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Passenger and freight ferry HERALD OF FREE ENTERPRISE ,On the 6th March 1987 under the command of Captain David Lewry sailed from Zeebrugge ( Belgium) .The HERALD was manned by 80 crew, 459 passengers and was laden with 81 cars, 3 buses and 47 trucks. Due to negligence her bow doors had not been closed before leaving the harbour. When the ferry reached 18.9 knots (33Â km/h), water began to enter the car deck in large quantities and loses her stability. At 6:28pm,after few seconds the ship listed 30 degrees to port. The ship briefly righted herself before listing to port once more, this time capsizing. The whole event took place in less than a minute. The water, destroyed both the main and emergency electric power supply and resulted the darkness .The HERALD OF FREE ENTERPRISE capsize after leaving the harbour ending and submerged in shallow waters due to a turn to starboard in her last moments. This accident resulted total no.of deaths of 193 crew members and passengers.
It was not the first time that a Ro-Ro ship had capsized but the circumstances of the disaster - Shortly after the accident the United Kingdom requested IMO to consider a series of emergency measures be considered for adoption. Most of these consisted of proposed amendments to the International Convention for the Safety of Life at Sea (SOLAS), 1974, the most important treaty dealing with the safety of the world's ships.
Seven years later on 28th of September 1994 the M.S ESTONIA was also lost as a result of water flooding through the bow door resulting in the death of 852 people.
Wrong operational procedures and implementation and monitoring of ship's staff, leading to the accidents.
The most important factor was that top heavy design for car ferries, with large opening on decks, are unsafe and unstable. The main reason for HERALD OF FREE ENTERPRISE the capsize being the outer and inner bow doors being left open and badly constructed bow doors. A small amount of water into the open deck area even in a gentle swell can cause the ship capsize very quickly. Again it was the human errors individual, management and design and for loss of 193 lives. The significant human errors included the following:
1. Ship's Design : In case of 'HERALD OF FREE ENTERPRISE' the master should have confirmed with the person in-charge if the bow door was closed. The design of the ship made it impossible for the master to see if the bow doors were open or close . In both the cases the bow doors were the cause of the accident. In the case of 'MS Estonia' the report showed that the failure of the locks on the bow door The official report indicated that thebow door caused flooding and listing due to the transverse force of the wave. The construction of the bow door was not good.
2. Lack of Communication : Lack of communication is also a main factor for this cause. There was lack of communication between the master and officer in charge of stations to verify the status of the doors. Everything was based on assumptions which should not have been the case for an efficient working atmosphere. Established facts and not assumptions should be relied upon.There was no positive reporting system as to confirm the closure of the doors and it was assumed that the doors were shut.
3. Fatigue of personnel : The Herald of free enterprise assistant bosun, who was directly responsible for door closer, There was no record of rest hours of personnel were being monitored . Maybe he was overworked or under the influence of alcohol thus he could not hear the station signal being called out.
4. Responsibility of Officers : The C/O,was also responsible for ensuring the door closure,.Towards the last moments of loading the chief officer took over from the second officer at the loading deck and later proceeded to the bridge not confirming the doors were shut . The chief officer showed lack of competence in ensuring the safety of the vessel again assuming that all was in order .The second officer being at stations did not realise that he was short of a person and it was not reported to the master
5. Stability : The chief officer sailed the ship three feet down at the bow which made the bow doors more close to the waterline and thus easily vulnerable.The ramp at Zeebrugge was short to reach the upper car deck. To remove the gap, the master puts ballast into the ballast water tanks to lower theship, but forgot to pumped out the water afterwards.
6. Overload of work : As the cargo duties were shared between two officers , managing time and work pressure had taken a toll on them . Fatigue must have set into them and duties were misunderstood as to who was responsible for being at the loading deck to check the loading was completed and all was in order.
The Chief Officer's primary duty is management and he was proved to be a bad manager because he did not plan the work and rest period of the crew
7. Standing Instructions :. The written procedures were unclear There was no written instructions about the responsibility of closure of the doors and duties were not properly understood , this being the reason for the bosun after seeing the bow doors open assumed that the closing of the doors was the responsibility of the able seaman.
