30 Years ago today - the largest UK maritime disaster since the Titanic

[lpdsn]

The assistant bo'sun was supposed to shut the door but was asleep in his bunk. The bo'sun saw that the door was open but didn't close it or tell anybody because that wasn't his job. The first officer - who was seriously injured in the accident - saw that the door was open but claimed that he thought he saw the assistant bo'sun on his way to close it. The captain assumed that the door was closed. There was no indicator in the bridge because P&O refused to pay for systems to check that crew members were doing their jobs.

The whole thing was a series of contributory cockups, but most blame must go to P&O, who worked their staff to exhaustion and ignored repeated safety warnings to save a few quid.

There was even more than that. Good few years since I read the enquiry report, but I see that Sailorman has linked to it. The chief officer who was supposed to be supervising the closing of the bow doors was also required to be elsewhere at exactly the same time, so it appears he was never able to supervise the closing. The stability was suspect, even compared to low requirements (interestingly, hastily-built WWII tank carriers were designed to float upright with the tank deck flooded, but RoRo ferries weren't). She was almost certainly overloaded, she was deliberately well down by the bow and there wasn't time in the schedule to pump out the ballast, and the schedule required her to get up to speed very shortly after leaving harbour. The bosun (or assistant bosun) was made into a scapegoat.

 

[Capt Popeye]

There was even more than that. Good few years since I read the enquiry report, but I see that Sailorman has linked to it. The chief officer who was supposed to be supervising the closing of the bow doors was also required to be elsewhere at exactly the same time, so it appears he was never able to supervise the closing. The stability was suspect, even compared to low requirements (interestingly, hastily-built WWII tank carriers were designed to float upright with the tank deck flooded, but RoRo ferries weren't). She was almost certainly overloaded, she was deliberately well down by the bow and there wasn't time in the schedule to pump out the ballast, and the schedule required her to get up to speed very shortly after leaving harbour. The bosun (or assistant bosun) was made into a scapegoat.

Humm indeed kind Sir, it all reads like a management lack of understanding or even a reluctance by management to actually manage the 'on board' systems, routines and rules, and come up with a 'workable' solution; oh, the old mantra 'time is money' certainly appeared to 'reign' supreme, urg

Yes the lower ranks were certainly pooood upon from all heights and unfortunately it appears to have stuck [;-(

 

[RupertW]

Humm indeed kind Sir, it all reads like a management lack of understanding or even a reluctance by management to actually manage the 'on board' systems, routines and rules, and come up with a 'workable' solution; oh, the old mantra 'time is money' certainly appeared to 'reign' supreme, urg

Yes the lower ranks were certainly pooood upon from all heights and unfortunately it appears to have stuck [;-(

Don't buy it. The lower ranks were sloppy and used to being sloppy and unmanageable in those unionised times. They (and the upper deck) simply didn't see open bow doors as an issue as they did it again and again on different ferries with nothing bad happening. It took the combination of habit, sloppiness, new practices of docking in Zebrugge bows down and a sharp turn to make it all happen and if they had had a single bit of pride in their jobs over the years then it would not have happened at all.

 

[JumbleDuck]

Yes the lower ranks were certainly pooood upon from all heights and unfortunately it appears to have stuck [;-(

The most impressive bit of sticking and spin is the association of the disaster with Townsend Thoresen, which was simply a trading name of P&O European Ferries, with whom responsibility lay.

Don't buy it. The lower ranks were sloppy and used to being sloppy and unmanageable in those unionised times. They (and the upper deck) simply didn't see open bow doors as an issue as they did it again and again on different ferries with nothing bad happening.

It was a management problem, not a union one. One of the many senior management failings was in not making clear the risks involved and both actively (stupidly tight turn around times) and passively (an indicator would cost too much) maintaining sloppy practice. The builders of the ship knew the dangers of improper operation; why did the crew not? Suggest you re-read sections 7 and 14 of the report.

It took the combination of habit, sloppiness, new practices of docking in Zebrugge bows down and a sharp turn to make it all happen and if they had had a single bit of pride in their jobs over the years then it would not have happened at all.

That is dangerously close to the P&O claim that there is no need to check people's work. There are many reasons beyond sloppiness why a job might not be done, or be done sloppily, or come undone. The Estonia, for example, had no way of checking that the bow visor was still closed underway, so there was no way of knowing that a particularly vicious wave had broken its catch. Sure, the assistant bo'sun should have been on duty to close the bow door - though as you say, crew at all levels were used to sailing with it open - but he might have been curled up with appendicitis. The system should have known. If you have ever flown in the cockpit of a commercial airliner you will know that the pilot and co-pilot constant refer to checklists and check each other's work.

