To their great surprise there was not any technical defect of the ferry. The main cause of this tragic accident was that the bow doors of the ship had been left open and the bosun, who has the duty to check it, had just slept.It was held a maritime inquiry. According to New York Times (1987) Lord Justice Sir Barry Sheen produced the report in the case of this accident, in which he stated: "Townsend Car Ferries, Ltd. are at fault at all levels, from the board of directors down to the junior superintendents. From top to bottom, the body corporate was affected with the disease of sloppiness".It is generally known that in most cases a prime contributor to accidents happening in various spheres of our life is human error. According to Wreathall & Reason (1992) sometime ago, "evaluations of accidents in terms of human contributions have most often focused on the immediate proximate human actions that were the final steps in the chain".Nowadays everyone realizes that such handling is not able to take into consideration all factors and to define all causes accounting for accidents. Therefore in order to make proper analysis of a particular case and to minimize the human contribution to accidents, one should investigate all the human factor elements that precede and influence these final actions. So we may say that a prime cause of most accidents is mixture of human and organizational failures combined with the imperfection and weakness of the existing management system.
Let us consider the case of M/S Herald of Free Enterprise, which is a "roll-on roll-off RORO) car passenger ferry that sank on March 7, 1987, killing 193 passengers, owing to negligence by the crew and company operating the ship" ("Herald of Free Enterprise", December 2006). First of all let us define what went wrong in both operational procedures and implementation, and monitoring of the ship's staff, leading to the accident.
As we know most of accidents happen due to combination of a number of various causes. Let us set the factors lead to the above-mentioned accidents in table represented in the Casualty Analysis Methodology for Maritime Operations (1999).
Table 1: Grouping and sequencing of main events of the HFE disaster
Vessel was overloaded
Inadequate control of passenger number and cargo intake.
Time pressure d/n allow adequate control
Pressure to leave port early
Delay at last port (Dover).
Vessel entered this service at short notice
Bow door not closed by Assist. bosun
Assistant Bosun at sleep.
Just relieved from cleaning and maintenance duties
Bosun did not take action
Did notice that door was still open.
D/N see it as his duty to call Ass. Bosun, to close door, or notice the bridge
No indication of open door on the bridge
Requested by vessel more than once.
Not granted by management.
Chief Officer D/N ensure that door was closed
Unable to check by himself; had to be on bridge 15 min before sailing. D/N seek confirmation from deck. Company standing order to accept "negative" reporting
Master did not ensure that door was closed
D/N seek positive confirmation
Did not complete ballasting
Considerable mismatch between deck and ramp. High tide. Required considerable time to ballast.
Leaves port still trimmed nose down
High water spring tide. Considerable