CHIRP Maritime FEEDBACK 79 (Summer 2025)

An independent and confidential Issue 79

MARITIME FEEDBACK reporting system for the Maritime industry Summer 2025

CONFIDENTIALITY SUBMIT A REPORT

CHIRP always protects the identity of our reporters. Reports can be submitted easily through All photos are stock library images. Persons, places our encrypted online form or vessels shown are not associated with the www.chirp.co.uk or via our app accompanying report unless otherwise stated.

Recurring risks, missed chances the most common failings, followed by poor safety Adam Parnell culture, lack of teamwork and complacency. All these Director (Maritime) factors can be eliminated through proper training and establishing a vibrant safety culture on board. Still, it is evident that many of us are a long way from achieving that ideal. We can and should be doing better. Maritime safety culture – we’re not there yet. Our regular readers will note that we have included a new section in each report, listing key Once again, we’re privileged to share real-world reports takeaways for seafarers, ship managers, and that provide valuable learning insights for the entire regulators. These highlight simple steps to improve maritime community, and our sincere thanks go to the safety yet further, and we hope that you find them seafarers and maritime professionals who have taken helpful – please let us know! the time – and shown the courage – to submit them. We always pay close attention to comments There is a report about the dangers of heavy from our readers. Your insights help us improve, and weather and another about the proper use of voyage your reports can help others to stay safe. If you have data recorders. We also learn about a dangerous lifting experienced or witnessed something worth sharing, operation, an accident during a rather unconventional don’t keep it to yourself – together we can improve pilot boarding, and a fire extinguisher that could not maritime safety for all. have been readily accessed in an emergency. Until next time, stay safe and may all your As always, there are common factors across voyages lead you safely home. the reports despite the different subjects covered. Situational awareness and poor communication are The CHIRP Maritime team

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

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

www.chirp.co.uk/maritime MFB 79 | Summer 2025

M2256 As the weather deteriorated, the master and OOW should have dynamically assessed whether the upper deck

Fatalities during remained safe for personnel. The lack of guidance regarding upper deck operations in the company’s heavy-weather

heavy weather checklist was also an indirect causal factor. The chief officer’s swift response to the alarm and the master’s decision to alter course toward the nearest port Initial report were appropriate actions. However, being unable to carry The weather forecast indicated an approaching low-pressure out a medivac underscores seafarers’ ongoing challenges in system with strong winds and increased swell activity. accessing timely medical support. This highlights the need At 0500 the pilot disembarked, and the master for improved coordination between vessels and shore- instructed the crew to secure all lines and deck equipment. based emergency services, especially in remote areas. The aft station was reported secure, but the crew left the Despite the pre-departure safety meeting addressing forward station unfinished, planning to return later. The the weather conditions, access to the deck remained master handed over the con to the third officer and left unrestricted. This raises concerns about how effectively the bridge. safety briefings are implemented in practice. Furthermore, During the passage, heavy swell caused the vessel the company’s deck access code procedures and heavy to slam against waves, waking the master, who ordered a weather checklist lacked clear thresholds to guide the crew’s speed reduction and course adjustment. By midday, the decision-making, leaving room for ambiguity in assessing second officer took over the watch, with increasing wind and the risks of worsening sea conditions. three-meter waves. This incident is a powerful reminder that risk checks, After lunch, the chief officer went on deck to check that clear communication, and adherence to heavy-weather the containers were still secure. Around the same time, the procedures must never be overlooked. Lives were lost— bosun and deck crew returned to complete securing the needlessly. If this report encourages even one crew forward station. A short while later, a large wave breached member to stop, think, and act more safely, then something the forecastle, washing crew members off their feet. meaningful can emerge from this tragedy. Please don’t wait The chief officer found four injured crew members and until it’s too late. Choose safety—every time. raised the alarm. The master altered course towards the nearest port, and the injured crew were transferred to the Factors relating to this report ship’s hospital. A medevac request was considered, but it Local Practices – Accepting local practices which are not was not possible, and the vessel proceeded to port, where in accordance with best seamanship practices creates an paramedics boarded that evening. Two crew members unnecessary hazard. later died due to their injuries; another required emergency surgery, and one was treated onboard. Culture – There appears to have been a laissez-faire attitude The pre-departure safety meeting addressed weather toward securing a vessel for the sea. Does your vessel have a conditions and crew responsibilities. Nevertheless, access deck access code when encountering heavy weather? to the deck remained unrestricted. The company’s heavy weather checklist was not utilised, as it lacked clearly Teamwork – By working as a team, they could have defined thresholds for heavy weather. secured the forecastle quickly and efficiently. There appears to have been no challenge to leaving it unsecured.

Overconfidence – Weather may be unpredictable, but poor preparation isn’t.

Key takeaways Seafarers – “Your actions shape the safety culture onboard.” Local habits that ignore best practices put everyone at risk. Speak up, challenge unsafe norms, and work together— especially in heavy weather. If something feels wrong, it probably is. You are the first and strongest line of defence.

