Why Did She Roll Over?
HTML-код
- Опубликовано: 13 сен 2024
- In this video, we ask what happened to the Herald of Free Enterprise.
✩SUPPORTED BY PLUS MEMBERS✩
/ casualnavigation
Thank You to all Plus members on Patreon. Your support helps keep these videos freely accessible to everyone across social media.
✩WITH THANKS✩
➼ Images used under license from shutterstock.com
Cars - Golden Sikorka / Shutterstock.com
Cars - ideyweb / Shutterstock.com
➼ Audio used under license from Epidemic Sound
Ruiqi Zhao / I Am Back / www.epidemicsound.com
Ruiqi Zhao / No More Sadness / www.epidemicsound.com
Victor Lundberg / The Call of the Wild / www.epidemicsound.com
Kikoru / Classical Smooth / www.epidemicsound.com
Jakob Ahlbom / Fracture / www.epidemicsound.com
Synthetic Tides / In Ruins / www.epidemicsound.com
✩DISCLAIMER✩
All content on this channel is provided for entertainment purposes only. Although every effort has been made to ensure the content is accurate and up to date, it remains the responsibility of the viewer to determine its accuracy and validity. The content should never be used to substitute professional advice or education.
This approach is wild
"Are the bow doors closed?"
"Well, they *should* be"
"Good enough"
It’s even worse.
“No one has told me the doors are closed so they’re probably closed. I’d check myself but then I’d get into trouble”
The policy was literally assume it's good if you didn't check. Like wtf
@@dasboots3272 My mid-grade sedan has audible and visual warnings for any of the four doors, trunk or hood (bonnet for some of y'all) being even slightly ajar.
If a person in my car does not have their seat belt fastened, there is a visual and audible alert.
If I try to leave my car and the key is in the ignition? Audible alert.
If I try to leave my car with the key in my hand and the markers or headlights are on? Audible alert.
-
Not having something at least equivalent on that ship when such systems were likely in place on every car it carried is unconscionable.
the 70s and 80s was a pretty wild time
@@MonkeyJedi99 feedback loops are so common sense thats the first thing I would expect for such safety critical system to have some mechanical pole / flag n the front or a door closed indicator. I mean there was also one catastrophic event in some nuclear plant when they assumed that actuator command = actuator state but it is not. With todays standards I would guess there would be even some supervisory system that wouldnt even let you to go into full speed if there is failure of doors state detection.
Safety regulations are often written in blood
And if they aren't then somebody was extra lucky.
Welcome to aviation
And even then there will always be people who think that if you understand why a rule exists, it doesn't apply to you.
In the military, you find out pretty much every rule is written in blood, though sometimes those rules were because of morons.
Yes, you're right, I have seen management stupidity in action, filling out reports but not checking what the report is written about was done by employees who just checked all the right box's saying no problem.
Both are at fault, I filled out a forklift report stating the brake on the left side was not working
Many times I wrote this before I ask management why is this not fixed, their ingenious answer was I was the only one to complain about it.
I showed them it was not working they said it's ok use it ,I took the keys hided then and but a out of service tag on it.
The next day, someone was there to fix the wheel cylinder.
Men not knowing or don't care is the killer from bottom to top.
A nice example of fail-deadly design and procedures. If something fails, the "default" outcome is unsafe.
Not really. As is stated in the video they had left the doors open without issue multiple times before. It was the confluence of events that made things fail in a catastrophic way. It seems these were poor designs and even worse procedures, but this wasn't exactly what I'd call the default outcome.
@@bobshowrocks The ship sailing with its doors open is unsafe. Just because it managed to do this and not sink doesn't change that.
@@bobshowrocks L + ratio
I am glad that you correctly placed the blame correctly on the management. Its is almost always management who create the environment where these accidents can occur and yet they rarely if ever get the blame for causing it
The management edict that "the master will assume .... the ship is ready to sail" , pretty much reduces his effective title to merely a title .
When the master of a vessel is superceded in his role of supervising its safety , by those sitting in an office on dry land , tragedy is sure to follow . This being an example of that , another being the Ocean Ranger ( an oil rig yes , but still a vessel with a master aboard ) both cases resulting in loss of life.
as the saying goes "to "assume" it to make an ass out of you and me!"