 

[RupertW]

If you have ever flown in the cockpit of a commercial airliner you will know that the pilot and co-pilot constant refer to checklists and check each other's work.

This is the telling statement for me. In a commercial airline the pilot and co-pilot are the lower ranks, just like a surgeon or nurse is in a hospital (an environment I'm more familiar with). The duty of front line staff is to be professional and work with each other and ensure safety as they have a much better grasp of what is in front of them than a manager or director (or captain of a ship).

So a good organisation works by having the safety culture embedded enthusiastically by its lower ranks, as a source of pride as well as personal protection. That was not the case in ferries then, and I suspect it isn't now but is instead supplanted by the much less effective approach of multiple checks by people, paper and technology. Both Chernobyl and Piper Alpha showed how complicated checking systems are actually worse than a culture of personal responsibility and pride.

I would fully accept that it was management and unions that collectively made TT a place with a poor culture (P&O seemed similar but can't be held responsible for the TT culture at such an early stage in their relationship).

 

[JumbleDuck]

So a good organisation works by having the safety culture embedded enthusiastically by its lower ranks, as a source of pride as well as personal protection. That was not the case in ferries then, and I suspect it isn't now but is instead supplanted by the much less effective approach of multiple checks by people, paper and technology. Both Chernobyl and Piper Alpha showed how complicated checking systems are actually worse than a culture of personal responsibility and pride.

People who really do have pride and take personal responsibility know that they will sometimes make mistakes, do not resent checks and use the results of monitoring to improve their practice. The notion that jolly good cheps can be trusted to do a good job without all that tiresome checking nonsense is precisely what gave us Chernobyl and the Bristol child heart surgery deaths scandal. The next time I have an operation I hope the surgeon will have personal responsibility and pride ... and I also hope there will be a nurse counting the swabs in and out.

 

[RupertW]

People who really do have pride and take personal responsibility know that they will sometimes make mistakes, do not resent checks and use the results of monitoring to improve their practice. The notion that jolly good cheps can be trusted to do a good job without all that tiresome checking nonsense is precisely what gave us Chernobyl and the Bristol child heart surgery deaths scandal. The next time I have an operation I hope the surgeon will have personal responsibility and pride ... and I also hope there will be a nurse counting the swabs in and out.

I don't think you read my post and you certainly haven't read reports on Chernobyl. Checking by frontline staff is absolutely needed, but without a professional pride it becomes a tickbox exercise with checklists ticked off in advance to save time (which I have seen). What also is hopeless is lots of checking to assure those up the chain including cameras and sensors - they are stopgaps for a broken system and only aimed at the exact same problem that happened last time. What is needed is a frontline culture that can respond to a new problem and staff that are not distracted by over-complicated checking systems.

 

[lpdsn]

Standard figures in the nuclear industry are (or certainly used to be) that the average Joe Soap carrying out an action will get it wrong 10^-2 times and a person who is directly responsible and diligent would make the mistake 10^-3. There's only so far you can go by encouraging people to try harder.

 

[RupertW]

Standard figures in the nuclear industry are (or certainly used to be) that the average Joe Soap carrying out an action will get it wrong 10^-2 times and a person who is directly responsible and diligent would make the mistake 10^-3. There's only so far you can go by encouraging people to try harder.

Agreed - but think its about professionalism rather than how hard you work and front-line simple checking systems are key if you want to keep mistakes to a minimum. Very complicated checking systems designed to reassure senior people are damaging as they distract the workers from thinking about the job they are doing and constraint the thinking on safety to specific mistakes. Again Piper Alpha and Chernobyl had more safety and checking systems than you could shake a stick at, so by following them people thought they were safe. In fact they led directly to a disconnection between peoples actions and thinking through the consequences. In Piper Alpha it was even worse with a backlog of forms being cross checked allowing a perfect bureacracy to allow a bit of welding in one section to be given permission to go ahead at the same time as a gas flow test in another connected section.

 

[JumbleDuck]

I don't think you read my post and you certainly haven't read reports on Chernobyl. Checking by frontline staff is absolutely needed, but without a professional pride it becomes a tickbox exercise with checklists ticked off in advance to save time (which I have seen).

