The Doors of Death: The Herald of Free Enterprise

Pushkin the port of Zebrugger, Belgium. Assistant Bosa and Mark Stanley is helping to direct all the trucks, cars and buses off the ferry after their four and a half hour journey from Dover, England. Then he'll help to load up all the trucks, cars and buses that are waiting to board for the trip back to Dover. It's a chilly Thursday evening in March nineteen eighty seven. The ferry is the herald of free enterprise. It's so relatively new design called row Row, roll on, roll off, as the name suggests, this type of ferry is designed so vehicles can simply drive on in one port and off in the other. There are big doors at the front and act that opens so a ramp can be lowered. The vehicles park on a lower deck and their occupants head

upstairs to spend the journey on one of the passenger decks above. Then, obviously those big doors must be closed again before the ferry departs, otherwise you're going to see with a hole in one end of your ship. It's the job of the assistant Bosa and Mark Stanley to close those doors. Four years earlier, on another row row ferry owned by the same company. The person responsible didn't close the doors he had fallen asleep. That could have ended in disaster. Had the waves been too high, or the open doors sitting too low in the water, the sea would have rushed in. They got away with it that time, but they were lucky on the Herald of Free Enterprise. On that cold z a brugger evening, the vehicles are almost finished loading for their journey back to Dover.

Mark Stanley's boss, the bo'sum, a kind of foreman, tells Stanley to go back to his cabin and take a break. It's been a long day. The ship's not yet ready to depart. When it is, the captain will call over the loud speakers, as always harbor stations. Hearing that will be mark Stanley's queue to return to his post and close the doors. Stanley goes back to his cabin and makes a cup of tea to warm himself up. He sits on his bunk, intending to read for a while.

He yawns and stretches. It really has been a long day. His eyelids start to droop. I'm Tim Harford and you're listening to cautionary tales. The first time I went on a holiday outside the UK at the age of twelve, we didn't fly. It was expensive, especially for a family with four kids. Instead, we traveled on a brand new row Row ferry. I still remember her name, Cunninghen Beatrix.

We loaded up the car at home, drove a few hours to the port, then onto the ferry. You could stand outside on an upper deck, feel the sea breeze on your face, to the seagulls and the chug of the diesel engines, and watch the shoreline receed into the distance, or go inside, where there was a cafeteria, slot machines, and a TV room showing cartoons. We enjoyed that journey I expect we'd have enjoyed it less if we've been aware of the memos circulating inside Townsend torreson the company that owned the Herald and several other row Row ferries.

Not long after that near miss on the Herald's sister ship when the doors weren't closed, the same ship had another near miss. The captain wrote a memo to the crew. Twice this ship has sailed with the stern or bow doors open. All the named persons must see that the system is worked to make sure this dangerous situation does not occur. Give it your utmost attention. The captain of the sister Ship was a thoughtful man. He understood that people are human. Utmost attention or not, things sometimes go wrong.

It's good to have a backup. He worried that from the captain's position on the bridge, he couldn't see the doors, so he couldn't check himself that they'd been closed before setting off. He wrote a memo to a company director. There was no indication on the bridge. He explained as to whether the doors are closed or not. The memo pointed out that a worker might be delayed in closing the doors, or there might be a mechanical problem the captain wouldn't know. He proposed a solution. Indicator lights could enable the bridge team to monitor the situation in such circumstances, a sensible lights on the bridge to show if the doors were open or closed. It would have been a bit of hassle and expense to implement, but not that much.

But when the director got the captain's memo, he was far from convinced that it was worth the bother. He circulated the memo to his company colleagues and asked for their opinions on the idea. Nice, said one, but don't we already pay someone? Another shrugged, Assume the guy who shuts the doors tells the bridge if there's a problem, well he should, but he won't if the problem is that he's asleep. The Captain's sensible, easy to implement solution went nowhere, and so two years later, as Mark Stanley dozed in his bunk on the Herald of Free Enterprise, there was no indication on the bridge that the ferry's doors were still wide open. As darkness fell and Zebrugger, the Herald left the calm of the harbor for the

open sea, carrying four hundred and fifty nine passengers and eighty crew. Ian Yardley's book Ninety Seconds at Zebrugger brings together accounts of what happened next. It started with the plates and the cafeteria sliding slowly across the tables. Everyone began to joke about it, recalled one passenger. Then there was a crash from the kitchen, the sound of smashing crockery.

