contributory to the accident. These factors were identified in number 6 of the report which reported the condition of the Herald, the rapid acceleration of the ship which was expounded in number 7 as maneuvering that led to the capsize, and management’s inability to design appropriate controls.
Leaving the inner and outer bow doors open was the primary culprit for the accident. Other factors: overloading, unclear policies on authorized person to open and close the bow and stern doors, acceleration to maximum speed, and lack of monitoring contributed to the accident.
3. An interpretation of an immediate/direct cause of the event.
4. The five of the most likely basic/underlying causes for the above immediate or direct cause.
There had been identified personnel whose failure to undertake their responsibilities, or who misunderstood policies, contributed to the failure of closing the bow doors.
In the report, the assistant bosun, Mr. Stanley, admitted that it was his duty to close the bow doors but failed to do so because he went to sleep.
The person who assumed Mr.Stanley’s duty, Mr.Ayling, the bosun, did not acknowledge that it was his duty to close the bow doors.
The loading officer, Mr. Sabel, who should have ensured that the bow doors were closed prior to travelling failed to do so because he knew that it was the assistant bosun’s duty to close the bow doors.
There was no one assigned to check, monitor, or even ensure that the bow doors were indeed closed prior to travelling.
There was reported pressure the leave the berth after completion of the loading process which left no one to see or check that the bow doors were closed prior to travelling.
The report disclosed that policies and procedures were unclear, and sometimes conflicting; especially with regards to the duty of closing the bow doors, as well as monitoring to ensure that the task was undertaken accordingly.
There was a general instruction reportedly issued on July 1984 which stipulated that it was the duty of the loading officer for the main deck to ensure that the bow doors were closed prior to leaving the port. This instruction was reported to be unclear and therefore, not enforced.
The interpretation was that the loading officer should merely see that someone was at the controls to close the bow doors.
There were conflicts in duties that created confusion in prioritization of work; especially with the pressure to leave the berth, presented as number 9 of the report where the Officer on Watch was also the loading officer; thus, the order to be on the Bridge 15 minutes before departure time conflicts his alleged duties.
The procedure on ‘ready for sea’ was reported to be designed in an unsatisfactory manner that contributed to laxity in ensuring safety and adherence to standards.
Incidences of previous failure to close the bow doors while travelling were not at all communicated to the Masters; as such, no corrections in policies were made.
There were practices reported that manifested Herald’s management and staff to disregard compliance with adherence to loading capacities, as dictated by their Class II Passenger Certificate.
The vehicles that were loaded were revealed to be underestimated as to their actual way-bill weights.
The structural design of the ship was not strictly adhered to and resulted to it being built heavier that stipulations in original designs.
There were overestimates in the reported accumulated weights of stores, paints, and other growth items which were noted to be onboard.
The passengers that were onboard totaled 459 which were noted to exceed stipulated levels.
The recording system for the official log of the ship was not duly or accurately undertaken.
There were identified proposed equipment to be purchased or those that need to be improved to ensure that the capsizing would be prevented.
There were recommendations to install indicator lights to be fitted on the bridge to see whether the bow doors were open or close; but these were not followed.
There were recommendations to purchase high capacity ballast pump so that removal of water from the ballasts would be efficient and effective; but this was not followed.
The ship should have conceptualized the need to upgrade the bow doors to automatically close when loading is completed.
The ship should have some warning systems to indicate whether the doors are still open.
Instruments for reading draughts should be provided to ensure that crucial information are disseminated and appropriately addressed,
There are factors in the internal and external environment which could be deemed contributory to the capsizing.
The time of departure was 18:05 or 7:05 p.m. which was already nighttime; and the weather was reported to be relatively good. As such, the captain could be overly compliant that nothing adverse could happen.
The rapid acceleration of speed to maximum seemed to indicate that the captain wanted to reach the destination at the earliest possible time.
The tides could be high and could have rapid waves that also contributed to water seeping in the open doors.
The area must have been very familiar to the captain and the staff that no intensified efforts were exerted to ensure vigilance.
The trip could be one among many during the day which contributed to the staff being tired and wanting immediately to go to sleep.
The effect is as follows: travelling in open seas, during nighttime, at accelerated speed, contributed to water rushing in the bow doors which were irresponsibly left open and led to the capsizing of the Herald.
