CHIRP Annual Digest 2024

An independent and confidential reporting system for the Maritime industry

WELFARE ISSUES PORT OPERATIONS DESIGN ISSUES RECREATIONAL AND DIVING CRUISE AND FERRY SUPERYACHTS ENGINEERING AND TECHNICAL 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

Annual Digest of Reports and Insight Articles 2024

YOU REPORT IT WE HELP SORT IT

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

Maritime Director’s Foreword

A s we reflect on another busy year, it is clear the need for our independent, impartial, and confidential reporting system is greater than ever. 2024 brought new challenges, from addressing emerging risks such as Marine Autonomous Surface Ships (MASS) to shedding light on operations within the ‘dark fleet.’ Yet, our reporters have stepped up, sharing their experiences with courage and conviction.

In 2024 we received over 200 reports from individuals and another 980 from maritime companies and other organisations, demonstrating that we are widely trusted in maritime safety. To everyone who reported, I give sincere thanks. We listened, and we took action. Your reports enabled us to engage across all levels and sectors of the industry, including over 20 maritime administrations, to transform your experiences into tangible safety improvements. We raised awareness of these safety issues via the 12 FEEDBACK newsletters we published and the 8 Sea Views podcast episodes we released. Together, our newsletters and podcasts reached over 244,000 people in more than 85 countries. The expansion of our global reach is greatly assisted by our 89 volunteer Maritime ambassadors in 39 countries who advocate for a just safety culture across their regional networks and raise awareness of our safety reporting programme, and I am grateful for their passion for safety. Closer to home, our outputs are immeasurably improved by the guidance of our Maritime Advisory Board members, each of whom is a subject matter expert in their own field. They guarantee the accuracy of our findings and ensure that they reflect best practice for the sector from which the report was submitted. Their work, and that of the ambassadors, is vital to our success.

Collaboration with other partners is central to our success. We work alongside other maritime charities, associations and academia on shared interests to achieve more impactful results. In 2024 we worked with IMPA and EMPA on the perennial issue of non-compliant pilot ladders, we engaged with flag states to highlight to the superyacht industry that working at height without a safety harness is unacceptable, and we are tackling enclosed space deaths with several industry partners. We co-hosted a Kind Leadership workshop with the Maritime Professional Council, co-sponsored the 3rd International Maritime Human Factors Conference held at the IMO Headquarters, and contributed to key discussions at the International Harbour Masters Association conference in Tangiers. These partnerships reinforce a vital truth—maritime safety is everyone’s responsibility.

Of course, none of this would be possible without the support of our committed sponsors, and we continually strive to repay their generosity through our efforts to make the maritime

The number of reports received industry safer.

Although we are proud of what we have achieved, we want to do more. In 2025, we

continues to increase year-on-year. aim to deliver greater impact by expanding our engagement and influence of maritime administrations, enhancing our global reach by recruiting more ambassadors, and

Many of these are the result of an expanding our collaborations with partners on critical safety issues. We hope that you will join us on this journey.

industry under pressure Yours in Safety,

Adam Parnell Director Maritime

CHIRP Maritime’s collaboration activities CROSS and CHIRP issued an Amber Alert CHIRP Maritime co-sponsored the third annual publication in November 2024 on Bridge Strikes International Maritime Human Factors Conference by large vessels. at the IMO Headquarters in London.

CHIRP Maritime co-hosted a Kind Leadership CHIRP Maritime was invited to participate in workshop on HMS President London in the International Harbour Masters Association June 2024. conference in Tangiers, Morocco.

Introduction Anonymous comments from the W elcome to CHIRP Maritime’s tenth Annual Digest, containing all the reports we published in 2024 and other items of interest. Once their reports are rendered anonymous, they are discussed by the Maritime Advisory Board (MAB), which is comprised of experts from various maritime- CHIRP survey October 2024 Our structure and staffing remain the same as I described last year, with Adam Parnell and David Watkins related fields. I am always amazed at the MAB’s depth and breadth of knowledge. Even when many of us were doing excellent work and somehow finding enough time struggling with the ramifications of the MASS report, to perform all the tasks for which they are responsible, one member knew the latest rules and guidelines, and Informative and edited for easy digestion. interesting to ably supported by Stephanie Dykes. was able to give informed and sensible expert opinion. compare the Our website is now more user-friendly, reporting is Whatever the problem, we always seem to have the Interested to learn lessons from mistakes made by safety culture in place today more manageable, and we offer translations of many expertise within the MAB to handle it. others. Active in safety risk assessment during the with the practices of my time of our publications into Chinese, Filipino, Indonesian, Finally, we must acknowledge the invaluable support working day (CEng MRAeS). Leisure sailor. in the business. While my key interest is large Portuguese, Spanish, Arabic and Ukrainian. If there are of our sponsors, without whom we could not function. Their yachts, I find it salutatory to see similar safety other languages you would like us to feature or, even generous commitment to safety allows us to bring you this They inform me as an industry professional. errors made across the board in commercial better, if you can volunteer to translate into another Annual Digest, and they are listed on its pages. To all the vessels and yachts. language, we would love to hear from you. sponsors of our work, we offer our sincere thanks. It is extremely wellpresented and informative. We now have 89 Ambassadors in 39 countries, and We hope you will find the Annual Digest useful and, It broadens my knowledge and makes me think they do an excellent job of spreading the word about our until next year, may all your voyages bring you safely home. I run Safety and Survival courses for yachtsmen about incidents in a new light. services, but we are always looking for more volunteers. through Australian Sailing and am always Our reporters are the key to our success, and it is an looking for good case histories. After 35 years in Great insight into the safety within the industry, honour to thank them on behalf of all our readers. When the Superyacht industry (1970s to 2010s), it’s nonbiased and objective. their reports are gathered together in this Annual Digest, it Editor: Captain Alan Loynd is obvious what a tremendous service they are performing FNI FITA MCIArb BA(Hons) for everyone at sea. This year, in addition to more traditional reports, they also provided us with our first report about Marine Autonomous Surface Ships (MASS), and even a report from within the murky world of the ‘dark fleet’. Their dedication to safety and their courage in speaking up is laudable, and I hope they will inspire others to do the same.

