Operational procedures and implementations and monitoring of the ships

All started on March 1987, a ro ro passenger vessel MS Heralds of free enterprise in charge of David lewry when departed Zeebrugge in Ned land from quay number 12. The vessel had 80 crews all together and was loaded with 81 cars, 47 lorries and 3 buses and459 passenger and was heading to dover, England.. The vessel was built in such way to meet the needs of Merchant Shipping, (passenger ship construction) rule 1980/solas 1984. The Heralds were built for the dover Calais running and they were built with very powerful engines,, capable of quick acceleration, in such way that she can cross with fast speed. It was also built in such way that she could disembark the passenger and vehicles quickly within the time and no other delay, and in same time embark the passenger and cars (vehicles) for next voyage. Normally a complement of a master, 2 chief officers and a second officer manned the ship. All the officers were required to work 12 hours on and such way that they couldnt have a day off (or 24 hour off). The passage between Dover and zeebrugge takes 4.5 hours, which in practice is a little bit longer than the passage between Dover and Calais, which means, the officer had more time to relax. The owner had to employ a master and 2 deck officers of this run. According to the court, the master and 2nd officer were entitled to do their job with no possibility of any mistake. They could implement more safety procedure and be All the cars deck bow and stern doors were hydraulically operated and were arranged in such way that they could swung it horizontally about vertical axes, or radius arms. Rubberized wheels supported it. The doors stowed against the shipside when open. The open in each side of the vessel. The initial reports shows that the problems or catastrophes was a result of Human Error and a loss of stability suffered in part due to a construction defect (design). The investigation revealed also that the superstructure design flaws and all emergency equipment procedures impeded passengers evacuation abilities in ship half submerged state. This assignment will analyze this ship and the accident and with a conclusion regarding to recommendations for the future action from authorities based on real information.

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Roll on roll off ship ferry became so popular after in year 1948, that is year later after second war ended due to movement of people for one place to another. Despite this, ro/ro ferries, a serious design default accompanies the large flat vehicle deck that had to be located near the water level for loading and discharge purpose. Navigating in this local is hard to obtain and When a large volume of fluid goes to the low side of this area, the Centre of gravity of the vessel also moves towards the low side. The way is movement of the CoG brings it near the vertical Centre of buoyancy and buoyancy force that acts to right the ship and decreasing the righting movement and increasing its possibility to capsize. This action did cause so many ferry disasters despite the high research in balancing the ferry capacity and abilities and market competiveness regarding to the with vessel safety. The main failure point if not the critical one on Ms Heralds vessel was the weathertight doors which were allocated fore and aft on the main deck, its important to know and understand the main point of these doors. It must possible the main deck one floor with water because of the weathertight door failure. The door split in the middle and swing open to either side, resting on the side of the ship when open. Once the door is closed, there are pressed with hydraulic power which and well sealed of around it. This door were built in such way to stand any force acting on it during the heavy weather or strong waves and with no possibility to show weakness during the operation.

What went wrong (description of events)

First the port of zeebrugge wasnt compatible with the loading decks of the vessel, all because of a height discrepancy between the port loading ramp and the vessels highest deck car. In order to compensate it the master of the vessel was forced to increase to water ballast, therefore increase the present draught and decrease the high of the deck to allow the safety loading on it, that is, aligned the deck ramp. This practice is common in ferry business industry, but this is done in so careful way to regard to the limit of high speeds till bow ballast tank had been unloaded. This process took about half hour and if the port had continued the operator had indicated that it intended to outfit the herald so that this ballasting procedure couldnt be necessary. On completion of loading, the ferry was ready to departure and unmoored operation was done. During this time of unmooring, the crew in operation should realize that the door gate was open and eventually the they could alert the master. 2 NPJ Assessment 3/3/2013 3