I've read quite detailed reports, and the idea that the reactor operators simply needed a bit more professional pride is an absurd oversimplification. They certainly made mistakes, but they were also put into a near-impossible situation by being asked to run a test at a time when the reactor condition far exceeded their knowledge of nuclear physics. Put simply, they did not know what they were doing and no amount of pride, professionalism or really nicely polished shoes could make up for that lack of knowledge. Another classic management failure.

What also is hopeless is lots of checking to assure those up the chain including cameras and sensors - they are stopgaps for a broken system and only aimed at the exact same problem that happened last time. What is needed is a frontline culture that can respond to a new problem and staff that are not distracted by over-complicated checking systems.

Cross-checking is not a sign of a broken system. On the contrary, it's a sign of a well designed system. If it's essential that, for example, a ferry does not put to sea with its bow doors open then you make sure that the person responsible for deciding whether or not to put to sea knows whether the bow doors are closed or not. It doesn't matter whether the crew member who should close them is sleeping in bed, devoid of pride, or lying full of pride at the bottom of a staircase holding a broken leg.

The notion that people should simply be told what to do and that no time or money needs to be spent on checking was endemic in P&O, and we know what happened as a result. Of course the systems which do the checks have to be sensibly designed, but in general I think it is safe to assume that people who complain about checking and monitoring systems are normally complaining about having their lazy shortcuts denied to them. Those who have nothing to hide have nothing to fear.

 

[JumbleDuck]

Agreed - but think its about professionalism rather than how hard you work and front-line simple checking systems are key if you want to keep mistakes to a minimum.

As a colleague of mine used to say "Professionals are people who know exactly how bad a job they can get away with. Amateurs do the best job they possibly can for the love of it". As the post you are responding to pointed out, mistakes can never be eliminated, so systems have to be able to deal with them.

Very complicated checking systems designed to reassure senior people are damaging as they distract the workers from thinking about the job they are doing and constraint the thinking on safety to specific mistakes. Again Piper Alpha and Chernobyl had more safety and checking systems than you could shake a stick at, so by following them people thought they were safe.

Anyone properly qualified to run the test at Chernobyl would have used the information available and would have needed the information available. They had the equivalent of a couple of airframe mechanics trying to flight-test an aeroplane. The main issue at Piper Alpha was that the out-of-service condition of Condensate Pump A was not conveyed to people who needed to know it. Too little information, not too much.

 

[Biggles Wader]

I remember sailing off Dover at night a couple of years before the disaster and seeing a ferry leave harbour at a good lick. The surprising sight was the lit up car deck fully visible and a guy with a broom sweeping between the cars. It all looked well above the waterline with the wake mostly higher just aft of the bow doors. Complacency and habit, I guess.

You'll need to expand on that.If you can see the bloke sweeping down the lit up car deck you must have been dead ahead of the ferry going at a "good lick".Did you avoid it OK?.How far outside Dover was this?The seas are notoriously choppy just outside and would easily get onboard in anything but flat calm.Im just having trouble understanding what you saw????

 

[Andrew E]

I understand modern car ferries now have around 1.25 metres of freeboard between the waterline and the lower car decks. I also understand that the lower car decks have "freeing flaps" which allows water to escape in the event of a flood. I also read that lower car decks are now divided, as IMO rules prohibit an undivided deck on a passenger RORO vessel. I'm guessing they must segment the car decks with sliding watertight doors after loading?

 

[Uricanejack]

Don't buy it. The lower ranks were sloppy and used to being sloppy and unmanageable in those unionised times. They (and the upper deck) simply didn't see open bow doors as an issue as they did it again and again on different ferries with nothing bad happening. It took the combination of habit, sloppiness, new practices of docking in Zebrugge bows down and a sharp turn to make it all happen and if they had had a single bit of pride in their jobs over the years then it would not have happened at all.

I take it as an infallible professional you have never made a mistake and never been late.

During the height of Lady Thatcher's popularity. I recall one of the last death throws of Sam Mclusky and the NUS. A Strike in the early 80's at P&O Dover. Being broken by all the lower rank union employees being fired. New non union employees hired to replace them. This was several years before the Herald. I am not sure If Townsend Thorrison were Union or Non Union prior to take over by P & O.

Blaming the Union. Standard first response of Poor Management. Not applicable at P & O Ferries though.

According to the Judge. A Sloppy operation from top to bottom.