In British culture, there's a reflex response to the smash of dropped crockery in a cafe or pub gray. A big cheer went up, said one passenger. Some people clapped, added another. The ship righted itself. Presumably it had just been hit by a wave. No need to worry. But it continued to roll to the other side, slowly at first, the passenger recalls. Then it suddenly accelerated like a wire had been cut. No one had a chance. Another added, the ship literally tipped over, as if you were knocking over a glass of water. It seemed that quick. One young man was drinking at the bar when he saw a baby hurtling through the air like a javelin. Instinctively, he dropped the drink and launched himself towards the baby,

but missed and grabbed onto a chair. I've never sobered up so fast in my life, another man recalled. I wedged myself up against a chair and table. People were flying past me like bullets. The furniture, at least was all bolted to the deck. One young woman recalled that holding on to a table took every ounce of strength and more. Another near the duty three had to hold on while being clattered by the falling bottles of whiskey and vodkast. One man was dangling from a table, trying to keep hold of his seven year old son, when a girl flew by and made a desperate grab for the man's legs. It was too much, his partner recalls, he lost his grip. That was the last I saw of them. Then the lights went out. For one crew member,

that was actually a relief. He had been clinging to a partition wall, watching with helpless despair. People were thrown like rag dolls thirty forty feet through the air. It will be embedded in my mind for the rest of my life. It took just a minute and a half for the ship to settle on its side. It was only by chance that it wedged on a sand bank instead of sinking completely. The sea rushed in. Those inside the ship who survived the fall now found themselves struggling to stay afloat in bitterly cold water in pitch darkness.

Then objects began to rain down on them, making it hard to find space. Ironically, they were life jackets. A locker on the wall now above them had burst open. There were so many life jackets, said one passenger. Everyone was tangled up in the straps. Assistant bosun Marks meanwhile, had found his boss Bows and Terry ailing the doors. Terry, don't worry about that now, said Ailing. We've got this to sort out. Cautionary tales will be back after the break.

I was thirteen years old when the Herald of Free Enterprise capsized in Zebruger. It's the first news story I remember finding personally shocking. The pictures on the television showed the faerry lying on its side, so agonizingly close to the safety of the harbor walls. I've been on holiday last year on a ship like that. It had sailed with the doors open. How on earth could that happened?

A senior judge, the Honorable Mister Justice Sheen, was put in charge of answering that question at an official inquiry. The immediate cause was easy enough to identify. Mark Stanley was supposed to close the doors and didn't. Stanley told the inquiry, I thought I was dreaming. I never fell off my bunk. I leapt because I knew something was not right. I thought, then was the doors. The doors.

The doors had not been shut. I knew I hadn't checked them. I was just hoping someone else had done it. Mister Justice Sheen clearly had some sympathy for the assistant Bosum. Mister Stanley has frankly recognized his failure to turn up for duty, and he will no doubt suffer remorse for a lot long time to come. But it was clear to mister Justice Sheen that the safety of a ship really shouldn't depend on whether or not one man nods off on his tee break townshend Torrison must have had backup systems, mustn't they? She wanted to know what they were.

He talked to Mark Stanley's boss Bows and Terry Ailing. Ailing could have closed the doors. Why didn't he? It has never been part of my duties to close the doors, said Ailing, or make sure anybody is there to close the doors. The judge was unimpressed. He took a narrow view of his duties, and it is most unfortunate that that was his attitude. Still, we can hardly get outraged about someone not doing something that isn't their job. But hold on, Ailing said, it wasn't his duty to make sure anybody's there to close the doors. Was there someone else who did have this duty? Yes, she discovered the ship's chief officer actually, in the company's written policy, his duty was to ensure that the doors are secured, but

in practice, Townsend Torreson defined that as checking that the person whose job it was to close the doors was somewhere in the vicinity of the doors and therefore presumably about to close them. Mister Justice Sheen shook his head. That's a weird way to understand ensure that the doors are secured. The chief officer told she that he thought he saw Mark Stanley on the deck approaching the doors, but must have been mistaken. Sheen interrogated the captain. It's his ponsibility to make sure that his ship is seaworthy.

