HERALD OF FREE ENTERPRISE
Ships and Planes and Managers who don’t know!
Have you ever wondered if a
pilot in command can learn safety lessons from a ship's captain? The answer is
unreservedly yes because the similarities between the two professions are
remarkable. Both are in command. Both are ultimately responsible for the safety
of their vessel, their crew, and their passengers. And strangely enough in
many cases they are working for people who are not experts in their profession.
One of the requirements of a Safety Management System (SMS) is to define an
accountable executive, he who controls the purse strings. How many pilots are
working for pilots? For that matter, how many sea captains are working for sea
captains? In both cases not many.
The
historical lesson we can take from previous accidents in either field, whether
in the air or on the sea, cannot be more clearly highlighted than by a study of
the Herald of Free Enterprise Disaster. This was a roll-on roll-off ferry that
capsized on 6 March 1987 causing the deaths of some 188
persons because it left port
with the bow doors open. This was, as
are many transportation accidents, a human error accident. The report into this accident (UK
Department of Transport MV Herald of Free Enterprise Report of Court No. 8074,
MV Herald of Free Enterprise) said, “At first sight the faults which led to
this disaster with the aforesaid errors of omission on part of the master, the
chief officer, and the assistant boatswain…" (Report paragraph 14.1) As
usual, this is not the whole picture. Somewhat controversial for the time, the
report's authors created somewhat of a precedent of adding the cause, "Failure of Management", to the list
of causes. The most damning piece of the report is, "…all concerned in
management, from the members of the board of directors down to the junior
superintendents, were guilty of fault in that all must be regarded as sharing
responsibility for the failure of management. From top to bottom the body
corporate was infected with the disease of sloppiness."
To best illustrate this
failure of management the report examined in detail the consideration that had
been given, at the request of the sea captains, to fitting an indicator system
to show whether the bow doors were open or closed. The captain's concerns were
repeatedly documented and yet rejected for the reasons of costs or even
trivial, sarcastic, and frankly incredible statements such as, “do not we pay
somebody to close the doors?" Another management failure was the lack of
clear orders for the crews and their officers. In short, nobody was actually
ordered to close the doors. There was evidence that on many occasions the ships
had been overloaded, that they sailed incorrectly ballasted and therefore
unstable, and that these shortcomings had been drawn to the attention of
management on many occasions by the captains.
So who were these captains
working for? The report states, "… those charged with the management of
the company's fleet were not qualified to deal with many nautical matters and
were unwilling to listen to their masters, who were well qualified." Does
this sound familiar to many a pilot? How many pilots work for management
qualified to deal with aviation matters? Are not many aviation companies run by
those with degrees in business, or accountancy, or almost anything except
aviation? Surely this must lead to the same frustrations the ferry captains
must have felt at the lack of action on serious concerns and other safety
issues they had raised with management?
So is there a possible way to
solve the issue of specialists working for layman? This whole story of the
Herald of Free Enterprise was actually a pivotal point in the history of safety
management. The introduction of safety management systems to the transportation
industry in particular has many attractive features. Perhaps the most important
has already been mentioned; the identification of the accountable executive.
This defines, perhaps for the first time, the desk upon which Harry S Truman's
sign, “the Buck Stops Here,” must sit. Part of the measure of a safety culture
is the attitudes and commitment of management toward safety; having committed
to adopting SMS that attitude is by design subject to change.
So if we are truly to learn
from this tragedy management must listen to those who are experts in their
appropriate field, react to hazards identified by their experts, and prove that
they really are committed to safety by their actions not by their words. Pilots
can learn from this too, for they are in the best position to find hazards both
in the air and on the ground. They only have themselves to blame if they do not
report these hazards.
So has your organization
recently adopted SMS? Have you had your Herald of Free Enterprise moment? Have
you noticed your management responding more positively to your concerns than
before?