Very true, and something that was addressed specifically in the ISM Code, where the Captain's responsibility is clearly laid out and wording is included to the effect that nothing in a company's safety management system shall ever relieve the captain of that authority / responsibility.
Safety rules are universal. In the paper mill I work in, the rule is "don't interfere with production". Then act shocked and confused when someone is hurt or killed.
Hope you can find a better job. I wonder if there's some way to report them to OSHA (or the equivalent, if you're not from the US)
im genuinely astounded that CasNav doesnt have more subs. He is so descriptive and detailed, without sounding like a boring lecture. He is amazing and comprehensive. Keep ti up man!!
600k is a lot for a niche subject appealing to a niche demographic.
He got me when his video on how anchors work. Niche but very cool
Subs aren't used in commercial shipping. Only military.
REAL
@@ssl3546 exactly
I say it so often in my job: complacency kills. There can be forgiveness for not knowing that something is dangerous, but if you know better and you do the unsafe practice anyway, it's tantamount to murder.
Im really glad you went into more of the details beyond just the three causal factors behind the accident. My opinion made a complete 360 after hearing the management policy which was "if you don't receive any reports, assume you're fine"
Yeah, that was a chilling thing to hear.
I'm working in aviation (maintenance) Our rule is never to assume, always check. "If you assume, you make an ass out of u and me".
Thats the literal foundation of Murphy's Law!
When building or maintaining a plane, assume that anything that can go wrong, will.
If a single screw is loose at 17,000 feet, people will die and millions of dollars of machinery will be destroyed. God forbid its a military plane loaded with bombs.... or a passenger jet with hundreds of people on board.
There is no such thing as compromising safety in a vehicle; Anything that sacrifices safety or comfort, is intentional harm caused.
Aviation also has learnt all the lessons the hard way over the years.
Aviation truly brings out the most strictest of methods to ensure safety.
A doctor can only kill one patient at a time,a nurse could wipe out her entire floors' worth of in care patients,a bus driver can end their double decker or flexible bus worth of commuters,a train driver is a bus but MOAR.
One would logically think that ships with thousands of potential victims would be deadly duty of the captain,but that brings in the second aspect.
Humans can walk,and humans can swim.
So it just takes one pilot,one maitenance engineer,or one air traffic controller to cause one little single seater ultralight to smash cockpit first into a fully loaded A380 and send it on a collision course with several parked A380s as the worst case,and anything not involving the surface is not where flightless humans should be.
The iron safety of aviation is extracted from the blood of the damned,what few incidents that continue to occur can be unsparingly lethal,and this is why aviation is made to be the safest.
I love the safety culture in aviation.
The push goes deeper than just "be careful and don't assume." People have to perform their jobs, or...they don't have the job. One thing exposed in the Great Boeing Saga is that employees were pushed to work at paces that didn't permit checking everything. It became normal to cut corners and defer work.
On the other hand, commercial airliners get checked regularly, including the pilot doing a quick inspection before each flight. The two pilots not only do their own jobs, but also check each other. For example, one will say to retract landing gear. The other pilot pulls the lever and replies landing gear retracted. It's not done until both pilots acknowledge.
This built-in redundancy is something I try to do in non-aviation safety-critical work.
Part of the safety requires pushing to find underlying causes, as Casual Navigation presented here. It's insufficient to blame "pilot (or assistant bosun) error." Why was he asleep? And why didn't others notice? Was this part of a larger pattern? And why, as someone else commented, was the system designed to fail to an unsafe state?
@@NareshSinghOctagon It's not surprising that aerospace has the strictest safety standards. If something goes wrong while flying your plane, you don't have the option to pull over, get out, and pop open the hood to try to fix it. Also, jumping out hoping for rescue later is an option aboard cars and ships. But it usually has a higher fatality rate than just staying in the plane.
This was also an important step in British case law.
Corporations are legally a person so, in theory, are also criminally capable of things like murder. Murder/Manslaughter requires mens rea and actus rea, the mental state and the act. The question is whether the corporation or human individuals involved are the ones with these criminal elements. i.e. Are individual managers the criminals or is the company the criminal?
The case surrounding this incident (which didn't actually result in anything) was the first time corporate manslaughter was recognised by UK courts and eventually lead to the UK enacting legislation that more clearly outlines Corporate Homicide and Manslaughter.