Table of Contents

1. WELFARE ISSUES 10 7. ENGINEERING 46 Rationed food 10 Potentially lethal near miss: elevator maintenance 48 Shortage of provisions on board 10 Marpol contravention 48 Allergic reactions 10 Fire in the laundry room 49 Harassment on board 11 Fingers amputated in rotating machinery 49 Rotating shafts create a lethal hazard 50 2. PORT OPERATIONS 14 Galley fire 50 Inappropriate pressure placed on the master 14 Confined space carbon monoxide poisoning 52 Fire – charcoal 14 Unfinished maintenance creates hazard 53 Good teamwork averts a serious incident 15 Difficulties leaving port in strong winds 16 8. DECK AND CARGO OPERATIONS 54 Personal Injury due to gangway malfunction 56 3. DESIGN 18 Unsafe tug/barge operations 56 A ‘bitt’ of a hazard! 20 Open hatches at sea 57 Poor internal design for securing shipboard appliances 20 Fire – Resin in a container 57 Unsafe pilot transfer arrangements 22 Hand injury while mooring on a workboat 58 Unsafe pilot ladders 22 Fatal tank inspection 58 Bunker station design 23 Open Manhole Cover Creates Hazard 59 Unauthorized entry into an enclosed space 60 4. RECREATIONAL AND DIVING OPERATIONS 24 Fall while working aloft 60 Diving SOP’s not followed 26 Personal injury due to not following a permit to work for working aloft 61 Lack of safety assessment by the Master 26 Close quarters situation 27 9. BRIDGE AND NAVIGATION 62 Grounding 64 5. PASSENGER VESSEL SAFETY 28 OOW asleep on watch! 64 Asphyxiation hazard 30 Collision Regulations and autonomous maritime vessels 65 Critical safety failures and crew fatigue on cruise ship during passenger excursions 30 Collision at anchor 66 Commercial pressures placed before safety concerns 67 6. SUPERYACHTS 32 Navigating the Challenges of Autonomous Shipping 68 Tender grounding 34 Contact with ground lines while departing a repair berth 34 10. APPENDICES 70 Capsize of a Dive Safari Vessel and Rescue of Tourists and Crew 35 Appendix I: Acronyms 71 Personal Injury during mooring operations 36 Appendix II: The Maritime Programme – How it works 72 Grounding and Dismissal 36 Appendix III: Our Publications 73 Lift E-Foil Battery Thermal Run-away 38 Reference Library 73 No Kill Cord was worn while operating a Tender 38 Our Sponsors 74 Near Miss 39 Near miss - breach of watertight integrity 40 OUR SPONSORS 74 Explosion in theengine room 40 Lack of crew in an emergency 41 Damage to a tender under tow 42 Working at height without any PPE 42 Vessel tender recovery injures crew member 43 Fouled anchors 43 Working aloft without proper PPE (again!) 44 Life raft maintenance was ignored 44 Breach of watertight integrity 45

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

1. Welfare A Safe Ship Is More Than Steel and Regulations We were shocked to learn that cases of crew abandonment more than doubled last year from 2023’s record levels. According to the International Maritime Organisation, there were 310 cases of crew abandonment registered in 2024. This is totally unacceptable and undermines the excellent work being done by the vast majority of companies and managers to look after their crews. It is appropriate, therefore, that we begin this Annual Digest with a section on welfare. Crew welfare is fundamental to a safe ship, yet failures in food provisions, medical care, and workplace safety persist. A vessel under- provisioned for a voyage or an unrecorded medical allergy can turn fatal. Harassment and poor conditions drive skilled seafarers away. Regulations exist, but without enforcement, they are meaningless. Seafarers deserve more than the bare minimum—does your vessel meet that standard? If not, we have included some valuable contacts at the end of the section.