8. Pre-Departure Checklist : There was no concise checklist determining the closure of the bow doors ,if there was one in place , this wouldn't have gone unnoticed .
9. Pressure to leave the berth : Due to the commercial pressure and the vessel was to sail immediately , the chief officer had to go to the bridge without confirming the doors were shut and the vessel was ready to sail , assuming the task would be carried out .
10. Bridge and Navigational Procedures: This conflict in duty reflects the poor thought by the management ashore These procedures laid down by the company was not transparent and had ambiguity in it's instructions as to whether the O.O.W or the master was to be on the bridge 15 minutes prior to departure. As the O.O.W (chief officer or second officer ) was in charge of loading at the final stage and then report to bridge was impractical as he couldn't be at two places at the same time.
11. Indicator Lights : There was no indicator light display on the bridge to know about the status of the bow doors . The shore management did not pay heed to the reports and suggestions given by the master of a similar vessel owned by the same company regarding a similar incident two years earlier, when the vessel had gone to sea with her bow doors open and had requested that a warning light should be installed, for the status of the bow doors.
12. Company Management: Company management did not accept its responsibility for safe management of the vessel. The management failed to give precise orders for safety of the ships. The Master was to assume that if no deficiencies have been reported vessel was ready in all respects to proceed to sea. Master found it safe to leave the berth in the absence of any reports .Since the chief officer did not report possibility of any such occurrence, Master assumed vessel is ready for sea. This was a very dangerous assumption which lead to this disaster. The company, Master and Chief Officer are equally responsible for this.
2. Steps that should be taken by the Company Management System and the shipboard senior officers to prevent the reoccurrence of such an event.
The company is the topmost level where management of vessel has to take place and this will lead to good management on ships. For a proper management to be in place there should be a written procedure in place. Procedure is a document describing a specific activity in the planned system and states the responsibilities and means required to obtain the expected results.
Most of the very serious accidents occurred during the late 80's and early 90's were caused by human errors and management faults were the contributing factors. Lots of human errors are due to bad management practices. In order to prevent reoccurrence of such a disaster procedural guidelines and proper management should be in place. The International Safety Management (ISM) Code is concerned with procedures whereby the safety and pollution prevention aspects of a ship are managed, both ashore and on board, rather than laying down specific rules dealing with the technical condition of the ship only. The ISM Code requires owners and operators of ships to set in place a Safety Management System (SMS).The effective implementation of a safety culture should lead to an improvement in safety consciousness and safety management skills.
In 1998, the ISM Code became mandatory. The ISM Code provides for the establishment of a safety management system by the company managing the ship as a part of the requirement.
As per Annex 1 to IMO Resolution A.741 (18) : ISM Code
Every company should maintain and implement a Safety Management System (SMS) which shall include the following:
1. Have a safety & environmental protection policy.
2. Have written instructions & procedures to ensure safe operation of ships & protection of marine environment.
3. Define levels of authority & lines of communication between & amongst shipboard & shore personnel.
4. Have procedures for reporting accidents, near misses & non conformities.
5. Have procedure to prepare for & respond to an emergency situation.
6. Have procedure for internal audits & management reviews.
Company Objectives in relation to the Safety Management System:
The objectives of the company should emphasize and cover the following points:
1. Provide operational practices in safe working environment.
2. Establishing safeguards against all identified risks.
3. Constantly improving personnel skills, ashore and on board ship , in relation to safety management and preparation for all emergencies, in terms of safety as well as environment protection .
4. Compliance with mandatory rules and regulations;
As in this case the following features must be installed by the company management:
1. Indicator lights should be fitted to all bow doors and the display panel should be located on the bridge and log entries should be made regarding the status of doors prior to departure.
2. CCTV monitoring of bow doors may be considered as it's installation would be an added advantage for monitoring the security of the vessel.
Master and Chief officer should take the following steps to prevent re-occurrence of such a disaster:
1.Vessel is to be seaworthy prior departing from port as the safety of ship, personnel, cargo and pollution prevention must be ensured at all times.
2. Implementing the Safety and environment Protection policy of the company.
3. Motivate and train the crew in the observation of the policy.Motivating the crew is one of the primary responsibilities of the master. Procedures should contain critical item checklists prior to departure from the port and all such operations. Also there should be a provision to crosscheck all the important methods. The training of the crew has to be done in two stages - on shore and on board.
