No One Confirmed the Doors Were Shut: Institutional Carelessness Was the Real Killer
In 1987 the roll-on/roll-off ferry Herald of Free Enterprise capsized with her bow doors open, killing 193 people. The real culprit was not the sleeping crewman but a system that left everyone feeling this was not their job.
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Closing the bow doors was one man's job, and he was asleep
A roll-on/roll-off ferry is designed so that vehicles drive straight into the hold, with a large door at the bow and another at the stern that must be closed before sailing. Closing them was the job of assistant boatswain Mark Stanley. On a cold evening in March 1987, his superior told him to go below and rest, and to come back on duty when the announcement came. He made a cup of tea, sat down on his bunk and dozed off. Four years earlier, another roll-on/roll-off ship belonging to the same company had put to sea with its doors open because the man responsible for closing them had fallen asleep; that time, nothing happened.
— Tim HarfordCaptains asked for a door indicator light and executives turned them down
After the sister ship sailed twice with her doors open, one captain wrote a memo telling the crew to take the matter seriously. Another pointed out that the bridge had no way of seeing the state of the doors and proposed fitting indicator lights. Senior management's response was that the man closing the doors could be assumed to tell the bridge if something went wrong; one asked whether they should also fit an indicator light to show whether the storekeeper was awake. Nobody took the proposal forward. The captains had spotted the gap in advance, and no one was willing to close it.
— Tim HarfordThe ship went over in a minute and a half and 193 people died
The Herald of Free Enterprise left port carrying 459 passengers and 80 crew, and seawater poured through the open doors onto the vehicle deck. Passengers first joked about the spilled meal trays; then the ship rolled over as though something had been pulled out from underneath her, and within a minute and a half she was lying on her side on a sandbank. Inside it was pitch black and freezing, and life jackets tangled people up rather than saving them. Some escaped by stepping on other people's faces; others arched their backs to make human bridges so that strangers and children could climb across. In the end 193 people died.
— Tim HarfordFour links in the chain each looked innocent on their own
Justice Sheen found that the disaster was not the work of one man. Stanley had fallen asleep. His superior said that closing the doors had never been his job. Under company policy, the first officer only had to confirm that the man responsible was near the doors. And under another policy, the captain assumed that no report meant everything was fine. None of these four things was gravely wrong on its own; put together, they left every line of defence wide open. James Reason later distilled the Swiss cheese model from this accident: disaster happens when the holes in successive layers of defence line up exactly.
— Tim HarfordThe judge pointed the finger at the top of the company
Sheen's conclusion was unambiguous: "the fundamental fault lay at a higher level in the company." The board of Townsend Thoresen had never treated safety as its own responsibility. Overloading went unchecked; the company did not know how many people were actually on board. The bow and stern draught figures were invented by the crew, because nobody ever checked them. In Sheen's own words, "the body corporate was infected with the disease of sloppiness." But the court of inquiry had no power to punish, and although the coroner's jury returned a verdict of unlawful killing, it could not name a single individual either.
— Tim HarfordThe law could not keep up with the new technology
The RoRo ferry was an innovation, but maritime law had been written before it existed. The law only prohibited leaving an unseaworthy ship in port; it said nothing about not putting to sea with the doors open, so Townsend Thoresen slipped through a gap nobody had imagined. Peter Spooner, who lost a relative, organised a families' association and pushed for a corporate manslaughter prosecution. But the law at the time required identifying the person who represented the company's controlling mind, and precisely because the lack of responsibility was organised, no individual could be found, and the case failed. As Spooner put it: "There is only so much regulation and legislation can do; it follows disasters rather than anticipating them."
— Tim HarfordThe seaman who dozed off blamed himself for the rest of his life
The company changed its name and carried on trading, and at the twenty-fifth anniversary a retired director was still complaining that the prosecution had been a "monstrous injustice," insisting it had been nothing more than "a tragic accident." Mark Stanley could not let it go that way. He said it was not for him to blame anyone else, and he carried the guilt for the rest of his life, dying in 2016. Britain did not pass a new corporate manslaughter law until 2007, and scholars say it has not proved as effective as expected. The story ends on the question asked by a nine-year-old girl: "I've always been a good girl, I've never told a lie, why am I going to die?"
— Tim HarfordIn their own words · checked verbatim
Twice this ship has sailed with the stern or bow doors open.
sister ship captain4:38
Assume the guy who shuts the doors tells the bridge if there's a problem, well he should, but he won't if the problem is that he's asleep.
Townsend Thoresen executive6:43
I've been such a good girl. I've never told any lies.
nine-year-old girl19:15
Do they need an indicator to tell them whether the deck storekeeper is awake and sober?
Townsend Thoresen executive23:28
A full investigation leads inexorably to the conclusion that the underlying or cardinal faults lay higher up in the company.
Justice Sheen24:29
the body corporate was infected with the disease of sloppiness.
Justice Sheen26:40
regulation and legislation can only do so much. They follow in the wake of disasters instead of anticipating them.
Peter Spooner31:51
It's not up to me to blame anyone else
Mark Stanley34:58
Figures
| Crossing (Dover, UK to Zeebrugge, Belgium) | about 4.5 hours | 0:15 |
| Times the sister ship had previously sailed with its doors open | 2 | 4:38 |
| People aboard | 459 passengers + 80 crew | 7:46 |
| Time from flooding to capsize | about 1 minute 30 seconds | 9:50 |
| Deaths | 193 | 20:16 |
| Place in the history of UK corporate manslaughter trials | the third (the first two both failed) | 32:53 |
| Year the UK's new corporate manslaughter law passed | 2007 (20 years after the disaster) | 33:53 |
| Year Mark Stanley died | 2016 | 34:58 |
Glossary
- roll-on/roll-off ferry (RoRo)
- A ferry with doors at bow and stern that vehicles drive straight into and straight out of at the other end.
- Swiss cheese model
- Accidents happen when the holes in successive layers of defence happen to line up.
- corporate manslaughter
- Criminal liability of a company as a whole for causing death by negligence; legislated in the UK in 2007.
- controlling mind
- Convicting a company required identifying the decision-maker who embodied its will; in this case nobody was responsible, so the company walked.
- pacing problem
- The new risks created by innovation always outrun the response of law and regulation.
How to listen
Operations and safety leads in high-risk industries, plus founders and managers who have to design error-proof processes for their teams.
The sources and membership promotion after 36:02 can be skipped.