In Ms Herald vessel, it was common practice for the assistant bosun to close the main deck after loading and ooffloading doors. In that day, the assistant bosun did take a quick brake in his cabin after he finished cleaning up the car deck on arrival in Zeebrugge. During the departure the alarm for departure sounded and is believed that the bosun was sleeping and could not hear the call. No one realize that the busun did not close the main vehicle deck doors. The another measure to make sure that the door were closed required the 1st officer to be and stay on the main deck until the door were closed ( similar measure is taken on during the anchorage operation where the officer in charge should stay in till the operation end, for reporting and securing the anchor, assumption could not be made in action of trusting the crew members report), but in day of disaster, the chief office went straight to the wheelhouse in an effort to reconcile a strained schedule. For more lost of the time, the 1st officer gave order to to set sail even before the bow ballast tanks were totally emptied from the previous stated unloading procedure. The Ms Herald were steaming through the harbor wiith the master and officers with eyes on hull bow because the nose was dipped towards the water line. According to records it is clear to see that the ferry wnt through the harbor with moderate speed that is, the speed were considered to be below its capacity just to keep the water from going over the hull bow. As the ferry left the harbours, all three engines she had were set to mamixum, that is, in such order to allow her to reach her maximum speed up to 18 knots. On reaching the 18knots, marks the combination of water flooding, squat and a notable increasing in bow wave height permitting the water to enter over the bow hull. At the same speed , we believed that the bow hull was approximately 2 meters below the water lever. The water entered through the open door and consequentially filled the gate, heeling the vessel 30 degrees to the port side followed. The vessel upright herself before more water accumulated on the port side causing a slow steady heeling that caused a partial capsizing. The ship didnt capsize in full about 90 degrees because of the rest sand bank present in that area. As per image below:

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Picture from google picture.

Operational procedure and implementation One of the main reason for herald vessel to capsize was the the loading gate which were left opened during the departure in short voyage from zeebrugge. It believed to be human error the cause of this mistake to occur and when the open gates were complemented with circumstance, a catastrophe couldnt be avoided. The Bosun on duty fell asleep when the call was raised to show that the vessel were departure after dropping of the mooring line. Complementary in this mistake was the fact that the 1st officer at the time of calling, he had went to the bridge wheel with intention of speed up the time for departure. It is to admire that this critical procedure relied only on crewmembers communication and had limited redundancy. It is known that is the water enter the main deck the ship stability would be compromised. The gate loading and discharge could not be observed from the bridge therefore, no form of mechanical detection existed which could compliment the human communication. Relying on all crew member doing their duty accordingly every voyage would not lead on such disaster. Herald was also a victim of ship squat during its acceleration period. When a vessels in shallow water, low pressure is created between the surface of the hull and seabed due to the higher speed of water surrounding the ship. The low pressure below under water volume causes the draft to increase or squat. Herald was traveling over sand bank, low pressure was created and the Free board of bow was less than anticipated when the crew took into account the partially full bow ballast tanks. 2 NPJ Assessment 3/3/2013 5

The reading of draught was also another problem involved, as the crewmember could not read properly the draught of the vessel and therefore their based themselves on assumption information. In that day if the crew were able to check personally , they would have a relevant information to reply to the master regarding to the present increase of speed and therefore, the present flooding of vessel which gave space to the accident to occur. The weight of the cargo on board gave also a big contribution to the vessel capsize. The present weight on vessel were 13% more that the average required weight for that vessel, therefore, the calculation of the ship draft with consideration of weight of the cargo was incorrect and the ship wsa more lower than the expectation or calculation given by the crew (wrong calculation). The lack of communication present when one of the crewmember try to reach the bridge, but no answer or the phone werent answered on the bridge. If the phone was picked, this disaster could be minimized and so many life and goods could be saved. Company should ensure a safety instruction manual and management system as well as the right document which establish sections of work onboard and owner should also that this procedure are being followed accordingly. The owner should ensure quality and safety of life while at sea for their own crews, officers, passengers and cargo onboard. Implementation of international regulations and conventions should be issued to all crew and passenger. Officers should ensure all measurement regarding to the safe are being followed at all the time and means necessary. Proper destribuition of work and manned sections of activities during operations should be implemented at all the time.

The use of performance appraisal as a tool to achieve safety awareness

It is important that ship company to address more in general lsafety of the ferry during construction, operation which include loading and discharge as well as vessel life saving ability during the emergency situation. There are need s for redundancy in the system responsible for guaranteeing and ensure that the load and discharge gates were closed before departure. The 1st step of redundancy for this system is to have a light automatic or mechinicall installed on a failsafe circuit in visible area of the wheelhouse. This light will present the status of deck doors at any times and a log would record the position of the doors before each voyage takes place. In addition to the main car deck indicator light, another indicator light will be installed to show status of all doors within the superstructure. 2 NPJ Assessment 3/3/2013 6

A safety measure brought fwd by the board to help officer on the bridge wheel monitor condition of the vessel through the an installed closed circuit televisions (CTV). CTVs helps to monitor the major superstructure doors, engine room compartment and cargo space, giving the offoicer present on the bridge important ability to monitor cargo shifts, evaluate the vessel condition and the stability of it in overhaul. Takingin consideration of loading problem faced by Herald interprise, it is important that the pneumatic draft gauges be installed and the freight weighting ramp. The present of draught gauge will provide the crew member with an accurate information regarding to the current draught vessel and the freight weight ramp, that is, the crew will be able to to calculate correctly the present draught when loading. It is clear that at the time of accident, the crew were relying themselves on wight declared such as the weight of truck and other cargos and in the average weight of the passengers, and this action could not prevent overloading.