4. Ensure strict discipline onboard.
5. Safety of the ship is of paramount and must be ensured at all times. Master should not bow to commercial or operational pressure where the safety of the ship is concerned.
6. Lookout for any potential hazards and the means of preventing accidents.
7. Verify that procedures laid down in the manuals and requirements are complied with at all times.
The company flowchart is the point of departure to clarify who does what, and who is responsible for what. Each function can have only one responsible person. This responsibility falls on the master and chief officer as well as other officers. There should be a section inthe procedure manual regarding the responsibility and authority to ensure that everybody concerned knows what the management expects from them.
8. Proper communications with shore and not succumb to pressure where the safety of the ship is concerned and within the ship between the different departments close co-ordination to be carried out.
9. Concise and clear orders to be given and positive reporting to be done.
10. Try and develop a high level of safety consciousness among the crew so that individuals work and react instinctively in a safe manner and have full regard to the safety not only of themselves but also of others and for the ship.
11. Review the SMS and report any deficiencies to shore based management.
12. Procedures should also contain methods for reporting of any near miss, accidents and Non-conformities..
Ensure procedural guidelines i.e. procedures/checklists are adhered to and not filled up only as paper-work but the officers understand the importance of it.
13. Regular training of drills, and briefing of all operations and risk assessment to be carried out. De-briefing of drills to be carried out so as to highlight the shortcomings and improvements to be made in future.
3. The use of performance appraisal as a tool to achieve safety awareness target and the development of personal goal with in the organisation..
CONDUCTING THE APPRAISAL :
There are multiple purposes that are served by the Performance Appraisal Interview:
1) To inform the employee of his/her overall performance rating, and of the criteria used in determining the rating.
2) To clarify misunderstandings about the job and about what is expected of the employee.
3) To provide a framework for discussion of employee strengths and how they maybe built upon, and
weaknesses and how they may be corrected.
4) To build a stronger relationship between the employee and supervisor;
5) To provide one source of information for compensation decision-making.
6) To achieve better results by informing the crew members as to what is expected of them.
The Key essential factor in management of any organization is the ability of being a good leader to your crew and set a good example yourself. The support of the right people at the right time with the right skills is important and very essential in successful functioning of any team. Management of people means gaining the trust of your superiors & subordinates.
Leadership is a trait not everybody naturally possesses, but could be developed. A good leader is one who;
Learns to think & makes sound decisions quickly & accurately
Is naturally helpful to his members
Cheerful, optimistic & inspiring
Knows to recognize & use abilities of other people
Knows how to organize himself & his team
As humans we hate being judged , so appraisal is a process which is important for the efficiency of the system but at the same time it has to be carried out with tact, respect and understanding, thus not making the other person uncomfortable but making him being wanted by the system and for the system.
The correct procedure for a performance appraisal and evaluation of how this can lead to higher levels of motivation and increased productivity is as follows :
If improperly conducted, the appraisal interview may result in more harm than good.
Prior to conducting the appraisal interview, consider the following elements of a successful performance appraisal interview:
1. Select a time and place for a performance appraisal interview where you are relaxed and and minimal opportunity for interruption, and maximal privacy
2. Be clear in your mind about the standards against which you are appraising your staff
3. A good job description is an essential starting point.
4. Provide a copy of the performance appraisal form to the individual and give him good notice.
5. Encourage him to think about what he wants to discuss.
6. Take into account individual's cultural background & dominant personality characteristics.
7. Review the performance criteria and his past performance.
8. Work out questions designed to find out whether you & the appraisee are in agreement over the objectives of the team.
9. Compare actual performance with previously agreed or established standards.
10. List the major differences.
11. Analyse the difference for possible causes.
12. Advise the appraisee to review own performance against previously set or agreed standards.
13. Ensure sufficient time is available for the interview.
14. Try to Arrange for uninterrupted interview.
15. Review the performance criteria and reasons for each of the ratings. Prepare to discuss the reasons, and suggestions for improvements
16. Prepare notes for use during interview.
17. Be sure that you are in a good frame of mind. If you are angry, upset, or otherwise unable to commit yourself fully and positively to the discussion, reschedule the appointment.