Why had he set off with a large hole in one end of it? He explained to Sheen that nobody had told him the doors hadn't been closed, so he assumed they had. If that sounds crazy, remember it was exactly what a senior company figure had shrugged in response to the sensible idea of an indicator light. Assume the guy who shuts the doors tells the bridge if there's a problem. It was even written down in a company policy.

Kind of the policy said that others on the ship had to report any deficiency which is likely to cause them to be unready for sea, and in the absence of any such report, the captain could assume that the vessel is ready for sea. Once again, mister Justice Sheen frowned at the drafting. Were open doors a deficiency? Unclear?

The company interpreted its own policy to mean that the captain could simply assume the doors had been closed unless told they hadn't. As mister Justice Sheen pointed out, that was, of course a very dangerous assumption. The sea wasn't especially rough in Zebruger, but the Herald was sitting low in the water and lower at the front, which was the end where the doors were open. As the ferry picked up speed, that pushed the front end lower still, and waves began to lap onto the vehicle deck. The deck was a big open space. As water sloshed about, the ship lost all stability, rapidly tipping onto its side. It took just a minute and a half to plunge everyone on board into a horrible, black, freezing nightmare. As eyes

slowly got used to the darkness, some passengers realized they were trapped under toughened glass partitions down the middle of the deck, just a couple of feet above where the water had risen. One pummeled the glass above with such force he dislocated all his fingers. Bosa and Terry ailing found himself above those glass partitions and went to look for something to smash them. I'll never forget having to walk on the windows, he said. It was like a scene out of a horror film. We were walking on people's faces. Fists hammering at the windows to struggle for survival brought out the best and worst of human nature.

In one part of the ship, with a yawning space above the fatally cold water, a rope was lowered. Two men shoved others aside so they could be the first to climb. Both lost their grip and fell to their deaths, but others were heroic. One man with his wife and daughter realized that their route to safety lay on the other side of what used to be a corridor and was now a vertical shaft filled with water and too wide to jump. I spread myself in the water, he recalled.

I arched my back and held onto the railings on the other side so people could use me as a stepping stone. He told his daughter to walk across his back, then his wife, then twenty total strangers the press dubbed him the human Bridge. People looked after children. It didn't matter who child. Babies were plucked from the water and handed up to those above who could hug them to keep them warm. A woman consoled a nine year old who kept asking, why should I die? I've been such a good girl. I've never told any lies. A middle aged truck driver found himself in charge of another small child.

I mean all is panic and chaos, he recalled. She just sat on my knee, smiling. I'll never forget her for as long as I live. One woman recalled how her husband made sure she was safe, then went back into the bowels of the ship. He was not looking for anybody in particular, just anybody he could help. She had no idea where he was for the next day and a half. It turned out he'd been helping people for hours until he collapsed with hypothermia and had to be taken off the ship by professional rescue us. He had saved many lives and was traumatized. I obviously didn't do enough. Assistant Bosa and Mark Stanley meanwhile spent two hours pulling people up thro a smashed window before he too collapsed, bleeding from a deep gash in his arm.

He kept repeating, it's my fault, It's my fault. One hundred and ninety three people died on the Herald of Free Enterprise. We've met four workers on the ship whose actions combined to cause those deaths. One fell asleep, one didn't do something that wasn't his job, one misidentified a colleague, and one followed company policy. None of these things seemed like hanging offenses. Regular listeners to cautionary tales will know that this is typical of many disasters. There's no obvious villain who deserves to be locked up, just a series of innocuous, seeming things that happen or fail to happen.

The classic way to look at such disasters is the famous Swiss cheese model, developed by the accident expert James Reason. It imagines safety systems as being like layers of cheese, each have holes in them, and the problem comes when all the holes just happen to line up. The Herald of Pre Enterprise was one of Reason's first case studies. Indeed, the idea of the Swiss cheese model traces back to nineteen eighty seven, the year of the Herald disaster. Reason and a colleague doodled the layers on a paper napkin in a pub. Often inquiries into disasters find that nobody had ever foreseen how the holes might line up. The inquiries inform new regulations that plug holes or add another layer.