The life saving measures on board of the vessel was clear that it was insufficient lighting onboard after capsizing ( apart form believing that the emergency generator was affected by the water after v/l capsizing) caused problem for the passenger trying to wear the life jacket. The superstructure lighting by itself were so poor, emergencies exits were difficult to be found because they only located at the fore and aft sections. In order to modify or eliminate this problem , it is important that ferry companies take in consideration the sufficient watertight battery operated emergency light be fitted on all ferries, so in such way that the routes or way can be illuminated even during emergency in failure of power supplies or flooding of vessel ferry. The location of lifejacket and the instruction of how to dom it should be so clear at all the time and visible to the all passengers. It is also recommended that the ferry the traditional slab sided superstructure to no longer be built. The slab superstructure has only emergency exits and muster station only on fore and aft area, creating an immediate restriction in escape from middle area of the ferry and create traffic at the ends. For this reason, the new ferry from or after the heralds were built with breakable glass and exits along the side decks in such order to allow the passenger easily to reach their muster stations in emergencies.

As a conclusion
The capsizing of the MS Herald of free enterprise weas the biggest tragedy after titanic, and there fore many life were lost in that tragedy, followed with environment poluition and caused an increase of fees and great economic hardship. It is really hard to see the change of procedure after loss of life. After investigation takes place in this accident, the seriours measures were implemented due to avoidance of the same to happen in society or within the ship company and to improve the marine safety. 2 NPJ Assessment 3/3/2013 7

The international marine safety (ISM) code was adopted by many nations after this accident and this code requires that safeguards to be established against the safety, protection of environment and pollution risks involved in vessel activities and and in same time is flexible to development and raise od safety to the owners specific operation. SOLAS implemented new regulations regarding to the improvement in monitoring of doors and cargo space and improvement on emergency lighting. An amendment was also made to the superstructure section of this code in order to increase emergency exits and new method were developed regarding to the stability assessment in a damaged conditions. International marine organization ( IMO) also introduced a new formal safety assessment ( FSA) which could be described as a rational e more systematic way for assessing the risks associated with shipping activity and evaluating the costs and benefits of international marine organizations options for reducing these risks. This codes are used to evaluate the new regulations to the existing standards or to compare the proposed changes to the existing standards.

References March 3, 20142

Marine technical information facility ( pages 2,3,4 July 1987), by CJ Parker- Herald of free enterprise. The MSA act 1984( report from court N. 8074 of formal investigation) copyright crow 1987, department of transportation. Naval archietecture by RB Zubaly, (carnell maritime press maryland page 35 to 47,1996 )

Assessment NPJ 8

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Part 2 Hours of work

MSN 1767 section 1 state: Hour of work regulations under the merchant shipping acts apply to everyone on board (including the master) that are employed or are engaged in any capacity on board sea going vessel other than fishing vessel In this scenario it is clear that both master and chief officer did not comply with this regulation, as the master has a responsibility to ensure that proper hour of work has been followed and that all seafarers including himself are having appropriate rest time in order to avoid fatigue and guaranty health and safety in working place. The requirement state that minimum of 10 hours rest in any 24 hours period and 77 hours in any 7 day period and 4 weeks annual paid leave Chief officer should know well clear the limit of his job and understand well the requirement of hour of rest under regulation. When the contract of working is assigned, its state clearly the time that he should work within 24 hours and the time he should rest in 24 hours. Proper record should be kept by chief officer daily to comply with regulation. The company and master of the vessel should ensure that the schedule regarding to time of rest or system of keeping vessel manned adopted by company is benefic to all seafarer while in port or at sea. Chief officer fail to record is time of work and therefore, he allowed the action of fatigue to be present at work place and sub-consequentially not keeping the proper lookout while on duty in bridge. The master should ensure that timetable of duty and proper records are been kept at all the time. It is the master duty to ensure that all crew are having appropriate rest time during operation in port and during voyage at sea. Master as representative of company should have in consideration the number of worker he had on board vessel and in case of needing of more worker, he should brought it up to the company requiring more people of board to avoid overtimes and affect of time of rest required by law. The record of hour of rest is important at all level as its proved that proper hour of rest are been kept on board. This record can be providing during the inspection and enforcement by the MCA. The master has the right to send anyone home if he found that the ship has been endanger by the action of any crew. Proper look should be kept by all mean necessary to ensure that the vessel is safe together with all crews and environment and that no other vessel is in doubt of action while at sea /port. 2 NPJ Assessment 3/3/2013 9

