Many errors in complex organizations, especially hospitals, occur when we fail to clearly define lines of responsibility. Like the gang that couldn’t shoot straight, the culprit in disastrous events often proves to be poorly designed systems that allow human errors (or equipment malfunctions) to cascade to a disastrous end. Recently, I came across an evaluation of a maritime disaster involving a car ferry, the Herald of Free Enterprise, which sank in calm seas off the coast of Belgium in 1987. On this occasion, system failures led to the 90-second capsizing of a 433-foot ship, numerous injuries and the loss of 188 lives.
The Herald of Free Enterprise was one of those car ferries where the bow opens up like a clamshell, allowing cars to drive on and drive off quickly and easily. On this unfortunate day, the ship left port with the clamshell bow mistakenly left in the open position. The ferry was heavily laden with cars and trucks as well as over 400 passengers. Only minutes out of the harbor it took on water, sank and almost immediately capsized. Most of the fatalities were people caught below decks as the ship dove to the bottom.
How could this happen? How could such a fundamental mistake be allowed to occur? A cascade of errors was allowed to propagate due to two factors: incomplete or non-existent communication among the crew with fuzzy lines of authority and a poor definition of responsibilities, coupled with the absence of adequate warning systems.
The sinking began when the person directly responsible for closing the doors—the assistant bosun—fell asleep in his cabin after completing his maintenance and cleaning duties. That error cascaded when the assistant bosun’s supervisor noticed that the bow doors were still open, but did not close them: He did not see that as part of his duties.
The captain of the vessel assumed the doors would be safely closed unless told otherwise; even though no one was specifically assigned the duty to tell him. The chief officer, responsible for ensuring door closure, thought he saw the assistant bosun going to close the door, but did not verify that such was the case and that the doors were actually closed.
Further, the ship had a serious design flaw: From the bridge, it was impossible to see if the doors were open, and there was no information display (not even a single warning light) to tell the captain if the bow doors were open. Yet after a similar situation two years earlier (that resulted in a near-miss discovered before disaster occurred), a captain had requested a warning light be installed. But no action was ever taken to do so, nor were other captains warned of the deficiency.
The result: Numerous opportunities were missed to correct a single error caused by neglect of one person’s duties. There was no redundancy, no checklist, no definition of duties, no personal assumption of responsibility for safety, no knowledge of requests for safety improvements made two years earlier.
Is this any way to run an airline, er…ferry? More to come in my next column.
