Introduction to Fire Safety Management

4.11
Case study
On the evening of 6 March 1987 a British car ferry, the 
Herald of Free Enterprise
, left the dockside at Zeebrugge, 
Belgium, for a routine crossing of the North Sea. The ship 
was of a design called ‘roll on roll off’ (RORO) whereby 
vehicles drove through large doors at one end of the ship 
when loading and drove out through similar doors at the 
other end to disembark. RORO vessels are constructed 
with large, unrestricted car decks for maximum capacity 
to allow them to load and unload quickly.
Shortly after leaving the port, while many of her 500 
plus passengers were in the restaurant or buying duty-
free goods, the ship suddenly began to list to port.
Within 90 seconds, she had settled on her side on 
the seabed and, despite rescue craft being on the scene 
in as little as 15 minutes, a total of 193 passengers and 
crew died. It was the worst British peacetime accident 
since the 
Titanic
.
The subsequent public inquiry found that the bow 
doors through which cars and lorries were loaded had 
not been closed before she left her berth. As a result 
water began entering the car deck and very quickly 
affected her stability, even though the sea was calm.
The accident involved a phenomenon called the ‘free 
water effect’, which can cause catastrophic instability in 
vessels when even a few centimetres of water enter a 
hold or deck and, moving when the vessel rolls or turns, 
destroy its stability.
It was the policy of the company at the time that the 
ship did not sail with the bow doors open. However, the 
routine practice had evolved to leave port with the doors 
open in order to allow the fumes which had built up in 
the hold during loading to dissipate. Members of the 
crew were very well aware of the risks associated with 
this routine violation of a fundamental safety rule and 
attempted to bring it to the attention of senior managers.
The inquiry into the disaster, conducted by Sir 
Richard Sheen, found that workers had in fact raised their 
concerns about the risk of leaving the bow doors open 
on fi ve separate occasions, but the message got lost in 
middle management. The inquiry concluded that the 
operating company, Townsend Thoresen, was negligent at 
every level and ‘From the top to the bottom, the corporate 
body was infected with the disease of sloppiness.’
A coroner’s inquest into the capsizing of the 
Herald
of Free Enterprise
returned a verdict of unlawful killing. 
Many of the victims’ families made it clear they wished to 
see the Townsend Thoresen company directors (now part 
of P&O) face prosecution but due to the existing legal 
framework it was not possible in this particular case.
Charges of manslaughter were bought against the 
company on the basis that the company could be held 
criminally liable for manslaughter, that is, the unlawful 
killing by a corporate body of a person. However, the 
prosecution of P&O for corporate manslaughter ultimately 
failed, since it was ruled that a prosecution can only 
succeed if within the corporate body a person who could 
be described as ‘the controlling mind of the company’ 
could be identifi ed as responsible, and that the identifi ed 
person was guilty of gross criminal negligence.