But what if an inquiry finds that people had foreseen exactly how those holes might line up and done nothing about it. Then a good way to prevent future disasters might be to identify who's to blame and hold them accountable. Mister Justice Sheen could see exactly who to blame, but could they be held to account? Cautionary tales will be back after the break. Two years before the Herald disaster, remember a sister ship had sailed with its doors open.

The captain made a sensible request for an indicator light and got a dismissive reaction from the higher ups at the company. Assume the guy who shuts the doors tells the bridge if there's a problem. Another response was outright sarcastic. Do they need an indicator to tell them whether the deck storekeeper is awake and sober? My goodness, mister Justice Sheen was scathing. It is hardly necessary to comment that these replies display an absence of any proper sense of responsibility.

A year later, another captain sent another memo after another near miss, to chase up the suggestion it is so important to the safety of the ship that the doors are closed, He pointed out, we should have bridge indication. Is the issue still being considered? The reply said, simply, if the doors are left open, then the person responsible for closing them should be disciplined. The failure of imagination is staggering. It should have been obvious that leaving the doors open might sink the ship. If that happened, how could anyone possibly think that disciplining the assistant Bosun would solve anything. The assistant Boson, Mark Stanley, didn't need anyone to tell him of The next morning in hospital, one

survivor recalls seeing him in a dreadful state, sobbing and repeating, it's my fault. Mister Justice Sheen disagreed. A full investigation leads inexorably to the conclusion that the underlying or cardinal faults lay higher up in the company. The more she learned about how Townsend Torreson was managed, the more appalled he became. She wanted to know who was responsible for those sloppy and ambiguous written orders. The company's lawyer replied, well, in truth, nobody, though there ought to have been. Nobody was responsible for safety either. Sheen found the board of directors did not appreciate their responsibility for the safe management of their ships. The Fairies regularly sailed with more passengers

than the legal limit because nobody had come up with a system for counting them. That, observed Sheen should not have been beyond the wit of the managers. When the Herald sank townshend Torreson had no idea how many people had been on it. Thet alone a list of their names. What about keeping track of how low the ship sat in the water at the front and the back. That should be measured before each journey, And the Herald's log book was full of numbers, But those numbers showed that it always sailed on an even keel. That wasn't credible.

The captain admitted that instead of actually doing the measurements, the crew had simply been making the numbers up. Nobody ever checked. Mister Justice, Sheen delivered a clear and damning answer to the question of how on earth a ferry had set sail with its doors open? From top to bottom. He said the body corporate was infected with the disease of sloppiness. She made some specific practical recommendations for preventing future disasters, such as install indicator lights. But if the real cause of the accident was corporate sloppiness, the best way to prevent a repeat might be to incentivize corporations to be less sloppy. She couldn't do that. Though. He might be a judge, but as chair of an inquiry,

his remit was limited to finding out what had happened. He couldn't hand down punishment. In parallel to Sheen's inquiry, another legal process was running its course, the coroner's inquest. It too had a limited remit to decide what cause of death to put on the victim's death certificates. The inquest's jury decided that the deaths on the Herald of Free Enterprise were unlawful killing, but they again had no power to punish anyone. They couldn't even say who they thought had acted unlawfully. So what would happen to Townsend Torreson?

Nothing much? It seemed. There'd be monetary costs, of course, but they had insurance. The brand name had taken a hit from all of those aerial shots of the capsized Herald with Townsend Torreson emblazoned down its side. But not to worry. They could and did simply change their name and keep on doing business. That seemed very wrong to a man named Peter Spooner. When Peter Spooner first heard the news about the Herald of Free Enterprise, his heart lurched.

His son, Martin, had planned to take that ferry with his friends. Coming home from a holiday in Bruges the next day, Spooner tried and tried to get through to an emergency hotline. He found a number for Townsend Torreson's head office and rang it. He recalls, I was shewed away by an unsympathetic executive. It was only when Martin's friend turned up ashen faced on Spooner's doorstep that he found out Martin hadn't made it. Peter Spooner went into a period of shock. After six months, he snapped out of it. The Inquiry had published its report. The Inquest was drawing to a cloone. Spooner realized that Townsend Torreson was going to face no meaningful consequences for their sloppy corporate culture, so what was to deter other companies in

future from being similarly sloppy with matters of public safety. Spooner helped to form a group, the Herald Families Association, that would take Townsend torreson to court. It was a case of seeking justice, said Spooner, not vengeance. The inquiry and the inquest had both had narrow terms of reference.

