CHIRP Annual Digest 2025

An independent and confidential reporting system for the Maritime industry

WELFARE ISSUES DESIGN ISSUES SEARCH AND RESCUE SUPERYACHTS ENGINEERING AND TECHNICAL DECK AND CARGO OPERATIONS BRIDGE, PILOTAGE AND NAVIGATION

Are you interested in becoming a 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 programme 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 2025-26

YOU REPORT IT WE HELP SORT IT

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Maritime Director’s Introduction Foreword W elcome to our eleventh Annual Digest, containing all the reports we published during 2025 and some additional material which has been specially commissioned. recently, we have been working with the international Search and Rescue community. The results of this collaboration will be seen in the pages which follow. Looking back over all the Annual Digests, it is possible None of this would be possible, of course, without the to see how our industry is changing. Who could have generosity of our sponsors. Their support is vital and we

T he past year has once again demonstrated that when maritime voices speak up, meaningful safety improvements can follow. In 2025 we received 330 reports concerning safety, welfare or compliance from all sectors: commercial shipping, imagined, eleven years ago, that we would be receiving reports about unmanned surface vessels or the dark fleet, for example? Yet there is also a sad continuity as we thank them all. Finally, we pay tribute to our reporters. They are the lifeblood of CHIRP Maritime and their dedication to safety superyachts, fishing, maritime pilots, offshore installations, ports, SAR units, recreational continue to see reports about dangerous enclosed space is admirable. We would not be here without them! vessels and even the “shadow fleet”. CHIRP responded to every case. entry, improper pilot boarding arrangements and the We hope you will find this Annual Digest useful Many of the issues raised were serious, and some were urgent. Through close traditional slips, trips and falls. The sea is a dangerous place, and, until next time, may all your voyages bring you engagement with companies, Flag States, Port States Control, classification societies and and it is up to all of us to do what we can to make it safer. safely home. MoU bodies, corrective action was taken in virtually every instance: unsafe equipment CHIRP Maritime is still run by our indefatigable Director, and procedures were corrected; abandoned seafarers repatriated; unpaid seafarers Adam Parnell and his excellent deputy, Dave Watkins. Ably received their wages; harbour staffing levels restored to safe standards; MARPOL breaches assisted by Stephanie Dykes and our newest member Liz investigated, and several allegations of criminal behaviour were escalated appropriately. Moran, they get through a remarkable amount of work and Alongside the casework, CHIRP continued to promote learning and share lessons it is thanks to them that CHIRP Maritime goes from strength widely: 10 FEEDBACK editions were published across maritime, superyacht and SAR to strength. They are supported by our Trustees and the programmes; 8 podcast episodes were released, alongside 2 short educational videos wise men and women of our Maritime Advisory Board, who Editor: Captain Alan Loynd on the dangers of enclosed spaces; and we published Mastering the Lee, our practical give freely of their years of experience and knowledge of FNI FITA MCIArb BA(Hons) guidance for improving the safety of pilot embarkation on larger vessels. almost every facet of the industry. Our engagement across the sector also increased. This year, CHIRP presented at the We continue to publish in several languages, and Palma Yacht Show, Metstrade, to the aviation industry’s ICASS conference, and many our Ambassadors continue to spread the word about others. We also co-hosted three significant gatherings: a safety event at the London what we do. International Shipping Week, the Kind Leadership conference and the 4th International In addition to our regular editions of Maritime Maritime Human Factors Symposium in Glasgow. FEEDBACK, we also publish specialized newsletters None of this would be possible without the generosity of our funders to whom we are for the superyacht and fishing communities and, most exceptionally thankful, and for our volunteer Advisory Board members and our international Ambassadors who represent us in over 40 countries. Most importantly, I want to thank every person who contacted CHIRP this year. Speaking up is not always easy, but your reports have prevented harm, corrected unsafe practices and improved working conditions for many others. I hope that this Digest encourages even more people to come forward in the year ahead.

