Editors Picks Science & technology

Devastating cost of ignoring human factors exposed in ferry sinking

MDX academic Roger Kline, who will appear in an upcoming Channel 5 documentary on the sinking of The Herald of Free Enterprise, explains what caused the disaster.

The sinking of the Herald of Free Enterprise on March 6th 1987 with the loss of 198 lives was an accident waiting to happen, highlighting the devastating consequences of abandoning safe working practices in the name of financial savings.

The issue of human factors in such disastrous events began to gain serious attention after the tragedy.

Human factor is the scientific discipline concerned with understanding how we interact with each other and with other elements of a system.

In turn systems are then designed to optimise well-being and performance among humans – and reduce safety risks.

The Herald sinking was avoidable had steps recommended by maritime inquiries and the ship owners Townsend Thoresen’s own captains been adopted.

It is now a case study in how such disasters could be avoided.

These were the main causes:

Firstly, Roll On – Roll Off (RoRo) ferries were inherently unstable

An official investigation into the sinking of the European Gateway ferry, which had a similar design to the Herald warned of another potential tragedy.

The 1986 European Gateway inquiry identified a new phenomenon, “transient asymmetric flooding”, to account in part for the rapid capsizing.

Unlike other ships, which are subdivided into watertight compartments, the vehicle decks of RoRo vessels meant any flooding on these decks would allow the water to flow the length of the ship. 

This issue had been identified as early as 1980, following the losses of Seaspeed Dora and Hero in June and November 1977 respectively. 

It was known prior to the Herald disaster that RoRo ships lost in collisions sank or capsized within ten minutes.

They were uniquely dangerous because their design features for quick loading led to high sided ships and lack of internal bulkheads which made the ships top heavy and vulnerable to a sudden rush of water through the bow or stern doors.

The company knew about the dangers.

Six years previously officers on its sister ship the Spirit of Free Enterprise threatened to strike unless safety standards improved, and in particular demanded a third officer to close the ship’s bow doors.

The owners insisted that only two officers were needed to simultaneously close the bow doors, let go the stern ropes and assist the captain on the bridge.

Secondly, the culture of the shipping line was rotten

Mr Justice Sheen summed up his findings at the subsequent Herald of Free Enterprise inquiry as “from top to bottom, the body corporate was infected with the disease of sloppiness”.

The inquiry identified a number of examples.

Ever since it had launched six years previously The Herald of Free Enterprise suffered from a permanent list, while repeated complaints from captains were ignored and it was forced to sail with a ballast tank permanently full of water to counter the list – which lowered the ship’s bow.

This was compounded at Zeebrugge harbour because other ballast tanks were filled at its low dock to allow car drivers to off load.

The time to empty these tanks was longer than the harbour turnaround time low dock to offload. The company was asked by its captains to fit pumps to clear the water more quickly but refused saying the cost was too high – £25,000.

One root cause was the failure of the assistant boatswain to close the bow door before dropping moorings, after he fell asleep on duty due to fatigue from working an excessively long shift.

The bow door remained open as the ferry set sail, the decks became flooded and the boat filled with water and capsized minutes later.

A crucial contributory factor was the absence of an indicator that the bow door was open.

As a result, the captain had no view of the bow door and no indicator light or other means for him to confirm they were closed. The absence of a communication channel with deck crew meant the captain had to make assumptions about the status of the rear door.

The company had dismissed requests by its captains to have an indicator installed on the bridge showing the position of the doors, partly because the company thought it frivolous “to spend money on equipment to indicate if employees had failed to do their job correctly.”

There was also pressure to remain on schedule and a clear deficiency in safety leadership at a higher level in the organisation.

There was one final contributory factor.

When a vessel is under way, the movement under it creates low pressure, which has the effect of increasing the vessel’s draught.

In deep water the effect is small but in shallow water it is greater, because as the water passes underneath it moves faster and causes the draught to increase. This reduced the clearance between the bow doors and water line to less than two metres.

After extensive tests, the investigators found when the ship travelled at a speed of 18 knots (33 km/h), the wave was enough to engulf the bow doors.

The relevance of human factors science

Human factors science tells us human beings make mistakes and any potentially unsafe system (all systems) needs to build in safety measures to anticipate that.

We had here an inherently unsafe type of ship with staff working 24 hours shift and poor communication channels. It was a lethal system.

Working 24-hour shifts increases the risk of mistakes by staff which was compounded because the captain had no warning of such errors.

The captain had no time to take corrective measures after the mistakes because this ship capsized in 90 seconds due to its design.

This free surface water is mirrored when carrying a tray full of water and the risk was foreseen in the RoRo ferry disaster inquiries.

In total, 198 crew and passengers paid with their lives for this disastrous failure to address predictable safety risks. The relentless pursuit of profit was a major contributory factor and continues to this day on ferries.

A year after the disaster, many cross-channel seafarers, including some who had played heroic roles saving lives in the Herald, were sacked by new owners P&O after protesting about longer hours and worse conditions.

Then some 23 years later, earlier this year, P&O’s new owners sacked their replacement crews for even cheaper ones, and got away with it as government ministers blustered and sat on their hands.

Human factors science learned from the Herald disaster and is widely applied in sectors as diverse as nuclear power stations and healthcare but the working culture of some shipping lines has not changed.

