corporate manslaughter law was strengthened following this. The "controlling mind" being a major change to enable prosecutions to be succesful.I watched it last week, very sad and infuriating at the same time ... why it happened was interesting to know but I found it galling that no-one was actually prosecuted in the end.
I was in Guetersloh from 1987 until 2016. I used to enjoy going to Paderborn, bit more lively than GT. I arrived 6 month after the tragic event and it had had a big impact on folk in BAOR. As those of us stationed out there at that time will remember, that particular ferry route was the quickest port to get to from BAOR/BFG so was heavily used by UK military and civilian personnel and their families.Pray tell…….where in Paderborn and when?
Swiss cheese model of causation. James Reason.A perfect example of disaster causality were lots of little events lined up to sink the ship, each one on its own wouldn’t have caused an issue.
That doesn’t help all those poor people who were killed.
Can only hope that safety standards never drop to that level again.
Really ! 1 inch !?The causes were truly shocking failures at all levels - the MAIB report makes for very interesting reading and I once used it as a basis for a presentation on management failings. It is true that due to the free surface effect (try carrying a tea tray full of water and see how much you spill) simply totally destroys all stability; about an inch of water in the car deck will sink the ship. There have been radical design and working practise/regulatory changes since then to make it much, much safer
Dona Paz 1987Swiss cheese model of causation. James Reason.
That’s why human factors is such a hot potato in the high hazard industry.
Unfortunately “corporate” have poor memories and forget the lessons of past incidents. Trevor Kletz
Piper alpha 1988
Texas city 2005
Deep water horizon 2010
To name but a few
Also a number of incidents in the railways over the years since.
Oh yes. I can dig out my Derret’s ship stability text book if you want. Have think back to that tray full of not very much water…….. then multiply that by several tens of metres of flat deck… a slight roll and it all gushes to one side and over you go. No way back, either. Cruise ships, car carriers and ferries are all very “tender” ships with slim (legal) stability marginsReally ! 1 inch !?
…..and numerous car carriers underestimating the free surface effect of bunker fuel in slack double bottom bunker tanks……Dona Paz 1987
Express Samina 2000
Salem Express 1991
All were RoRo's that should not have sunk.
Hence I always know my route to the deck, in the dark at all times.
There is no such thing as 'corporate memory', only regulation and the threat of personal prison time and excessive fines will keep 'corporations' in check
Bophal in 1984 is a classic 'it wern't me guv' corporate avoidance case, thousands dead, no one to blame.
Look up the 2006 story of the "Probo Koala" (if you don't already know it)
In summary: a large corporate dumped thousands of tonnes of toxic waste in west africa, killed hundreds and made thousands sick. CEO goes to sort it out with suitcase of cash, gets thrown in jail locally and not let out until each and every person affected is paid off and the mess cleared up.
It's amazing how fast they managed to do that with the CEO and CFO inside until the last dollar paid.
(Which is not quite the version of the story told on Wikipedia, but it's version told in West Africa and also by Trafiguria)
Inverted icebergsOh yes. I can dig out my Derret’s ship stability text book if you want. Have think back to that tray full of not very much water…….. then multiply that by several tens of metres of flat deck… a slight roll and it all gushes to one side and over you go. No way back, either. Cruise ships, car carriers and ferries are all very “tender” ships with slim (legal) stability margins