A criminal trial they thought might focus minds in other companies and help prevent other tragedies. But the families faced a problem. Setting Saalle with the doors open didn't seem to have broken any specific law. That might seem surprising. But the rowrou ferry, remember, was a relatively new design of ship. Maritime laws had been written long before they were invented. Those laws said it's an offense to keep a ship in port that's unfit to go to sea, But a row row ferry in port with its doors open isn't a problem. The law said nothing about going to sea in an unseaworthy condition. Row Row ferries sailed through a loophole that no one had ever imagined. The rowrou ferry is an early example of what's since become

known as the pacing problem. Innovations create risks that laws never envisaged, and regulators don't always notice until after something's gone wrong. As Spooner put it, regulation and legislation can only do so much. They follow in the wake of disasters instead of anticipating them. Still, though the risk of sailing with the doors open should have been obvious to Townsend Toaurreson, the company's failure to manage that risk seemed like it might fit the legal concept of gross negligence.

If a person causes death by gross negligence, they can stand trial for manslaughter. How about a company. The Herald became only the third trial for corporate manslaughter in English legal history. Neither of the first two had succeeded. The prosecution soon bumped up against an ironic problem. The offense of corporate manslaughter was as sloppily worded as town Centarosson's company policies. It required the identification of controlling mind behind the company, but as mister Justice Sheen had made all too clear, nobody was in control. The case against Townshend Torreson collapsed. Paradoxically, the company's very failure to designate responsibilities had let it off the hook. The problem wasn't with

one individual, but the cumulative effect of a rotten culture a flippant memo here, some loosely interpreted phrasing there. The sloppiness infected the whole body corporate, and the law simply wasn't set up to deal with that. In two thousand and seven, twenty years after the Herald disaster, the British government introduced a new law on corporate manslaughter. It followed a law campaign by the Herald Families Association and Peter Spooner, But legal scholars say the new law isn't working as well as they'd hoped. How to deter companies from being sloppy with public safety seems to be a harder problem to solve than we might hope. Five years later, on the twenty fifth anniversary of the disaster, one retired director

of Townsend Torreson, saw fit to complain to a newspaper that it was a monstrous injustice that the company had ever been prosecuted. He sniffed, it was just one of those tragic accidents. The assistant bosun Mark Stanley could never shrug it off like that. It's not up to me to blame anyone else he said, and I'm not going to with his remorse as best he could, and died in twenty sixteen. A grandfather and much loved coach at his local football club. He once reflected, you thought, how can I ever live with this? You can in the end, but perhaps the final word should go to a nine year old. I've been such a good girl. I've never told any lies. We tend at age nine to think that the world is just that actions always have consequences.

As we get older, we realize that's not true. But even as adults it's a lesson we never stop having to relearn. Key sources for this episode include Mister Justice Sheen's nineteen eighty seven investigation report and Ian Yardley's book ninety Seconds at Zibruger, The Herald of Free Enterprise Story.

For a full list of sources, see the show notes at Timharford dot com. Cautionary Tales is presented by me Tim Harford. It's produced by Georgia Mills and Marilyn Rust. The sound design and original music are the work of Pascal Wise. The show also wouldn't have been possible without the work of Jacob Weisberg, Greta Cohne, Corn Gilliard, Fisher benderdaf Haffrey, Eric Sandler, Christina Sullivan, Kira Posey, and Owen Miller.

Cautionary Tales is a production of Pushkin Industries. If you like the show, please remember to share, rate, and review. It really does make a difference to us. And if you want to hear it, add free and receive a bonus audio episode, video episode, and members only newsletter every month. Why not join the Cautionary Club. To sign up, head to patreon dot com slash Cautionary Club. That's Patreon, p A, t R, e o N dot com Slash Cautionary Club

The Doors of Death: The Herald of Free Enterprise

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