So who gets punished if the corporation is found guilty? In the case of a lawsuit, it's pretty straightforward (the company pays damages), but I'd like to know how this situation would be handled. I've also heard that US case law has made provision for "piercing the corporate veil" and holding certain individuals accountable for certain situations, but I don't know the ins-and-outs of it.
@@jeffbenton6183 Well, that's still the hard part that isn't really known yet (no good examples in cases). Sentencing for humans is a mix of punishment, removal from society/societal safety, rehabilitation, and deterrence. Realistically, corporate punishment is more likely to stem from other legislation. On the off chance a company is found guilty of a crime that would be a life sentence for a human, I would imagine punishment would involve crippling financial punishment or forced closure of the company (ceasing its existence as a legal entity)... Also, I expect humans involved in such a case would also see prison.
@@MindlessWanderings Thanks for that detailed response; I just saw it right now.
That is certainly the difficulty with case law; we'd like to have a statute to spell these things out. Of course, lawmakers often don't realize there's a problem, and judges are stuck doing the best they can with what direction they have.
As mariners under guidance, first years, we went out to smoke one night and came back making a little noise, one accidentally walked into the stop sign. Our floor was visited the next night by the reg commander and we were made to run back and forth to our rooms and quickly change uniforms. We vouldnt change fast enough so they made us write a paper about how the herald of free enterprise sank so fast, there was barely enough time to get on immersion suits.
Surprised Hanft didn't waterboard you all instead 😂
@@somebonehead 2022
@@srb_guy3487 2021. Nobody was hiring so I commissioned in the Navy.
What a crazy idea it is to assume everything is fine and ready just because it is a specific time. The door open light with sensors and stuff would be a few grand at the most and could have saved lives and ship.
The bus company I worked for had impossible running times. In contrast, we had a system that monitored driving to discourage harsh braking, steering and acceleration. Obviously the two weren't compatible, however I was invariably late as I refused to rush, but consequently there wasn't time to check the vehicle as percscribed and no time to use the toilet. Tardiness isn't appreciated by passengers waiting at the stops and the next driver waiting to take over. After seven and a half years of this I'd had enough. I wouldn't mind betting that such things contributed to the sinking of this ferry, basically not enough time to do the job properly!
Similar to the fire service I worked with, asking us to use less fuel under operation conditions...
@@slarratt please explain further...
I feel you're throwing a lot of shade at Dover with the state of the dockside building. I mean you're not _wrong_ but I feel there's a story here.
Well, I also spotted that- curiosity is killing me now...
@@eight-double-three The Kent coast has a lot of very pretty and pleasant places to spend time. Dover's not really one of those.
I live in Dover. Its a shithole. The video is honestly being kind.
@@loading9110I was just happy to see Deal on a map
@@AllMappedOut86 And that it left Folkestone off.
I remember this happening and wondered at the time how a captain would be so stupid to set sail without confirming something so basic as "are the loading doors closed?" before heading out. Thanks for doing an in-depth review.
It's sad hearing about the accident but I always love hearing stories of how new regulatory bodies get formed to prevent loss of life
This tragedy is one of my earliest memories. I was 8, and I guess it was all over the telly. For some reason it's stuck with me ever since.
It's because "The Harald of Free Enterprise" is such an memorable name
"Herald of Free Enterprise" is such a fitting name for a ship that didn't have enough safety regulations and overworked the crew
my thoughts exactly.
Yeah, talk about "Nomen est omen"
Unfortunately it is near-impossible to have a crew on board of a ship (at least a dry cargo ship - profit margins are paper-thin) that is not overworked. The easiest way to achieve this would be to hire 30-50% more crewmembers but that would put most smaller shipping companies in the red. A more realistic way is to sign shorter contracts for crew members outside the top-4: 4 months instead of the industry standard of 6-7 (in practice often extending to 8-9) months. FYI everybody works a 7-day, 60+ (80+ for some positions) hour workweek on a ship.
@@VileGecko sounds like the simplest solution to that is to require overtime pay. anyone who says they have to work a short staff overtime, because they can't afford to hire enough people to work them proper shifts, is fudging numbers somewhere.