Roger Kline is a Research Fellow at Middlesex University and advised the Herald seafarers when they were dismissed by P&O in 1988.

If you are interested in knowing more about Human Factors at work, Roger recommends Steven Shorrock’s excellent book Human Factors and Ergonomics in Practice: Improving System Performance and Human Well-Being in the Real World (2016).

The documentary ‘Why Ships Sink: The Herald of Free Enterprise’ will air at 9pm on Channel Five on Sunday October 20th

Business & economics

Bringing the factory back in

Dr Nico Pizzolato Middlesex UniversitySenior Lecturer Nico Pizzolato from the Institute for Work Based Learning has been working with Görkem Akgöz from Hacettepe University, Ankara, to put the study of factories back on the research agenda.

Western societies have seen the percentage of industrial production diminishing since the 1970s. Factories, once the symbol of capitalism, have declined in numbers, but, in particular, they have retreated from the centre of politics, policy and the collective imagination, as well as from cutting-edge scholarly research. However, the goods we consume are still manufactured in factories and, even though the geography of industrial production has changed in shape, becoming more global and more dispersed, factories still continue to exist in the West too, though outside the limelight.

Back to the factory

The project ‘Back to the Factory’, which has brought to Middlesex University Görkem Akgöz (Hacettepe University, Ankara) as a Newton Advanced Fellow for the British Academy, and which involves me in the quality of co-investigator, aims to set up a research agenda to place the study of the factory back in the centre of historical and social inquiry. This is in counter-tendency to theories that argue for the irrelevance of the study of the factory to understand a contemporary world steeped in a ‘knowledge economy’.

Over the course of the last year, we have presented the project and led conference workshops in Istanbul, Turin, Valencia, London and gathered a group of researchers who, independently from each other, were working along the same lines. Two of these scholars have now visited Middlesex University and were hosted by the Interdisciplinary Labour Studies Seminar at the Business School. Introduced by Görkem Akgöz, both Gulhan Balsoy and Aslı Odman have focused their research on Turkey, a country that has used outsourced industrial production to enter the club of fast-growing economies.

Though looking at the past, both research projects talk to the present and fill important gaps in the literature on Turkish industrialisation, within a wider international context. Gülhan Balsoy (Istanbul Bilgi University) looked at the question of workers’ health hazards in the Cibali Tobacco Factory, in early 20th century Istanbul.

The Cibali Tobacco Factory in Istanbul, where work was carried out in precarious conditions

Precarious conditions

Located in the Golden Horn, the factory was one of the largest of its kind in Turkey and employed female and male workers belonging to different ethno-religious groups in a productions system that was rigidly divided along gender lines in terms of tasks, skill and pay. Female workers earned a fraction of the male wage, yet neither of them received enough to live comfortably. Workers suffered malnutrition, low living standards and ailments linked to their working conditions: tuberculosis, asthma, bronchitis and other lungs problems. Notwithstanding their precarious conditions, they battled with management against the introduction of machinery, though they were not able to counter the unhealthy working environment in which they laboured.

The consequences of unhealthy working conditions were particularly excruciating for women

Balsoy challenged the audience to look at the factory shop floor as the site of a different kind of ‘production’, not only geared to produce the processed tobacco leaves that constituted the basis for cigarettes, but also a production of bacteria, infections, diseases and long-term ailments the affected workers throughout their lives and sometimes caused their death. The consequences of unhealthy working conditions were particularly excruciating for women who also suffered miscarriages, infertility or were unable to provide safe breastfeeding to their babies. The risks of working in tobacco manufacturing and dire conditions of the workers became so proverbial that they also featured in popular novels, while being constantly minimised or ignored by the employer.

The Ford factory in Istanbul, where production fell short of meeting the expecting target of hundreds of assembled cars per day.


Aslı Odman (Mimar Sinan University, Istanbul) has unearthed the forgotten story of Ford’s failed experiment in establishing a car assembly plant in Istanbul in the interwar period. Crossing the boundaries between geography and history, Odman reconstructed a chapter of Turkish economic history entangled with the emerging process of globalisation of capital and of industrial models.

In the Turkish factory “swarthy Egyptians and morose-looking Afghans could be seen rubbing shoulders with trim Rumanians and athletic Greeks”, reported the New York Times, but, “all trying to decipher the fine details of the new Ford model”. A lot in this story sounds strikingly contemporary: Ford was granted a free zone for its plant. The new republican state forsook its sovereignty in return for industrial capital investment and the ‘training’ of workers on the assembly line, which echoes strategies of the contemporary globalisation of capital through Free and Special Economic Zones (FEZ and SEZ). A strategic node between Europe, the Middle East and Soviet Russia, Ford conceived the Istanbul plant for grandeur, but it fell short of meeting the expecting target of hundreds of assembled cars per day.

We learn from this story also how Ford’s philosophy of production was tremendously influential toward the Soviet Union and how Ford was mindful of pushing forward an internalisation strategy that would give him access to Communist market. Istanbul’s plant was a clog in this strategy. Victim of the Great Depression and of a renegotiation of the geography of industrial capital investments, Ford’s Istanbul plan ended in the same way it had began, as an instance of the international dynamics of capital, which had effectively de-nationalised a sovereign territory during the same process of the formation period of a national market in Turkey.