A public court of inquiry into the disaster placed the blame on three of the ferry's staff: assistant boatswain Mark Stanley, who failed to close the bow doors after falling asleep in his cabin during a short break; first officer Leslie Sabel, who failed to ensure the bow doors were closed; and captain David Lewry for ...

The Zeebrugge disaster (MS Herald of Free Enterprise) in 1987 was a catastrophic failure of both individual personnel and a toxic corporate culture at Townsend Thoresen (Townsend Car Ferries Ltd.). The official public inquiry, led by Mr. Justice Sheen, famously concluded that the disaster was the result of the "disease of sloppiness" that had infected the entire company "at all levels of management." While the immediate cause of the capsizing was the Assistant Boatswain (Mark Stanley) falling asleep and failing to close the bow doors, the inquiry placed the ultimate blame on the company directors and managers. These managers had consistently ignored repeated warnings from the ship's masters about the dangers of their "speed-at-all-costs" turnaround times and had refused to install simple, low-cost "warning lights" on the bridge that would have alerted the Captain that the doors were open. The Captain (David Lewry) and First Officer (Leslie Sabel) were also faulted for failing to verify the doors were closed before sailing, but the Sheen Report made it clear that they were victims of an incompetent safety management system that lacked clear lines of responsibility.