Sample Report On Herald Of Free Enterprise

Summarize the various forms of loss, which did occur as well as were likely to have occurred as a result of the event.
After reviewing the report entitled “The Capsize of the ‘Herald of the Free Enterprise’”, the various forms of loss, which occurred, as well as were likely to have occurred as a result of the event are as follows: (1) loss of lives of people; (2) loss of properties (those owned by the passengers, employees, management, as well as the assets of the Herald; (3) loss of reputation (negative image to the company, Townsend Car Ferries Ltd.; (4) financial loss due to legal and medical expenses to address injuries and deaths; and (5) potential significant loss in terms of creating environmental risks due to increased propensities for polluting the water where the Herald capsized. Using the ILCI Loss Causation Model, the evaluation on how the accident (capsizing) happened was analyzed through a sequence of events that eventually contributed to the identified losses. As learned, these events transpired according to the following sequence: lack of control, basic causes, immediate causes, the accident, and finally, the loss (according to people, property, product or service, legal, material, time, and public). The components of the loss would be described in greater detail as follows:

People: Loss of human lives, injuries sustained, the costs spent by the company to

Property: The cost of the damage for the entire Herald of the Free Enterprise, the assets
in the passenger and freight ferry, as well as the properties owned and brought

Herald.

Product: The capsizing of the Herald is tantamount to a loss of the passenger and
freight ferry which could not be used to generate revenues and profits for the
company, Townsend Car Ferries Ltd.

Legal: Due to the capsizing, Townsend was perceived to have faced legal charges to pay

for lives and properties that were lost, as well as the environmental hazards and
risks inflicted due to its capsizing on the body of water.

Material: The assets and resources in the Herald that were destroyed due to the capsizing

and could not be recovered, repaired, or be reused. These could include the ferry’s
basic navigational equipment, supplies, furniture and fixtures, accommodation
fixtures; including stores, paints and growth items mentioned in the report. Other material or asset brought with the passengers while in the ferry are included.

Public: The risks imposed on the lives the public due to the capsizing which could

include risks in the environment (pollution in the water which could harm plant
and animal species, as well as biodiversity, within the area). Moreover, it could
also include undue anxiety, emotional stress and other health-related issues that
could have ensued to local community members after hearing the events that
transpired from the incident.
Develop a brief description of the loss-producing event, focusing on the “Accident/Near Hit” phase of the ILCI Loss Causation Model
The loss-producing event could be described using the ILCI Loss Causation Model and the Ishikawa or Fishbone Diagram. The sequence of events that transpired and was comprehensively examined using the ILCI Loss Causation Model and the Accident/Near Hit phase is briefly summarized below:
The accident: The facts from the report disclosed that the accident was due to an interplay of the following: travelling with overcapacity onboard, the rapid acceleration to the maximized speed level within a short period of time, and leaving the bow door open while travelling in open seas. As a result, the acceleration to maximum speed caused natural force that allowed sea water to enter the lower deck from the open bow door. The accident ensued from the condition of the Herald on departure (contained in number 6 of the report) in conjunction with environmental factors (travelling on water).
As emphasized, the Herald’s condition manifested overloading due from three important factors: (1) the weight of the vehicles that entered the deck were grossly underestimated; (2) the ship was reported to be heavier in actual weight, as compared to the weight stipulated during the design stage; and (3) the weight of stores, paints, and other growth items mentioned in the report were noted to be inaccurate and were in fact underestimated.
Another important aspect that contributed to the overload is the water that was retained in the ballast, as mentioned in number 6 of the report. As disclosed, a considerable amount of water was actually retained in the forward ballast tanks which could rationalize the fact that sea water seeped through the open bow door.

Provide an interpretation of an immediate/direct cause of the event.

The immediate or direct cause of the accident, specifically the capsizing of the Herald, was due to the following substandard act which is failure to close the bow door; while the substandard condition is that due to the open bow door, water entered the ferry and increased the load and capacity that the ferry could contain.

Substandard act: Bow door left open

Leaving the bow door open was considered a substandard act since it is a very important activity that should have been paramount in the ferry’s operation. The role and responsibilities noted to delegate authority to an identified person was unclear. Likewise, no accountability, monitoring, as well as sanctioning for violating rules pertaining to accountability was explicitly designed, communicated, and understood by the personnel.

