CHIRP Annual Digest 2023

An independent and confidential reporting system for the Maritime industry

PORT OPERATIONS COMMERCIAL FISHING RECREATIONAL AND DIVING CRUISE AND FERRY SUPERYACHTS ENGINEERING AND DESIGN DECK AND CARGO OPERATIONS BRIDGE, PILOTAGE AND NAVIGATION

Are you interested in becoming a CHIRP Maritime Ambassador? CHIRP and the Nautical Institute seafarers (see map) who also share to improve safety outcomes. The have an established ambassador your passion for safety, and you key attributes of a successful scheme to raise awareness of will quickly gain a broad knowledge ambassador is a passion for safety our incident reporting schemes of current safety issues. These and a willingness to speak up for and encourage the submission are great additions to your CV and CHIRP among your colleagues of incident, accident and increase your employability. and contacts. near-miss reports. Together we can promote the If this sounds like you, please contact As an ambassador you will join an development of a ‘just’ reporting us to discuss this opportunity at international network of over 50 culture across the maritime sector mail@chirp.co.uk

YOU REPORT IT WE HELP SORT IT

Annual Digest of Reports and Insight Articles 2023-24

The CHIRP Charitable Trust, 167-169 Great Portland Street, London, W1W 5PF United Kingdom © The CHIRP Charitable Trust Designed by Phil McAllister Design Printed in the UK by The Print Consultancy

The number of reports received continues to increase year-on-year. Many of these are the result of an industry under pressure

www.chirp.co.uk/maritime CHIRP Annual Digest 2023-24

Maritime Director’s Foreword 20 year’s in – and still going strong!

I am delighted to present our Annual Digest for 2023-24. The power that this compendium of safety-focused incident reports and in-depth ‘insight’ articles draws upon is that they are all based upon the real-life experiences of our reporters. These span almost every part of the maritime industry and represent a broad cross-section of the topical safety concerns and issues facing our global maritime audiences. 2023 is the 20th anniversary of the CHIRP Maritime programme. As ever, our primary focus has been on improving safety for seafarers worldwide. We respond to every report that we receive, and we have continued to assist our reporters in many ways. For those reporters who felt that they could not use their own company reporting system, we advocated for them while protecting their identity. In other cases, we liaised with Flag States or Classification societies regarding serious design or compliance issues. In yet others, we engaged with national regulators on recurring issues such as pilot ladder arrangements. The results of these activities are recorded in each of the reports, and regular readers will detect that this Digest contains more than previous editions. This year we augmented our primary Maritime FEEDBACK newsletter with additional editions for the commercial fishing, ports, and superyacht sectors in recognition of the unique challenges that each face. This year, CHIRP has also co-produced a new podcast series called Seaviews, with each episode focusing on a particular topic of interest from a safety perspective. All of these activities and initiatives, and the positive safety impact that they enable, are only made possible by the continuing and very generous support of our funders. We are truly humbled by their continued financial and moral support – thank you. Finally, I hope that you find this edition both interesting and informative. We are always keen to hear your thoughts and ideas, too.

Yours in Safety,

Adam Parnell Director Maritime

CHIRP Annual Digest 2023-24 www.chirp.co.uk/maritime

Foreword

William H Moore Director Maritime, The American Club

Incident Reporting Is Key to Loss Prevention W hat is it that makes near misses and reporting so effective for safety? Humans learn best through direct participation, increased engagement, creative thinking and real problem solving, i.e. collective, active learning. Learning from mistakes and interventions that prevent incidents in the hands-on, active engagement environment, through the sharing of stories and experiences that not only makes it easier to absorb complex material, but also makes it easier to remember. The best way to learn a lesson permanently is to experience a terrible outcome that spurns actions to ensure it does not happen again. The ultimate objective of those types of experiences is a greater appreciation and awareness for executing tasks safely. P&I clubs, including The American Club, take a particular interest in encouraging near miss reporting mainly for the benefits of identifying, assessing, and mitigating risks in order to prevent loss and support seafarers’ safe return to their loved ones ashore. Near miss reporting is an opportunity to learn from real incidents, without the devastating consequences of tragic and costly claims. Traditionally defined as “a narrowly avoided incident, damage, or close call,” near misses are a much more acceptable outcome to a real accident. CHIRP Maritime provides a mechanism for reporting hazardous situations, near misses, and incidents that can be assessed and analyzed, and recommendations disseminated for the greater good of mariner safety. All maritime stakeholders benefit from such assessments and recommendations but most importantly, seafarers and their families are the ultimate beneficiaries.