“Top Five Risk Factors”
A brief risk analysis of the factors that increased the propensities for leaving the bow doors open and eventually leading to the water seeping in the open doors and sinking the ship are as follows:
Failure to pinpoint the actual person who should close the bow doors.
Confusion on the authority and responsibility of closing the bow doors due to the unclear policies.
The lack of controls to monitor actual weight and overload capacities.
The lack of proper equipment to assist in determining whether the bow doors are still left open.
The over compliance that nothing adverse would happen given the short distance and the good weather condition.
5. The primary management error, which most likely corresponds to each of your perceived basic/underlying causes.
A. Inadequate management activity
There paramount lapse in management’s performance of expected duties is in performance management and designing of control measures. At the onset, there was lack of organizational structure that defines roles and responsibilities, as well as delineate tasks that should be undertaken by each personnel. There was predominance of unclearly structured policies, instructions, and procedures which were merely ignored and not followed. No sanctions for violations on following orders were also designed. From the scenario, the simple closing of the bow doors was assumed to be performed by the assistant bosun. His immediate supervisor, the bosun, who assumed his task when he was relieved; failed to ensure that closing the door which is a very important task is undertaken by him. Likewise, the loading officer failed to visibly check that the doors were closed prior to going to the deck and prior to departure. The captain failed to ask the chief officer whether all standards have been secured and checked, especially closing the bow doors.
B. Inadequate internal standards
There were virtually no risk assessment or risk management in place to
determine risk factors and hazards at Herald. Moreover, the confusion in understanding policies and procedures, as well as the inability to address weaknesses noted in official correspondences, contribute to failure to design control measures that would address and mitigate risks. For instance, in closing the bow doors, the internal standards should include: delegation of duties to an authorized person with proper accountabilities and sanctions for non-performance. Likewise, proper checking and monitoring should be designed to ensure that in no instance should the bow doors be left open prior to travelling. Therefore, management and engineering controls should have been developed (counterchecking visually, automatic door closing mechanism, installation of indicator lights).
C. Inadequate compliance with established internal standards
The proof that there were inadequate compliance was the fact that the bow doors were irresponsibly left open prior to travelling with no one from Herald being warned or made aware that it actually happened. Likewise, the fact that there was no system of rewards or punishments to promote or sanction personnel, based on compliance or non-compliance to policies and procedures, attest to inadequacy in compliance to internal standards.
6. Ways to correct the above identified primary management errors.
A complete overhaul of the management system at Herald and the company should be undertaken from job organization to performance management and control. The proposed ways to correct the management errors are as follows:
Undertake a risk analysis and assessment to identify risks and to design strategies to mitigate these risks.
Review the current policies and procedures and update these by restructuring the instructions that are confusing and that gives conflicts to duties.
The policies and procedures should include a code of discipline to guide management and personnel in proper conduct and behavior; as well as provide opportunities for promotion and sanctions for violations of policies.
Create an organizational structure, including job description for each position to explicitly define basic responsibilities and qualifications needed.
Assign a safety manager to address safety and health concerns, including policies and standards, as proposed by health agencies and regulators for the industry. The safety manager also assumes responsibilities for performance evaluation and continued monitoring for compliance with internal standards.
Assign a personnel manager or human resources manager to take care of communicating all policies and procedures, as well as designing maintenance and development strategies for the continued professional growth of management and staff.
7. Reaction to the exercise including perspective towards accident causation.
The paper was instrumental in advancing one’s knowledge on investigating the root cause of an accident, as well as the contributory factors that led to various losses. The ILCI Loss Causation Model was most helpful in determining how inadequate management control could lead to actions that emerged as basic and immediate causes of an accident. The sequence of events that were learned from the model assists in appreciating investigating the cause of an accident; and therefore, propose measures for improvement.
Through the unfortunate capsizing experience of Herald of Free Enterprise, one learned that a simple remiss in closing the bow door, which could be prevented, caused the significant loss for the company and to all people who were onboard at that time. The various losses that were identified could have ultimately been prevented through collaborative placement of policies, in conjunction with effective application of management theories. The exercise was a learning experience that provided insights which emphasized that accidents could have been easily prevented if effective management controls and risk assessment were undertaken, as required. As students, these lessons should be applied in diverse endeavors to prevent various forms of losses, injuries and even fatalities that could happen anywhere.
Please remember that this paper is open-access and other students can use it too.
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