Yours in Safety, CHIRP Maritime’s collaboration activities Adam Parnell Director Maritime

We organised a co-sponsored event for London We attended a Forum for Contingency Planning- International Shipping Week. Fire on Roll-on / Roll-off passenger Ferries carrying passengers We organised a co-sponsored event for the International Maritime Human Factors Symposium, We collaborated with CROSS for a publication Glasgow, December 2025 in the Structure Magazine, published in October 2025. We organised and co-sponsored a Kind Leadership workshop at the NI Headquarters in November 2025

Table of Contents

1. WELFARE ISSUES 6 5. ENGINEERING AND TECHNICAL 44 Pest infestation 8 Eye injury 46 Crew abandonment 9 Fire on a large motor yacht 46 MLC living conditions 10 Chemical injury to the crew 47 Bullying ship manager – safety and leadership culture ashore? 10 Illegal disposal of waste at sea 48 Unacceptable living conditions 11 Chemical exposure in the engine room 49 Hull integrity compromised during refit 50 2. DESIGN ISSUES 14 Near miss: potential poisoning and asphyxiation of a crew member using a chemical Unacceptable design for pilot boarding and crew attendance 16 for cleaning a confined space 51 Corroded walkways over deck pipes 17 Poor fuel handling causes blackout 53 Working aloft: unsafe by design? 17 Near miss: poor configuration of CO2 firefighting system 18 6. DECK AND CARGO OPERATIONS 54 Near miss: escape route blocked 18 Fatalities during heavy weather 56 The ship’s aerial plans were incorrectly labelled 19 Container fire 57 Safety equipment obstructed by cargo gear 20 Near miss: fatality avoided 57 Integrating wearable tech into the maritime safety ecosystem 20 Injury to a crew member during an enclosed space periodic inspection 58 Anchor operations compromised by unfamiliarity and tiredness create a hazardous situation 59 3. SEARCH AND RECUE 22 Entanglement and fall from height during lifting operations 60 Lifeboat crew injured during rescue operation 24 Why seafarers don’t report — and what actually makes them speak up 61 Lifeboat capsize during a capability demonstration 24 Leakage into the lifeboat engine compartment 25 7. BRIDGE, PILOTAGE AND NAVIGATION 62 Unexpected injury – the hidden hazard of a paddle blade 26 Non-compliant pilot ladder 64 A fall into the water by a trainee crew member while mooring to a buoy 26 Voyage data recorder issues 64 Sinking of a fishing vessel during a rescue operation 27 Pilot falls into the water while boarding 65 Near miss: Incorrect passage through buoy gate at night 28 The welfare of the pilot while boarding 66 Inverter alarm and explosion of batteries 29 Severe injury caused by a fall from pilot ladder 67 Person overboard in a person overboard exercise 30 Near miss between an uncrewed surface vessel (USV) and a large number of yachts 68 Application of the collision regulations 31 Unmanned survey vessel (USV) capsize 68 Rescue drill – gas escape into a life raft 31 Close quarters situation 70 Grounding and sinking of HMNZS MANAWANUI Location and time: Samoa, October 2024 33 Pilot transfer arrangement (PTA) – significant safety concerns 71 IMO Marine Safety Investigation Working Group Report 33 Injury to SAR Swimmer 34 8. APPENDICES 74 Appendix I: Acronyms 75 4. SUPERYACHTS 36 Appendix II: The Maritime Programme – How it works 76 Fire on a large motor yacht 38 Appendix III: Our Publications 77 Drug use on board superyachts 38 Reference Library 77 Identification of eclosed spaces on a superyacht 39 Our Sponsors 78 Safety concerns dismissed 39 Working aloft without proper fall protection 40 Crew injury while mooring 41 Grounding incident 42 Yacht’s anchor damages hull 43

CHIRP Annual Digest 2025-26 www.chirp.co.uk/maritime

1. Welfare Issues When living conditions become safety risks This section highlights how poor living conditions directly undermine safety, wellbeing, and regulatory compliance. Reports detail pest infestations, crew abandonment, substandard MLC accommodation, bullying behaviour ashore, and unsafe hygiene and welfare arrangements. They also highlight themes of weak safety culture, fear of retaliation, poor communication, and management failing to meet legal responsibilities. CHIRP emphasises that welfare is inseparable from safety: when crews are unsupported or unsafe, risks escalate rapidly. A strong reporting culture, regulatory oversight, and accountable leadership are essential to prevent recurrence.