www.chirp.co.uk/maritime CHIRP Annual Digest 2023-24

Acclamations and CHIRP Maritime’s collaboration activities Abuse, bullying, harassment, and discrimination (ABHD), Invitation to the North American Maritime Ministry and violence against seafarers Association (NAMMA) Conference in July 2023.

CHIRP Maritime is very proud to be a part of the CHIRP was honoured to be invited to the annual working group to eradicate ABDHV against seafarers. NAMMA conference in Seattle, USA, to listen to and participate in the fantastic work carried out by the various ministries that visit commercial shipping in the Maritime Professional Council- Kind Leadership Webinar United States of America and Canada.

Members of the Maritime Professional Council (MPC) World Maritime University and CHIRP were invited to participate in a Webinar hosted by the Nautical Institute on the subject of Kind Leadership in the Maritime Industry in November 2023. Citation from the World Maritime University for CHIRP advertising the report on the “Barriers to personal protective equipment use among international GCaptain citation. seafarers: a UK perspective”.

International Maritime Human Factors Symposium Glasgow, Scotland, 30 Nov – 1st Dec 2023

CHIRP Maritime was part of the organising team and participated in the event, which was attended by over 100 participants.

Five organisations signed the MoU for the safety and Seafarers’ Charity Award security of global tradez

Dave Watkins, the Deputy Director of CHIRP Maritime, CHIRP Maritime was honoured to receive an award expressed delight in being part of the MOU, adding that from the Seafarers’ Charity President, HRH The CHIRP Maritime would work with its partners to collect Duke of Edinburgh KG GCVO, for CHIRP’s invaluable information on operational cargo-related accidents contribution to seafarers’ wellbeing and helping and incidents and share the learning with the wider seafarers to thrive. maritime community to promote best practice in the The award was presented to CHIRP Maritime supply chain and reduce the number of cargo incidents Director Adam Parnell at the Seafarers Charity AGM in on board ships and terminals. London June 2023.

CHIRP Annual Digest 2023-24 www.chirp.co.uk/maritime

Introduction O ne of the great pleasures of compiling our Annual Digest is that it gives us an opportunity to revisit all the reports we have received during the year. The excellence focused editions of Maritime FEEDBACK. The first of the new publications covered the superyacht sector and was so successful that we have produced four subsequent of the reports and the commitment of our reporters is editions. They then turned their attention to the fishing inspirational, and this ninth edition of the Digest is as varied sector, and ports and harbours, each of which is expected and thought-provoking as any of its predecessors. to be published twice per year. Although I have described Without our reporters we would not exist, and we owe these as ‘focused’ editions, the safety message is universal them a tremendous debt of gratitude. The world’s seafarers so they contain useful lessons for all of us. If you have not face constant challenges, not only from the traditional yet read them, the reports are all included in this Digest, forces of the oceans and the weather, but increasingly from and I urge you to study them. conflict and violence in many parts of the world. A senior In other news, we set about recruiting more shipping executive recently described the past year as ‘one Ambassadors to help spread the safety message. At time of of the most dangerous times in memory’, so the fact that writing, we have 58 Ambassadors in 31 countries, and we our reporters still find time to make a real contribution to the thank them all for volunteering their time in a very worthwhile safety of others is a tribute to their character and dedication. cause. If you would like to join them, please contact us. It is an honour to thank them all on your behalf. As always, every report we publish is discussed Director, Maritime Adam Parnell and Deputy Director at the Maritime Advisory Board (MAB) once it has Dave Watkins continue to implement improvements. In been rendered anonymous and the reporter cannot addition to the new website (still a work in progress), they be identified. MAB members are all experts in their have produced 7 podcasts which are described elsewhere respective fields, and our analysis benefits enormously in the Annual Digest, and have launched a range of sector- from their skill and experience.