Really “Omen of Free Enterprise” would have been more accurate
6:58 Who wrote that insanity?
"If nobidy tells you the ship is on fire, ignore the black smoke from the bow."
Simple. Management wanted maximum throughput. Safety measures slow down operations and damage productivity.
Profits before lives.
Well you see, independent confirmation of safety costs time, and means shipments arrive an hour later than schedule, and falling behind one hour means paying employees an extra $9 each! Theres like, almost 200 people on board, do you think I just have $1800 laying around on this ship carrying $5m in cargo that costs $150m to build?
@@Nazuiko This is compared to the gamble of loosing the ship and cargo.
@@christopherg2347 ,something which has never really stopped grubby money makers before,nor ever will.
Thank you for peeling through to the underlying conditions leading to these tragedies!
Love the way you dig below the obvious factors and draw out industry-wide lessons.
It would be interesting to get the take of an airline professional on how their safety culture compared with that of seafaring in 1987…
The airline industry has long had far more rigorous safety standards than the shipping industry. Are there holes in both? Sure. The far greater clear and present danger of falling out of the sky versus bobbing in the water is a greater driver of air safety. Also, if the plane isn't safe, the pilots are usually the first to die 😂 so they are extra diligent.
There's actually a channel called mentour pilot, that gives pretty neat descriptive information about airline safety anfld regulations. You'll like the channel
@@atulaprabhu Oh I do! I'd love to hear from Petter how the safety cultures compare. Great shout.
feels insane that a boat can somehow go full ahead with bow doors open AND ballast dipping the front... these days you can't even start a car without belting up! how can a ship meant to carry 1,400 not have better failsafes from the get go?
Because free enterprise of course. Can't have annoying regulations restrict the glorious free market. I'd never get on a ship with a name like that jfc.
Upper management trying to cut costs, that's how.
Because this was in 1987. Just like with cars safety regulations have improved.
Remember when they first introduced seatbelts and people actually complained about it?
@@XMysticHerox As a business owner, I can tell you right away. If these ferries were mine, the first thing I would do would be install video cameras looking at all the key points. And the car door is definitely a key point. Monitors and cameras cost pennies compared to the potential damage. Then I would install an indicator that the locks on the doors and the like are locked. There are many other things that can be done to ensure safety.
I have not had a single employee injured in 12 years of my work. I work with industrial equipment, heat presses, cutters and the like.
I wrnt on all the Spirit class, including a trip from Zeebrugge in a storm where just about everyone was seasick except the crew and me,since I had the restaurant to myself (I'm immune to seasickness, a useless attribute for a complete landlubber). Anyway, it was pretty normal for them to open the bow doors well before port. There was a really lax attitude to safety. P&O re-liveried the ferries shortly after the accident, as the brand was toxic.
Told us doors were open "to vent the car fumes". We couldn't really believe it was safe.
If someone names their ship; 'Herald of Free Enterprise', you just KNOW they are going to cut corners on safety and overwork their staff.
If someone names their RUclips account LittleNala you just KNOW that it's some lying big-ass Nala!
Spoken like a true leftist
@@TamCloncey The facts have a very strong left-wing bias.
@@TamCloncey If being a "leftist" means opposing the abuse of workers for the pursuit of profits, then call me the leftiest man alive.
@Lucius_Chiaraviglio Nah, the facts are facts, the left has a very strong "fact" bias, while the right prefers their "alternative facts".
The accident also led to massive changes in emergency and supplementary lighting regs aboard vessel as during the rescue and escape attempts, most people who became trapped had no way to find a way out as it was complete darkness.
Every passenger going ship had to have a minimum amount of lux to cover all escape routs and for those to have a minimum illuminated period of 3hrs, its something that we would check on our ferries every year during there annual docking and a few of the vessels that were built in the early 90s really went overboard with it but it was due to not wanting to have to little,
I was on the sister ship several times around the time as a passenger. They routinely started off and closed the doors as they sailed off, this was not done accidently, it was cutting corners. I did not read a report, I watched it as as a 15 year old lad...!!!
I’m impressed you got the through the whole film without mentioning booze. People who worked on the boats at the time told me the drinking culture of TT and Channel ferries in general took a long time to manage out of the industry.