Substandard condition: Water entered the ship

As a result of leaving the bow door open, while the ferry accelerated its speed, the natural condition was for water to enter the ferry. Thus, within just a very short time from the point when the ferry left the port, up to the time of the capsizing, the accident already evolved.
Based on the completion of Ishikawa diagram analysis, identify five of the most likely basic/underlying causes for the above immediate/direct cause.

People

The people in the ferry were instrumental in perpetuating the accident. The contributory factors that pinpointed people’s participation are as follows:

No job description and position description which should have explicitly provided accurate roles and responsibilities in the ferry;

Officers failed to design and follow expected functions, including designing controls, standards, as well as monitoring and performance evaluation of personnel under their jurisdiction;
Conflicts in responsibilities and roles ensued while transitioning from one shift to the other (for instance, the duty of closing the bow door was vested on Mr. Stanley, the assistant bosun; yet, he was relieved of his duties and was replaced by Mr. Ayling, the bosun).
There was no sense of commitment and accountability to adhere to safety standards or to understand the need to correct weaknesses and make necessary improvements.
Frequent changes in deck responsibilities caused failure on consistency, as well as in affirmation of who is accountable for which action (like closing the bow door).

Procedures

The company failed to design, develop, communicate, and update policies and procedures that should have been clearly understood to be consistent and uniform for the Herald and other ferries that were owned.

No procedures on job organization that should have developed job description and position description for each position in the ferry.

No system of rewards and sanctions were developed to motivate ferry personnel and impose sanctions in cases of violations.
Policies and procedures were not accurately and clearly communicated which contributed to different understanding or complete misunderstanding of these policies.
No communication protocols were developed, especially in terms of disseminating memos or correspondences that contain relevant suggestions or areas for improvement.

No organizational structure was communicated to ferry personnel to identify chain of command and to ensure transparency in accountabilities.

Materials
No correct logging of vehicles with appropriate identification of weight to
ascertain load capacity.

The ferry was revealed to be heavier than expected according to prescribed structural designs.

The passenger loading capacity is not followed.
There were failure to record actual weights and load capacities in the ferry’s draught in official logs.
No materials logging system was actually designed for proper inventory, monitoring, and up keeping.
Equipment
High capacity pump for ballasting which was recommended to be purchased was virtually ignored.
Indicator lights for bow and stern doors were not installed.
The location of the controls to close or open the door are remotely situated from the actual door premises.
No system of alarms to indicate that the bow or stern doors remain open.
No system of alarms to indicate the location of initial urgent problems (for instance, that there was water seeping in the deck)

Environment

At travel time, the environment was already dark and could contribute to the staff wanting to sleep.
The clear weather condition pre-empted the captain to assume that no risks in travelling could have been met.
The short distance from the port to their destination contributed to assuming that no accidents could happen.
The ferry was assumed to be travelling in safe and shallow waters.
The captain could have some plans which caused his actions to accelerate speed, which reportedly contradicted the normal practice of restricting the speed.

The effect is as follows:

The “Top Five Risk Factors”
After identifying the risk factors the top five (5) factors that contributed to the accident are as a combination of people, procedure, material, and equipment. These are the top risk factors since the negligence of assigned and authorized people to close the bow door, as well as to develop and communicate clear policies instigated the accident. Other contributory factors (the weight of materials on board, as well as the inability to install engineering controls) were risks that have not been effectively addressed.

People: failure to identify the person who is accountable for closing the bow and stern doors.

People: failure to develop management controls.
Procedure: failure to design and communicate policies and procedures in crucial operations in the ferry, especially adherence to safety standards.
Material: failure to log in actual weight and load capacities and adhere to the standard.
Equipment: non-installation of alarm system and indicator lights.
Describe the primary management error, which most likely corresponds to each of your perceived basic/underlying causes.
Management has the responsibility to develop policies and procedures, as well as ensure that these policies are communicated and adhered to by all personnel. Their failure to undertake basic responsibilities significantly contributed to the capsizing of the Herald. Therefore, as presented in class, those errors are:

Inadequate management activity

The failure of management to design policies and procedures that include risk management and control contributed to the accident. The policies and procedures should have included a pre-designed job organization (description and position) to clearly stipulate roles and responsibilities of each personnel. Likewise, these should also include a system of rewards and punishments to propose corrective measures in sanctioning those identified to violate these policies. Moreover, there was evident lack of performance evaluation on whether the actions expected to be complied by delegated personnel towards the conduct of their responsibilities were indeed performed accordingly. Managers or officers are expected to perform functions such as planning, organizing, directing, and controlling. These functions are not appropriately undertaken by the Masters and Officers assigned at the ferry. The lack of communication protocols also contributed to inadequacy to perform expected managerial responsibilities.
For the opening and closing of bow and stern doors, the policy and procedures should clearly define the person responsible for the task and in his absence, who is expected to be delegated. Likewise, equipment such as indicator lights and alarms (which should warn them that the door is left ajar) should be an integral part of the safety procedures.

