ABSTRACT
Maritime accident investigations historically tended to focus on the behavioural factors or those aspects readily observable and directly attributable to the accidents under investigation. This meant that focus was limited to the sharp end – that is the seafarers – with lack of training, poor lookout, a disregard for safety rules, risk-taking behaviours, violations and complacency often cited as the causes. The 1989 capsize and sinking of the Herald of Free Enterprise is perhaps one of the first cases in which the investigation and subsequent inquiry went beyond the traditional ‘individual’ focus to uncover the deeper, organizational safety issues (Grech, Horberry, & Koester, 2008). This led to increased concern over the management of risk in shipping and henceforth the regulated implementation of safety management systems further discussed in Chapter 3.
