Learning from the past for pro-activity -A re-analysis of the accident of the MV Herald of Free Enterprise

Paper in proceeding, 2011

On the evening of the 6th of March, 1987, the Roll on/Roll off Ferry Herald of Free Enterprise left the berth in the port of Zeebrugge at 18.05 and capsized about 20 minutes later. 188 people died in this tragic event. A formal investigation report concluded that both the crewmembers and the shipping company were to be held responsible for the outcome. Although the shipping company was considered partly accountable, the investigation based its result on a rather person-centered view on how accidents occur. This perspective on accidents, being the outcome of a chain of events leading to an unwanted consequence, has been challenged during the past 20 years by several researchers. This article re-analyzes this specific accident from a systemic perspective. Functional Resonance Analysis Method (FRAM) is used to shed new light on what may have cause the ship to capsize. In addition, we discuss whether results from accident analysis can be used to develop pro-active measures for the safe operation of ships.