1:09 Someone has an opinion of Dover methinks
The company instruction that the master should assume the state of the ship based on scheduled time alone says a lot about how that company operated.
The master will assume that at the due sailing time, the vessel is ready for departure in all respects - that has got to be the most ridiculous policy I have ever heard. That policy alone killed those people…
The phrase might not mean "close eyes and scream YOLO as you cast off." It could be read to mean the master is responsible that the vessel is ready.
@@j_taylor yeah I don’t fall out with that however, the actual wording of that policy was terrible, to use the word ‘assume’ in any policy that relates to passenger safety is ludicrous
Once again management being cheap bastards led to disaster. Crazy how that keeps happening.
Right? Had to pause the video to get my BP down. A ship costing millions, and they skimp on light bulbs, wire and a bunch of switches. This is unbearably dumb!
@@datenraffzahn6094 Welcome to capitalism. The only thing that ever matters is making our shares go up! That means cut costs wherever possible and make everyone do twice as much work as they're physically able.
@@datenraffzahn6094 I've witnessed similarly stupid, but less tragic, stuff - like management skimping on calibration procedures for extremely expensive machines processing extremely very products that require precision. Unsurprisingly quality suffered, the wrong conclusions were drawn, people lost jobs (don't worry, there were other factories desperately in need of good engineers).
I used to be into cryptozoology - the Yeti, the Loch Ness monster, competent managers - I tried to find them all. I gave up on most of them. I'm still on the fence with Nessie though. 😝
This type of decision process is common across all management structures. I work in tech, and in the 80's we were short the number of technicians to wire a complex chip packaging machine. Instead of hiring more techs, they sent us engineers over to do the work at 3x the tech salary. On top of that, there was only one pair of $2 wire cutters there, so all six engineers and eight technicians had to work one at a time as we passed around the single wire cutters.
It's a very hard thing to argue or budget, in a lot of ways. If there have been no issues, arguing that preventative maintenance is needed means that money needs to be spent to no visible effect. Which means that no one can point to numbers of disasters averted or whatever - it's a very abstract expense. And on the other hand obviously the ship doesn't need to be kept in absolutely pristine condition to work, so it is possible to spend to much on maintenance. So it's a widespread issue, as the question is always 'do we spend money now to prevent the *possibility* of an issue in the future?'. As long as the issue never happens, it's hard to say that the money needed to be spent.
This video is a true tour-de-force and shows it's creator as being several steps above mere mortal men. The mental discipline in talking about an accident with a ro-ro ship for 9 minutes and not even once referring to it as Roll-on/Roll-over is absolutely mind-blowing.
As somebody who was working within the ferry industry at the time and lost Relatives and freinds that awful night this is very thought prevoking and what happened changed the ferry industry overnight for the good i feel
So short sighted not having something in the bridge to tell them if the doors are open
I’m curious how so many people died so close to port
Probably things like being trapped underwater below deck, getting crushed by shifting cargo, or being on the starboard side and falling badly.
@@bluesbest1I looked it up and seems like it was during winter so unfortunately the cold water got most of them : (
It was at night in March so darkness and sea temperatures would be a factor.
Early March in the North Sea. Water temp would have been barely above zero. It was also extremely difficult for rescuers, once they arrived, to enter the ship.
Rooms and passageways are designed to be navigated when the ship is upright. If you tip it over on tis side, rooms become inescapable pits, and doorways become holes into those pits that you need to somehow jump over. Now add to that navigating lengthy and unfamiliar passageways, in the dark when power fails. Finally, the fact that the ship is filling up with water means that even if water entering your room allows you to escape the pit, you how need to swim a considerable length of (sideways) hallway to try to find another way out. In the dark, in cold water, which is rising and threatening to drown you.
Blows my mind the person that opened the door isn't responsible for closing it.
Two things that strike me about this, and rail accident reports that I'm more familiar with:
The causes of so many accidents are blindingly obvious in hindsight.
We only learn by mistakes.
Anyway, good video. I moved to SE Kent a few years later, locals talk about other accidents and incidents, but this one is almost taboo, it affected so many people.
If your solution to a vital task is "a human will handle it", its just a matter of when.
nice video. I remember that incident well.
There were changes, yes, but something was not changed:
ferries and cruise ships are so freaking unstable. They are balancing on a very very thin rope.