www.chirp.co.uk/maritime CHIRP Annual Digest 2023-24

We also benefit from the sterling work of Stephanie Once again we have divided the Digest into themed Dykes, our Administration and Finance Manager, and her sections to allow readers to find the topics which most maternity cover Alexandra Fairclough. They are responsible interest them, but there are many reports which could for the smooth running of the general and financial have been allocated to several different sections, so we administration of CHIRP, which allows Adam and Dave to urge you to study them all. There are useful lessons both concentrate on our safety mission. They do a superb job of for seafarers and shore staff in every report we publish. keeping everything shipshape. We also include a number of Insight articles We continue to publish FEEDBACK in as many which discuss topics in greater depth, or shed light on languages as possible, and recently added Arabic to the important safety matters. They are written by experts, English, Chinese, Filipino, Indonesian, Spanish, Portuguese and all worth reading. and Ukrainian versions on the website. Our translators Finally, we hope you will find this Annual Digest give their time and skill to help us reach as many people both interesting and informative. Please let us know as possible, and we are enormously grateful. Please let us your views, because your opinion matters and we read know if there are other languages you would like to see all your comments to ensure we continue to provide the or, even better, if you would like to sponsor a version in information you need to make our industry safer. another language. Until next time, take care and may all your voyages As always, we rely on the generosity of sponsors to lead you safely home. produce our publications, podcasts and other offerings, and we simply could not function without them. The companies and organisations which have supported the Editor: Captain Alan Loynd publication of the Annual Digest are listed within these FNI FITA MCIArb BA(Hons) pages, and all our sponsors are acknowledged in our other publications. We thank them all. This year we received more reports from the fishing sector, but we still see almost nothing from the offshore industry. Such a large and important sector undoubtedly has many useful lessons to share, so we hope to hear more from them in the future.

The world’s seafarers face constant challenges, not only from the traditional forces of the oceans and the weather, but increasingly from conflict and violence in many parts of the world

CHIRP Annual Digest 2023-24 www.chirp.co.uk/maritime

Table of Contents

1. PORT OPERATIONS 11 Vessel grounding in harbour 12 Lone Fisher Falls Overboard 13 Mooring launch crushed against the side of a container vessel 13 Contingency action to avoid a close quarter incident with a passenger Ferry 14 Fouled Towing Line Bridle 15

2. COMMERCIAL FISHING 16 Potentially fatal near miss 18 Propellor fouls on pot line 18 Caution: short-cuts can bite! 18 Collision between a fishing vessel and ferry in port 19

3. RECREATIONAL AND DIVING 21 Tender capsize when towing inflatable places 4 in lethal danger 22 Collision with a Yacht in a busy traffic lane 22 Capsize of a Dive Safari Vessel and Rescue of Tourists and Crew 24 Personal injury while diving 25

4. CRUISE AND FERRY 26 Inadequate supervision and Risk Assessment 28 Passenger ship evacuation procedures 28 RoRo crewmember hit by vehicle while unloading 29 Insight: Seafarer Welfare Meets Seafarer Safety 31

5. SUPERYACHTS 33 Pressurised to make a fatal decision 34 Near miss during lifting of a tender 34 Lithium-ion Battery Fire 35 Tender grounding 35 Entrapment in running equipment causes serious personal injury 36 Lack of familiarity with equipment puts the vessel in danger 37 Dangerous recovery of a person in the water 37 A shortcut they’ll remember for a long time 38 Near miss approaching port 39 Maintain control… right to the bitter end 39 Near miss due to distractions 40 Grounding and Dismissal 40 Lifting eyebolts failed while launching a Tender 41 Anchoring Angst 42 Inappropriate risk assessment 43

www.chirp.co.uk/maritime CHIRP Annual Digest 2023-24

6. ENGINEERING AND DESIGN 44 Engine status not known 46 Personal Injury due to gangway malfunction 46 Dredging a ship’s anchor to reach a temporary anchorage 47 Fatigue issues for Contractors who work on ships 47 Incorrect response to fuel leaks results in an unintentional power shutdown 48 Galley fire 49