Inadequate internal standards

No accurate and explicitly communicated internal standards have been noted. These internal standards were supposed to be understood by all personnel in the ferry. For instance, the importance of closing bow and stern doors prior to travelling is paramount. Yet, the policy designed to ensure the proper personnel is accountable for this task was not clearly created. In addition, there were no control measures and performance standards that were set to check and countercheck whether the task is complied with, as expected. Apparently, safety standards on various aspects of the ferry’s operations were not undertaken to identify risks and hazards and to propose control measures that would mitigate these risks.

Inadequate compliance with established internal standards

There were no control measures and performance standards were set to check and countercheck whether the task is complied with, as expected. For the closing of the bow door, Mr. Stanley, the assistant bosun, admitted that it was indeed his responsibility to close the bow door. However, his duties were noted to be released by his supervisor, Mr. Ayling, who then, by assuming his role, should have assumed the responsibility to the important task. Moreover, the personnel who was actually on deck while leaving the port should also have the responsibility to ensure that the bow door was closed by checking on Mr. Stanley, known to be the person responsible. Thus, the absence of performance monitoring and compliance to the standard evidently contributed to the accident.

Based on the top five (5) risk factors, the following specific activities should be undertaken to correct the identified management errors:

Develop a mission and vision statement for the company and the ferry to include goals for safety and health.
Design job organization on all job positions at the ferry and within the company.
Review and update policies and procedures pertinent to overall operations in the ferry and to include safety and risk management.
Design control measures based on risk analysis to comply with safety standards.
Communicate the newly designed policies and procedures, with integrate safety and risk standards; as well as incorporating a system for rewards and punishments.
As part of engineering controls, install recommended equipment such as the indicator lights for the doors, the alarm system, and the high capacity pump for ballasting for improved operations and to lessen risks.
Implement an open communication system to ensure that all crucial messages, suggestions, and inputs in the normal course of duty for the ferry are immediately communicated to the persons concerned.
Schedule proper training and development to staff of the ferry and in the company to frequently orient them on the need to adhere to safety standards, as well as to conform to policies and procedures.
Schedule leadership and management training to officers to acquaint them on knowledge and skills that should be improved, especially in enforcing control measures, motivating personnel to assume a more responsible stance in making ethical decisions, and in adhering to safety and health standards.
Implement performance monitoring based on roles and responsibilities, as well as the ability to achieve identified goals, objectives, and standards set.

Formulate a reaction to the exercise including your perspective towards accident causation.

The entire exercise provided ample opportunity to recognize and acknowledge the need for risk assessment and management. Likewise, the exercise enabled the improvement of learning on loss causation models like the ILCI Model of Loss Causation. The model aptly developed one’s skills in identifying the root causes of accidents or incidents that contributed to diverse kinds and types of loss. As such, from the experience of the Herald of Free Enterprise, one realized that a simple remiss in the task of closing the bow door could contribute to much loss that cost the company financial losses and a negative reputation for gross negligence.
In retrospect, one appreciated learning the structure for evaluating or investigating the actual cause of an accident that brought substantial loss for the organization. Through going through the process of applying the events that transpired from Herald’s capsizing experience, one was made more cognizant of the role that management takes in ensuring that policies and procedures are designed in the most effective manner to incorporate relevant aspects such as risk assessment, safety and health standards, as well as strategies to ensure that these standards are met. In addition, an examination of the events that transpired, as well as the results of the court investigation revealed various lapses in undertaking functions expected from management. The control function has been remiss and caused the failure to anticipate the risks, as well as to design strategies which would mitigate these risks. The simple act of closing the bow door, in conjunction with the identified contributory factors, resulted in generating grave losses for the company. It was indeed a learning experience for them as well as for students like me. The experience would prepare me for exercising due diligence and commitment in identifying risks and hazards in the work setting. More importantly, the lessons learned should be used to propose measures that would improve safety standards in current or future work settings.