M2459 cabins when fumigation began; an unacceptable practice Factors relating to this report damaged mattress was only replaced following a formal that exposed them to serious health risks. Video evidence Local Practices – management appears to have its own request. A missing toilet seat was replaced only after a Pest infestation supports the crew’s account. The psychological effect on the crew regarding the infestation and the lack of rules for managing the vessel, with no adherence to the safety management system, despite a specific reference complaint was lodged. There was no privacy in cabins due to the absence of curtains, and bathrooms were described Initial report support by the master and company until intervention by to fumigation. as damp and poorly ventilated. These conditions made We are facing a severe infestation of pests on the ship, with CHIRP led to very high stress levels, according to the crew quarters uninhabitable. The crew were relocated cockroaches present throughout the vessel. They are found the reporters. Culture – There is no authentic safety culture, except for the multiple times, including to a hotel, student dormitories in food supplies, refrigerators, utensils, bedding, and other CHIRP managed to obtain the Safety Data Sheet for the fact that you should not get caught! without hot water, the captain’s private home, and other areas. This situation has caused significant psychological fumigant used, and the risk of health issues associated with guest spaces. and emotional distress among the crew. We are unable inhalation was high. The crew was instructed to conduct a Capability – The vessel’s operational leadership appears In addition to the living conditions, serious safety to eat or sleep peacefully, constantly feeling anxious and second round of fumigation en route to their next port but incapable of operating a safety management system. concerns were raised. The vessel was reportedly operating stressed. The captain’s behaviour exacerbates our situation. was left without hazmat gear or proper masks, rendering the in violation of SOLAS and Flag State safety requirements. He behaves erratically, making threats to ensure our silence fumigation unsafe. Key takeaways All fire extinguishers were either expired, corroded, or regarding these issues. There is fear among the crew, and The master’s behaviour reflects a person under severe Seafarers: When silence endangers safety—speaking inoperable. No flares were carried on board, and there speaking out feels unsafe. During recent inspections, port stress and not capable of making informed decisions up saves lives A severe pest infestation, improper were no life jackets available in the crew or guest cabins or inspectors did not inspect the onboard condition closely. concerning the safety of the crew. The management fumigation, and a captain’s threatening behaviour created anywhere within the vessel’s interior. Despite these critical This same behaviour by port officials also occurred at the company appears to be severely lacking in experience and a psychologically unsafe and physically hazardous deficiencies, the vessel continued to operate at sea, placing last port and during the current inspection. The captain has support for the crew. environment. Despite formal procedures existing on paper, both crew and passengers at risk. warned us against saying anything. This case serves as a stark reminder that documentation none were followed, placing the crew at significant health risk. alone does not guarantee safety. Procedures must be CHIRP Comment CHIRP Comments understood, implemented, and routinely verified. CHIRP Managers: Leadership without listening breeds risk— This case highlights a broader concern regarding vessels CHIRP contacted the flag state, which in turn contacted has escalated this matter to the flag state and continues to your safety culture is what happens when you are operated solely by their owners, where the usual checks the company, and arrangements were made to carry out engage with the crew to ensure their safety concerns are not on board The breakdown in leadership, procedural and balances provided by an independent management fumigation of the vessel. However, the arrangements made heard and addressed. enforcement, and crew wellbeing in this case reflects deep- structure may be absent. When command and ownership to fumigate the ship did not follow the procedures outlined Superficial or weak auditing, whether internal or rooted safety culture failures. Procedures were ignored, are combined, especially on vessels under 30 metres, in the company’s safety management system. CHIRP external, can miss serious risks, especially if the crew risks were unassessed, and the crew was left vulnerable. external oversight is often limited and accountability difficult was allowed to review the relevant sections of the safety feel unable to speak openly during inspections. Such Managers must ensure that documented systems to enforce. management system, and none of the risk assessment circumstances not only endanger seafarers but also erode translate into lived practice and that masters and crews are CHIRP shares this report to encourage greater scrutiny controls were implemented. trust in the regulatory framework meant to protect them. empowered and psychologically feel safe to raise concerns. of crew welfare and vessel safety on owner-operated This report highlights a breakdown in safety culture and The presence of procedures means little if they are Leadership accountability and visible commitment to safety yachts. It is essential that crew members feel able to raise procedural compliance on board. not being lived and enforced on board. This case is are non-negotiable. concerns without fear of retaliation, and that enforcement No safety meetings were conducted, and there was a textbook example of “paper compliance”, where mechanisms are strong enough to prevent recurrence of no explanation of the fumigant’s chemical data sheet. documentation exists primarily to tick boxes rather than Regulators: Silent crew resulted in missed signals— such incidents. Safeguards must also be in place to ensure Some crew members were reportedly asleep in their to drive real safety outcomes. regulation fails when crews cannot speak freely This that new crew are not recruited under false pretences, and case highlights how inspection regimes can overlook critical that international standards such as MLC and SOLAS are hazards when crews are too afraid to speak up. Despite clear consistently upheld. procedural violations and health threats, port inspectors CHIRP advocates extending MLC protections to all CHIRP managed to obtain overlooked the issues on two separate occasions. Regulators yachts, regardless of size or tonnage, because working must strengthen inspection protocols to uncover both conditions can vary significantly between MLC-compliant the Safety Data Sheet for the technical noncompliance and suppressed reporting cultures, vessels and those that are not. The same applies to SOLAS: fumigant used, and the risk of ensuring seafarers can safely disclose concerns and that just vessels not obligated to comply may operate under lower culture principles are allowed to flourish. safety standards, and seafarers should be aware of these health issues associated with differences when seeking employment. inhalation was high CHIRP encourages prospective crew to ask clear M2491 questions during recruitment and urges owners and management companies to take greater responsibility for ensuring compliance, transparency, and fair treatment Crew abandonment across all vessels under their remit.