Lol nothing like planning a trip to cross lake Michigan on a ferry then casnav posts a video of ferrys capsizing
I remember the news reporting at the time of this disaster and the journalists reports led me to believe that the doors were closed, but not properly sealed. Or rather the early reports were not that clear and either the reporters passing on those reports (and myself) thought there was no way such a large ship could have left port with those bow doors open.
I'd never followed up, not being in that industry and that accident occurring an ocean away allowed me distance to not be invested in that story. Your video helps to clarify for me, at least, that memories can be faulty and our own notions can corrupt our own understanding of an historic event.
The reframing and restating of the events from a thorough understanding of the full accident report changes my opinion of what happened and why. Thank you.
2:31 this is not the first time, you want another ferry that we was unable to see the bow before sinking? The MS Estonia
I think the Estonia was later, but that makes your point even stronger.
The Estonia sank? No way... when?
@@WhatALoadOfTosca The MS Estonia sank on Wednesday, 28 September 1994, between about 00:50 and 01:50 (UTC+2) as the ship was crossing the Baltic Sea, en route from Tallinn to stockholm, she's now in the Baltic Sea, Coordinates 59°23′N 21°41′E
@@thibaud_benjamin_vandenhoven Gosh really! Wow, how I missed that. You sure it sank?
@@gtgibb indeed The MS Estonia sank the 28 September 1994, when the MS Herald of Free Enterprise sank the 6 March 1987
There is still a lovely slate painting of the ship on the beach. Dover has not forgotten.
Also as a resident of Dover, I appreciate the wonky letters on the Port sign to show how shite the town is.
CASNAV POSTED WOOHOOO!!!!!
This is one of those events that no matter how many videos or documentaries I watch about it, I'm eager to watch another. A pivotal tragedy I think about often.
Thank you for this video of the highest standards.
Incidents like this and the Estonia are interesting when compared to something like the Queen of the North Sinking in BC, Canada. Namely the fact that she didn't roll over once water breeched the car deck. Would be really curious if this was due to the free surface effect being negligible when the watertight compartments are breeched, or if some other safety system kept her upright
Thank you for discussing this sad case.
Travelled RORO on this route as a kid in the early 80’s. The doors often stayed open “to vent the car fumes”. We did wonder how this was safe at the time. Never saw it done after this accident.
"Herald of Free Enterprise"
I cannot the only one who finds that name on chronic for actively demonstrating why regulations are necessary, thus curtailing the "free".
I actually don't understand how when no information about the state of key systems of the ship are unavailable, the captain could've just *assume* all was good, knowing full well that if said door was open, they would surely risk a major catastrophe - which they did, precisely because the doors were left open while everyone wrongly assumed they were closed.
As lapses in safety protocols go, "Just assume the door is closed when it's time to sail." seems a fairly egregious one.
Not that it's funny, but it is fairly hilarious that the SOP of a safety critical operation would use the word "assume" anywhere except to "assume command" or something like that.
Or, I suppose, the other way around. "Assume that the ship is not safe to leave port until all systems have been checked."
The name of the vessel is ironically apt. It is indeed the free rein of free enterprise that led to this disaster.
Ayn Rand, Rand Paul and Paul Ryan walk into a bar. The bartender serves them tainted alcohol because there are no regulations. They die.
The ship wasn't named The Free Rein Of Free Enterprise.
You say that like some leftie to who thinks capitalism is bad. If it weren't for free enterprise those ferries wouldn't have existed. Companies operate under what's known as conscious capitalism. Treating the employees, equipment, and customers like crap isn't good for profits. It's actually government sponsored/subsidized companies like utilities and public transport that end up treating employees and customers like cattle. Amazon has great customer service, the post office doesn't even pick up the phone.
@@thomasjoyce7910They're not saying that it was or that it needed to be, they're clarifying why the name of the ship is so apt. Do you know what a "herald" is?
No it wasn't. Free enterprise does not encourage risk taking.
The same old story: management placing profits before safety and common sense. But adding insult to injury very few (if any) of the senior management team are held accountable. Coming up with a new regulatory system is all great and fine but generally useless if it hasn't got any teeth to back up the rules.
Terrible night, and weekend. I remember it so well.
