Nobody Confirmed the Doors Were Shut: Institutional Carelessness Was the Real Killer
In 1987, the roll-on/roll-off ferry Herald of Free Enterprise capsized because its bow doors were left open, killing 193 people. The real culprit was not a sleeping crewman but a system that let everyone feel "this isn't my job."
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Who was supposed to shut the doors
A roll-on/roll-off ferry is designed so vehicles drive straight into the hold, with a large door at the bow and another at the stern that must be closed before departure. Closing them was the job of assistant boatswain Mark Stanley. On a cold evening in March 1987, his superior told him to go back to his cabin and rest until the announcement called him on duty. He made a cup of tea and dozed off on his bunk. Four years earlier, another RoRo ship in the same company had put to sea with its doors open because the man responsible for closing them had fallen asleep; that time it was only luck that nothing happened.
— Tim HarfordThe indicator-light proposal was rejected by executives
After sister ships had twice sailed with their doors open, one captain wrote a memo urging the crew to take it seriously; another captain proposed fitting indicator lights, since the bridge could not see the state of the doors. The company's senior management responded that the assumption was that whoever closed the doors would tell the bridge if something went wrong; someone else retorted by asking whether they should also install an indicator light to check that the warehouse manager was awake. The proposal went nowhere. The captains saw the hole in advance, but nobody was willing to plug it.
— Tim Harford193 people died within a minute and a half
After Herald of Free Enterprise left port carrying 459 passengers and 80 crew, seawater poured through the open doors onto the vehicle deck. Passengers first joked about dropped plates, then the ship capsized as fast as if it had been pulled out from underneath, lying on its side on a sandbank within a minute and a half. Inside it was pitch dark and freezing, and life jackets only tangled people up; some escaped by stepping on other people's faces, while others arched their backs as human bridges so that strangers and children could walk across them. In the end 193 people died.
— Tim HarfordAll four links looked blameless
Justice Sheen found that the disaster was not caused by one man. Stanley had fallen asleep; his superior said "closing the doors was never my job"; the first officer, under company policy, only had to confirm that the man closing the doors was "near the doors"; and the captain, under another policy, assumed that no report meant everything was normal. Taken individually, none of the four acts was monstrous; together they opened every line of defence. James Reason later distilled the Swiss cheese model from this disaster: catastrophe comes when the holes in successive layers of defence happen to line up.
— Tim HarfordThe judge pointed the finger at senior management
Sheen's conclusion was unambiguous: "the underlying fault was at the higher level of the company." The board of Townsend Thoresen had never treated safety as its own responsibility; nobody policed overloading, and the company did not even know how many people were on board; the bow and stern draught figures were fabricated by the crew because nobody ever checked them. Sheen's own words were: "the disease of carelessness was infecting the body corporate as a whole." But the inquiry commission had no power to punish, and although the coroner's jury found this to be unlawful killing, it could not name a single individual.
— Tim HarfordThe law cannot keep up with 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 did not say "you may not put to sea with your doors open," so Townsend Thoresen slipped through a gap nobody had ever imagined. Peter Spooner, a relative of one of the dead, organised a families' association and pushed for a corporate manslaughter prosecution. But the law at the time required finding the person who represented the company's "controlling mind," and precisely because responsibility was organised to be nobody's, no individual could be found, and the case failed. Spooner reflected: "There is only so much that regulation and legislation can do. They follow disasters rather than anticipate them."
— Tim HarfordThe dozing sailor blamed himself for the rest of his life
The company changed its name and carried on, and at the 25th anniversary a retired director was still complaining that the prosecution had been a "monstrous injustice," saying it was merely "a tragic accident." But Mark Stanley could not let it go that way. He said it was not for him to blame others, and carried the guilt for the rest of his life; he died in 2016. Britain did not pass a new corporate manslaughter law until 2007, and scholars say it has not been as effective as hoped. The story ends on a question from a nine-year-old girl: "I've always been a good girl, I've never told a lie, why do I have 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
| Length of the fatal crossing (Dover, England → Zeebrugge, Belgium) | About 4.5 hours | 0:15 |
| Number of times sister ships had previously sailed with their doors open | 2 | 4:38 |
| People on board the fatal ship | 459 passengers + 80 crew | 7:46 |
| Time from water ingress to capsize | About 1 minute 30 seconds | 9:50 |
| Death toll | 193 | 20:16 |
| Historical rank of the British corporate manslaughter trial | The third (the first two both failed) | 32:53 |
| Year Britain passed its new corporate manslaughter law | 2007 (20 years after the disaster) | 33:53 |
| Year Mark Stanley died | 2016 | 34:58 |
Glossary
- roll-on/roll-off ferry (RoRo)
- A ferry that vehicles drive straight into and out of on arrival, with doors at the bow and stern.
- Swiss cheese model
- The idea that 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 negligent killing; legislated in Britain in 2007.
- controlling mind
- The principle that convicting a company requires finding the decision-maker who embodies its will; in this case the company escaped because nobody was in charge.
- pacing problem
- The new risks created by innovation always outrun the legal and regulatory response.
How to listen
Operations and safety leads in high-risk industries, and founders and managers who need to design error-proof processes for their teams.
The sources and membership pitch after 36:02 can be skipped.