Initial Report Key Issues relating to this report CHIRP received a report from several crew members who Communications – Crew concerns were often ignored or were abruptly dismissed from a 24m vessel after raising dismissed, and formal complaints were needed to prompt repeated concerns about living conditions and on board basic responses (e.g., mattress and toilet seat replacement). safety. The captain, who was also the vessel’s owner, Are your concerns truly heard when you raise them? terminated their contracts without notice, support, or provision for repatriation. It was only after intervention from Pressure – The crew were placed under pressure to remain an ITF Inspector that assistance was provided. This incident in unsafe and unfit conditions without repatriation or appears to meet the criteria for abandonment under the protection of their welfare. Maritime Labour Convention (MLC) . The crew had previously reported a persistent spider Complacency – The continued operation of the vessel infestation in the accommodation spaces. One crew member despite expired fire extinguishers, the absence of lifejackets, required hospital treatment as a result. Alongside this, there and the lack of flares indicates a command that does were ongoing concerns about black mould, poor ventilation, not appreciate the risks regarding practical safety and Representative image. Credit: Shutterstock and unsanitary accommodation. A heavily stained and compliance with safety regulations.

Local Practices – Unacceptable standards appear to have It’s important to emphasise that standards must be records of incidents is crucial, and seafarers should company’s safety culture. Many seafarers are unaware become normalised (e.g., operating with no lifejackets or strictly applied whether the vessel is MLC-compliant or a seek support from professional welfare or