I saw a yt short that used one of your animations without crediting you anywhere.
I was four the day the Herald was towed into my town. I remember standing there, and not understanding why everybody was sad.
A black black day in maritime history.
As always, a very good video from CasualNav, thank you Sir!
This incident is like the sewol ferry tragedy
Imagine thinking that $3000 door indicator light upgrade package wasn't worth the money because you assume that the human operators will absolutely never fail to close the doors for any reason whatsoever, therefore the risk of sailing with a door open and sinking the whole ship is 0% so the appropriate amount of money to spend on mitigating that risk is $0.
I was a child when the Herald of Free Enterprise capsized, and was still scared when later that year we went on holiday that involved a car ferry trip.
It was a much smaller vessel, probably only 20 cars, but still seemed a massive ship to me. My fear turned to terror when mid-voyage the Greek mariners stopped the ship and lowered the bow car ramp… to land a fish they’d caught!
I remember waking up that morning to the news reports on the radio. There were some extremely vivid accounts told by terrified survivors. I still hear the horror and despair in those voices today. Whenever I travel by sea (which I do often) or air, I always pay particular attention to the emergency procedures.
In the military, you're not allowed to leave your post until you are relieved. I've experienced that as a grunt in the Army and I recall one time my dad (Major, Air Force) wasn't allowed to leave his security post because his relief was sick. My dad had to do an extra 8 hour shift that night. (I'm certain there were more, but that one sticks out.)
You can definitely tell this one was a culture of a top down mentality. "If you can't verify, assume." I wonder if these were union people, "it's not my job to stay extra."
As a kid in the early 90s we'd take the ferry from N. Ireland to England/Scotland then drive down to Dover towing a caravan for that same ferry to Calais.
My da scared the shit out😅 of me as a kid, describing in detail how with that tragedy the car deck wasn't closed and hundreds died within minutes.
I remember like 30 years ago him instructing me and my big sis what to do if the ferry started sinking.
That easily preventable horror has never left me decades later, nor have my Da's simple safety lessons.
I worked in the lift industry. The failsafe principle rules absolutely. The lift will not go unless the doors are not only closed…but locked closed
While I agree we need to dig deeper to avoid these accidents happening in the future, 65% of the ones contributed to people (such as this one) are due to complacency. Even the Atlantica incident was due to complacency. They knew how to use the trial course function, but not how to read it on THAT radar system.
This accident was 100% complacency. 1st officer was complacent in that the assistant bosun would close the doors. Assistant Bosun was complacent in that someone might make sure he's awake. The Master was complacent in that he just took the 1st officer's word for it.
Complacency kills.
After learning from RUclips that ships like this are referred to as "roll on, roll over", I have been pondering how we're often willing to ignore just how unsafe our daily lives can be. I don't take a ferry, but I drive one of the most notoriously dangerous US highways every day. It's crazy how we cozy up to death without really thinking about it until things like this happen.
Hobit music when all is well and good is a mood, but when disaster strikes is just hilarious
On Tuesday, I move into the Massachusetts Maritime Academy and start my career as a merchant officer. Thank you, Casual navigation.
Apart from all the specific causes IMHO also a good general example of why assuming "common sense" is never a good idea and should be replaced by rules wherever lives are t risk, as there is no common sense/understanding of safety necessities. If I would be the captain of a ship that basically has a giant more than barn door sized hole in the front and back, you bet that I would either personally check that these holes are closed or have gathered reliable current information that they are closed before leaving port. Others obviously were fine with "the guys did it correctly the last 100 days, so they must have done it correctly today, too, cause this is a perfect clockwork and clocks don't break". ;)
@@johncage5368 I've known people who stood up for what was right, refused to shortcut official procedures and policies, and gave every task the necessary attention, despite pressure from above.
Most recently, it was a QA engineer responsible for signing off on big equipment that was sold for safety critical applications. If the line got behind schedule, the plant manager did what was necessary to fix it. His team was given a time limit per part and a quota of how many they could reject. He quit before he got fired.
I sincerely wish that a safety system like this could be mandated for all industries. Of personal interest to me, the rail industry. Far too often, serious accidents get flashed on the immediately responsible people with absolutely no discussion about the underlying management decisions which created the situation.