7. DECK AND CARGO OPERATIONS 51 Unsafe access for the crew on a logger 52 Imminent mooring failure averted by vigilant crew 52 Fire in Container 53 Incorrect stowage incidents 54 No gas detection equipment carried on board 55 Severe Near Miss – accommodation ladder wire parts after pilot disembarks 56 Damaged cargo securing equipment 56 Personal Injury during mooring operations 57 Insight: Advancing safety in the shipping industry: the rise of automated vessel self-cleaning systems 58

8. BRIDGE, PILOTAGE AND NAVIGATION 60 Loss of steering control on a bulk carrier approaching a berth 62 Workload distractions lead to a high-speed collision 62 Unsafe fendering arrangement for Ship to Ship Operations 63 Incorrect Information Provided during Master-Pilot Exchange 63 Communications difficulties hinder understanding 64 Insight: The Crucial Role of Mental Health in Seafaring Professions 64 Insight: Tiredness Can Kill – Take a Break (Fatigue Management for Bridge Watchkeepers) 65

OUR SPONSORS 70

10. APPENDICES 71 Appendix I: Acronyms 72 Appendix II: The Maritime Programme – How it works 73 Appendix III: Our Publications 74 Reference Library 74

CHIRP Annual Digest 2023-24 www.chirp.co.uk/maritime

1. Port Operations A number of themes can be identified in this section. Language difficulties, a lack of situational awareness, lack of supervision and the need to avoid close quarters are all prominent. Most of the problems could have been overcome with better planning so the ability to plan ahead and make contingency arrangements is vital. This is clearly shown in a report of a passenger ferry which had pre-planned abort positions in the port approaches. Of all the human factors discussed in this section, communications appears most often. We stress that everyone needs to know what is going on, and this often means informing not just your own crew but third parties as well. In addition, we identify alerting, fatigue, situational awareness, pressure to avoid delays, poor safety culture and a lack of teamwork as contributing factors. These all appear in more than one report, but most of them can be avoided with better planning and preparation. Among the human factors we identify are: communications y the bridge team should affirm the pilot’s actions y clear communication from the port authority is vital y closed loop communications are the safest option alerting y do you provide the support the pilot needs? fatigue y elements of fatigue may always be present, especially at night y can operations be timed for daylight when the crew are better rested? y situational awareness y take additional care when working lines if other vessels are in the vicinity y night operations require enhanced situational awareness pressure y time pressure can result in poor supervision y mooring operations must never be rushed y poor safety culture y company safety culture must empower employees to prioritise safety y lack of teamwork y check that all members of your team know what is happening

CHIRP Annual Digest 2023-24 www.chirp.co.uk/maritime

M2100 the vessel had drifted due to wind and tide and had grounded on a charted shallow patch. The port authorities

Vessel grounding were informed, and a fourth tug was despatched to push onto the vessel’s port quarter. With this assistance, the

in harbour ship safely manoeuvred off the shallow patch at 0506 and subsequently berthed without further incident after extensive checks on the hull’s watertight integrity.

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Vessel 400m LOA Ri Establishment and operation of aids to Draft 15m Wind navigation should be reviewed for each Tide 90 minutes after high water port as the volume of traffic justifies and City the degree of risk required River CHIRP Comment Maintaining situational awareness at night is challenging. Port Visual references are difficult to make out, particularly against background lights, and they can change over time due to development ashore. IMO SOLAS Chapter V regulation 13, As part of the assessment, port authorities must consider whether their navigation aids are sufficient to enable safe navigation, including appropriate lit aids to Open sea navigation if the port is open at night. To determine which aids are required, countries and port authorities must conduct risk assessments of their ports. IALA guidance Initial Report (G1124) provides a guide to safety assessment. The pilot boarded a very large container ship at 0200 before The briefing