The company should ensure that there are enough crew to the required job and operation and that the manning level is adequate all of time necessary and in all respects in accordance with the principles contained in merchant shipping note. The owner or company should require a report regarding to the hour of work at every single operation to ensure that the number of employees is enough of any individual operations or activities on board vessel. The company should identify all the functions undertook on board during a voyage and or during any operation period, this include also the number of personal involved in operation and the required number of personal for undertaking the relevant tasks and duties during the voyage or while in port.

Merchant navy code of conduct

The merchant nay code of conduct state in serious cases the master may suspend a seafarer from duties and take such action to preserve the safety of the ship, persons or cargo on board or the marine environment, as he consider appropriate. The master of the vessel took the right decision to send home the chief officer, despite of his action of fall asleep was regard to the less time of resting. The code even further says, master may require for the seafarer to be disembarked and repatriated as soon as partible. In any case, the master should give a formal warning before taking into account the option of sending him home. It may be clear that dismissal someone from the vessel will not automatically terminate employment. A shore manager will be chosen to investigate and consider the near future of the seafarers employment apart from his dismissal form the ship.

The requirement of safety management system

Safe management system is a way of controlling risk and identifies multiple hazards. It provides the right measurement and setting of performances. On board ship, safe management system become our of the factor that influence the safety culture on ship, that is by taking in consideration the safety way people on board do their job to avoid risks and accident in such level as practicable. So many companies implement the job hazard analysis or checklist, which provide the required and relevant information regarding to the safety at working place and measure to be taken to prevent accident happen. Safety management system provide the real tool to many companies as its work as a form to identify hazards and minimize risks of accident to occur due to the safety culture implemented by company and by the seafarers themselves. 2 NPJ Assessment 3/3/2013 10

Safety culture applied by seafarer is a good informal tool to reduce risk at workplace and eventually the risk of pollution to the environment and society. The crew based on their own experience they determine the good way of manage the things without putting into danger the safety of the vessel and their won safety. Human error is considered to be an action failure taken by someone without any intention of doing that. Chief officer did not have any intention of falling asleep on the bridge during the watch, but the consequences of action can lead in environment pollution and lost of life. Master of oils tank made a big mistake, which can be considered as a systematic error. Systematic error can be a error made by someone because of failure of system or because of lake of good management on working place. Master and company they should implement the safety culture on place, by doing constant meeting and drilling regarding to the operation and take that it can take, taking in consideration the possibility of machinery failure. Human error can lead to damage to the environment compered to the systematic error, where men can control the impact of damage. Job analysis taken in place where so poor and dangerous for company, crew and environment, because before any job take place it is important to have the permit to work on place and other permit associated such as working in enclosed space permit and so on. When the permit is filled it state the people involved on work and the estimated duration of the work. The master should be aware of this situation when He signed the permit (if any), he should advice chief officer to take the relevant rest to avoid fatigue and therefore falling asleep during the watch. Safety management helps a lot the company and master to view the safety implemented on their vessel and how it correspond to the reality of present circumstance and of the work to be done. The relieve officer did not take in consideration the physical aspect and quick assessment to the chief officer when he was taking over the watch. If he should do so, he could realize how tired and fatigued was the chief officer. A company failed to ensure a proper systematic manner to keep the vessel safe and healthy. The implementation of safety culture should be encouraged by the company, master, officer and crew at all the times and should have on place a proper module as a sign of example to be followed.

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Risk assessment
Before any job take place in an enclosed place the following should be considered: The access on working place (how to get in working place) A proper stand by man with talk talk (UHF) radio Vented place and portable fun on place Breathing apparatus equipment Stretcher Heavy line and harness Appropriate torch And proper PPE Oxygen measured and reading 20.9% Measurement of gases, Hs It is very important to determine the possible area where accident or risk is likely to happen and to find the proper procedure to minimize the impact of the risk present in working place. In annex there are a proper job hazard checklist regarding to the pump repair. Tuesday, March 4, 2014

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