A nice example of why root cause analysis is necessary. Unfortunately in my experience most people tasked with this seem not to understand how to do one.
0:38 it has a rudder and propeller in the front?
Probably because it's a fairy which needs to back away from the loading ramp. Some ferries don't even turn around the bridge can see both ways. So they just switch back and forth and don't bother turning around
@@Charlie-dx6bv interesting.
@@PCrailfan3790yep. It’s a roll on roll off. So basically it has car deck doors on both sides. This means the ferry has a bridge on each end or in this case, a single bridge but twin propellers to manoeuvre in each end into the berth.
I agree on all, it might also be used for steering (Port and Starboard)
It's pretty common on this kind of ship. Eases navigation in harbours.
ah, the classic - the roll on, roll over ferry.
In the world of events when loading flight cases onto trucks sometimes the loaders will ask for a flight case to be belgianed or tip it belgian so the case will be flipped completely upside down wheels up in the air. This accident is supposedly the origin of that term.
Another case of how crappy management and stingy higher ups jeopardize the safety.
My father was due to be on this ship, but his brakes failed just as he entered Belgium so he never made it on time.
Let me tell you, a man who knew my mum who was from Bedford, who once bought a bottle of milk from the co-op in the town who knew the girl behind the counter, who was related to the brother of a man who once upon a time bought a lottery ticket while in a unicycle was meant to be on it. Maybe they knew each other.
My conclusion is that a lack of communication and verification of necessary tasks being completed was what caused this to happen.
Once again upper management cheats out and lives are lost. Why are they immune from the consequences of their actions?
Dick Francis' short story "Dead on Red" is based on the loss of Herald of Free Enterprise.
"So they assumed all was good" that's why for every maneuver on a heritage railway, a "right away" signal, followed by an acknowledgement by the loco crew are required. Unless the people needing to do certain jobs tell you that they're done, you must assume they didn't do anything at all. That something like this wasn't the automatic assumption mandated by company policy is shocking to me.
I seem to remember it was rather known as the "Herald of great surprise" at the time
This accident happened because they forgot a fundamental rule. It must be confirmed by the
Mate or duty officer that the vessel is in all respects secure for sea. They had forgotten that.Too many routine trips across the Channel ?
I was 16 years at sea and spent time on Roll on Roll off vessels. The ships may become more and more sophisticated but the fundamental rules do no not change. Forget that at your peril.
I would argue that there are even more fundamental rules that should always be taken into account when designing safety procedures and that is that people make mistakes and get complacent with routine. Forgetting things should have been designed into the procedure through redundancies.
@@Taladar2003 Aviator here, makes me think of the swiss cheese model used by airspace regulators.
The captain was literally told to ignore that rule by management.
They were specifically instructed to disregard that, because it cut into profits to waste time double checking things. really, the name was very apt.
"We are paying greatly for professional workers"
There is no such thing as a professional. No matter who you hire, they are humans and humans are flawed.
And that is long before you consider that many "professionals" are just faking it and still making it.
It's actually rare that you have the right person for the job. Since it's more about who you know and who's knob you've been polishing.
exactly what one would expect from a ship named "Herald of Free Entreprise"
A lot of holes in the cheese had to line up for this. 😢
This incident is used as a case study in the US nuclear industry as an example of how a series of individual systemic failures can result in a catastrophic event.
Excellent video. I had forgotten about that one.
i like how the writing on the port of dover is delapidated
I could have sworn you already did a video on this accident.
I fully agree with the conclusions about top management’s responsibilities, as described in the latter part of the video… but still think that professionalism of the men involved on the ship should have prevented the disaster. I mean, they were not selling potatoes on a small town market, they were operating a large boat with passengers at night. I suppose it’s another case of “being used to” getting detrimental to caution and prudence.
Strangely enough, despite the elapsed decades, the video immediately brought back the jokes of my then British colleagues of the City about Townsend Thoresen’s stock being floated.
Everyone: "Safety first"
Management: "Safety what?"
At sea, complacency kills!
RORO - Roll On Roll Over
If you refuse to be responsible, you will be eventually be held responsible.
I wonder if this is covered in Checklist Manifesto. Having a standard departure checklist could have prevented this.
Great video!
The French name of a Flemish port was a surprise.
As in relationships, communication is key.