M2266 The provision of poor-quality, inexpensive food not only The investigation revealed that the crew member found his behavior inappropriate, too. During this outing, leads to higher wastage but also poses long-term health had unknowingly consumed citrus fruit juice during their he kept asking me to join him at a restaurant, despite my

Rationed food risks to the crew, including increased rates of diabetes, obesity, and heart problems. Running out of food for the prepared lunch, which they were allergic to. The tingling gums, throat tightness, and difficulty breathing matched the refusals. When I reminded him that I was there to work, he pushed back, asserting his authority as captain to justify crew is totally unacceptable and should only occur in symptoms of an allergic reaction. taking more time. I had to set boundaries repeatedly, but he Initial report exceptional circumstances. ignored them. A vessel was provisioned with a month’s supplies for a The master and crew failed to give adequate attention CHIRP Comment Back on the vessel, the night shift issues continued— two-month passage and planned anchorage, and the to provisioning, a critical aspect of ensuring the vessel’s Although the company ensured that chefs were aware he’d stay up, offer to do my tasks, and try to start personal crew was instructed to ration its provisions. Since they seaworthiness. The amount of food required must be of the allergic effects of some foods, neither they nor the conversations. I had to find another area to work, but he had not been paid for three months, they could not assessed based on crew size, trading pattern, and the master knew that someone on board was allergic to citrus. followed me, persisting with the interactions. At one point, purchase additional provisions, so they approached CHIRP availability of suitable victualing companies. Neglecting this Persons who know that they are allergic or intolerant to he presented a new seasonal contract, despite my earlier for assistance. assessment can result in severe consequences for crew certain items are encouraged to declare this when they refusal, and seemed upset when I declined again. health and morale. sign on. While such information is ‘medical in confidence’, it The situation escalated during another night shift. CHIRP Comments Purchasing expired, or reduced-price food indicates needs to be recorded somewhere so that effective first aid After promising to drop the subject, he returned from bed The shore management company claimed they did not that the food budget is driven by cost-saving measures can be given should they be incapacitated and unable to shortly after to try discussing personal matters again, have enough money to provide sufficient provisions. CHIRP rather than prioritising the crew’s well-being. This practice communicate this. disregarding my request to keep things professional. I was contacted the vessel’s Flag State, which immediately is unacceptable and compromises the safety and welfare of To ensure your safety, your manning agents must so uncomfortable that a crew member offered to stay with intervened, directing the company to supply adequate those onboard. be aware of your allergies, and your medical chest me so I wouldn’t be alone with him. victuals and water and to pay the outstanding wages. should carry sufficient medication in case of a reaction. Later, at a crew gathering, he followed me back to the The Maritime Labour Convention regulation 3.2 Human factors Additionally, ensure you know your medical response boat and tried engaging in more personal talk. I eventually requires vessels to ensure that sufficient food and drinking Capability – The master usually has the responsibility of contact details, especially when you are not in or near began recording the conversation to document his behaviour. water of appropriate quality is on board. It also states that checking the quality and quantity of food on board. This a port. When he wouldn’t stop, I called a friend, then another pay arrears of more than two months can be considered requires close attention to the requirements and working CHIRP would like to commend the officers and crew crew member, to avoid being alone with him. The tension crew abandonment. closely with the cook. How well do you manage this job? of the motor yacht for their excellent response in seeking culminated in him making a derogatory remark before Do you feel your provision budget is too tight to order good advice and promptly getting the crew member to the local finally leaving. Factors related to this report quality food? clinic for further assessment. The company’s commitment to This morning, the captain created a group chat and called Capability – The shore management company lacked the a strong safety culture, prioritising the crew’s well-being, is for a meeting today. He also sent me contract termination financial ability to operate safely and thus put the crew at risk. Capability – Does the cook on your vessel hold the highly commendable. rules, saying I need to give seven days’ notice. Right now, I’m appropriate cooking certificates? Are there regular in my cabin, unsure how to proceed. I feel very uncomfortable Culture – The company does not respect the workforce refresher cooking courses that can be taken? How Factors related to this report here and cannot continue in this environment. employed to operate its ships. Crew welfare is inextricably varied are your meals? Alerting – Ensure you alert your managers and the crew While I am unharmed, I am deeply upset that this linked to safety, and the safety of the vessel’s crew was you work with about your allergies. It can save your life! situation has disrupted my work, my contract, and my compromised. Have you experienced anything similar? Alerting – If you felt that your food quality and quantity learning experience. I’ve stayed professional, but I’m at a were insufficient, would you contact your DPA? Communication – Does your company have a policy loss on how to handle this. Any advice on how to proceed Local practices – Keep local practices from becoming on allergy reporting? Society has more allergic reactions today would be greatly appreciated. Thank you.” established norms. Report them! Culture – Having the right type of food available than ever, so we must be