CONDUCTING THE INTERVIEW
There is no one ideal way to handle an appraisal interview. Techniques may vary according to the supervisor's assessment of the situation. As a Chief Officer I will ensure I make the individual comfortable and put him at ease by creating a friendly and calm atmosphere .Start the interview by giving him a brief idea regarding the objectives of the interview , key areas to discuss and the time scale.
The following are useful guidelines:
1. Your opening remarks frequently will set the tone for the entire interview: construct your opening remarks to create a friendly, constructive atmosphere. Put the employee at ease and establish rapport.
2. Explain the purpose of the interview and how the employee was appraised. The employee should have a clear understanding of the criteria used in determining the rating.
3. Ask questions, and listen closely. Make him feel important and encourage him as some people may want to say something but cannot express themselves.
4. Keep the interview focused on the job. Avoid discussing personality shortcomings unless they are directly related to lack of performance.
5.Address the performance criteria where improvement is needed Ask the employee for suggestions on how performance may be improved. Discuss your ideas similarly and come to agreement on what each of you will do.
6. Don't interrupt, but do not allow irrelevant topics to dominate discussion. Express the positive areas of the performance assessment.
7. Design questions to find out whether there are differences between the individual and me over the objectives of the team and accept responsibility for those areas in need of improvement where i have not provided sufficient support .
8. List the major differences and analyze the possible causes.
9. Compare actual performance with previously agreed or established standards.
10.You may mutually decide with an employee that your independent preparation of performance appraisal is a useful technique for sharing perspectives on the employee's performance. If so, allow the employee at least a week to do so, and compare notes during the appraisal interview.
11. Encourage the employee to make written comments which can be followed up.
12. Summarize discussion and plans for improvement. If appropriate, develop a set of goals and objectives 13. Schedule a follow-up interview, if necessary.
Conclude the interview with friendly and constructive note ensuring that the person understands and agrees with what has been discussed during the interview. Correctly done performance appraisals lead to higher levels of motivation and increased productivity. Main goal when conducting performance appraisals should be to impart a true appraisal of that employee's performance from management's perspective.Â
This type of feedback is essential to improve performance of employees at all levels and improved performance by staff will lead to better performance of company.
Performance appraisal plays an important role in controlling and avoiding such type of situation on board ship and ashore. On board ship Master and Chief officer send confidence report of all crew members at regular intervals, and as defined in company manuals . The whole purpose of this report is to judge the performance and standard of on board staff. Hence with report , company can also take a decision of recruiting a crew in near future on board its fleet. The appraisal reports to be true and actual reports.
Now days most of the accident or incident that are happening around the shipping world is mainly due to human error. Human error itself has got many factors involved within itself that is fatigue, lack of knowledge, motivation , leadership , training , lack of command from top, proper equipment on board . The quality of the crew coming on board are also not up to the mark. They just want to earn money , complete their contract and go home . Some of the crew do not think at all about the maintenance of the ship .
On the other end Company also are not always up to the mark. They run sub standard ships , want to make maximum profit out of it. Company some time does not even think about the safety of the vessel , crew ,cargo and environment. Loss of life on board ships are not a result of any one reason but every one involved in it , that is company , flag state , Surveying company , on board staff also.
It has become evident from all the above incidents that ISM has just become only a paper work for the company and on board staff on ship. It is practiced on paper only. Due to commercial pressure and time bounding ,all people are just filling the checklists. Checklist are a guidance, we should follow them strictly , not only for audits but for our own safety. We should always maintain a safety culture on board. We should train and motivate our crew in all aspects and be prepared for any incidence/emergency. We should make them work in team. For a seaman the biggest gift ,he can give to his family is a safe return home without any injury.
Company should also sets its goals and should appreciate anybody who help them to achieve these goals. Company should set its own standards and should be proud to follow them .
Accidents can be prevented only if all the people on board the vessel are aware of the consequences of such a mistake like leaving the bow door open. All these prove without doubt that the master and chief officer were not monitoring the performance of individuals, appraising the individuals, were not holding safety committee meeting upto the standards required, not imparting the training or monitoring the work of the crew nor were the orders kept simple and made clear to all.