Ship managers – “What you walk past, you accept.” A culture of overconfidence or casual preparation starts ashore. Managers must set clear expectations for securing Representative image. Credit: iStock the ship for sea and adverse weather and ensure crews are trained and supported to follow them. Audits should not just CHIRP Comments check boxes—they should test real-world readiness. Several key opportunities to prevent this incident were missed: crew members at the forward station should have Regulators – “Standards mean nothing if they are remained until the area was secure; the master should not not applied.” have proceeded to sea until they were satisfied the vessel There is a vital difference between compliance and safety. was secure; and the handover to the third officer should A vessel can tick all the regulatory boxes and still be have included the status of the forward station. unsafe. Regulators must recognise when local practices

undermine global standards regarding paperwork and real- Key failures included the lack of parallel indexing, world safety outcomes. Intervention should go beyond the absence of position verification, no anchor plan, and audits, including proactive oversight, education, and inadequate use of radar plotting during critical stages of follow-up. The goal is not just compliance—it is genuine the voyage and at anchorage. Additionally, the master who safety. That cannot be left to chance. approved the passage plan did not directly oversee the planning process. This highlights a fundamental breakdown in compliance that requires immediate corrective action to maintain safety standards. M2450 A fleet-wide audit by the company found similar issues across all vessels, suggesting that this was a systemic issue

Voyage Data rather than isolated non-compliance. CHIRP cautions all companies to take a closer look at

Recorder issues their navigational procedures to ensure that they meet the requirements of the company SMS and the bridge procedures guide (BPG). Initial report During a company fleet-wide navigational audit, several Factors relating to this report discrepancies and procedural gaps were identified after Culture: Unsafe norms have developed, making non- comparing the passage plans, bridge logbooks, and compliance routine and accepted. Complacency, norms, Voyage Data Recorder (VDR) data. A significant and lack of knowledge create a dangerous environment. observation was that passage plans lacked an anchor Training, leadership, and culture play critical roles, indicating plan, which is required by the Bridge Procedures Guide systemic issues beyond individual lapses. (BPG). Additionally, there was no objective evidence to verify the frequency of position fixing or proof that Communication: Insufficient communication between the radar was used to plot the ship’s position to ensure bridge team members and the master led to gaps in the secure anchorage. execution and understanding of the approved passage plan. Although supported by radar recordings, parallel indexing was not observable during critical wheel-over Complacency: Repeated non-compliance across the fleet manoeuvres. There was also no indication of regular checks suggests unsafe norms have become accepted, such as not at frequent intervals to confirm that the vessel remained updating the VDR or omitting radar plotting. This indicates a securely anchored by taking bearings of fixed navigational dangerous level of complacency. marks. In several instances, only the X-band radar was Deck officers lacked the training and knowledge to operational during anchorage, and essential data points properly maintain the VDR and conduct thorough passage such as the actual date and time were absent from the planning, including anchor plans and radar usage. passage plan. The method of obtaining the ship’s position was not Alerting: Junior officers may not feel empowered to specified, and parallel indexing was not utilised while the question inadequate plans or voice concerns, perpetuating vessel was underway in coastal waters. Although connected unsafe practices due to a culture of silence. to the VDR, the echo sounder was not monitored, and the rudder angle indicator was absent from the VDR live player. Situational Awareness: Poor understanding of critical The passage plan was not updated to reflect changes in navigational steps, from radar use to anchoring procedures, circumstances, such as drifting, and the anemometer, indicates a broader issue of a lack of situational awareness despite being connected to the VDR, displayed data only on and risk appreciation. the radar screen. The X-band radar was found to be switched off at a Teamwork: The bridge team’s lack of coordination, proper critical point during anchorage, and the depth indicator was monitoring, verification, and shared responsibility in navigation not visible on the VDR live player, even though the Echo and data logging points to systemic failures in internal Sounder was connected. Furthermore, the ECDIS voyage communication and a culture discouraging speaking up. log contained an incorrect year, and the master approved the standing orders and passage plan. However, despite the Key Takeaways SMS checklist indicating that the ship’s position was verified Seafarers, “Feeling normal doesn’t mean it is safe.” through bearings of fixed navigational marks, the VDR data Just because something feels routine, like skipping radar provided no supporting evidence. checks or not updating the VDR, does not mean it is safe. During the voyage, radar playback identified nearby Speak up. You are the eyes and ears of safety onboard. vessels, with the closest point of approach breaching Do not stay silent. Raise concerns, look out for each other, the master’s requirement in the standing orders. Not all and practice solid seamanship. Your voice matters and can targets were acquired, and only radar trails were monitored save lives. throughout the passage. Ship managers, “A large number of ships, same problems? CHIRP Comments That is a management issue.” The significant discrepancies in passage planning If crews repeatedly cut corners, look at the training, leadership, procedures raised serious concerns about the vessel’s and support they are getting. Make sure crews know what is navigational safety. These issues were uncovered during an expected and feel confident speaking up. Safety culture starts internal audit rather than by external authorities. ashore, and it is your responsibility to build it.

www.chirp.co.uk/maritime MFB 79 | Summer 2025

Regulators, “Administrative compliance cannot mask Communications—Clear verbal and visual communication operational risk.” is essential for safe lifting operations. Crane operators should When critical tasks like radar plotting or passage plan not start lifting until they communicate with the deckhand. checks are skipped across a fleet, it is a sign that the system, not the sailor, may be broken. Regulators must look Alerting- The crane operator and the deckhand were not beyond paperwork and into practice. Targeted SMS audits, alone, and other crew could have assisted by advising that anonymous crew feedback, and follow-up visits can reveal safe lifting operations had not been established. If you saw where safety culture fails. this situation, would you step in to stop the job if you saw this happening?

Pressure- There can be pressure when there is a deadline M2257 to meet. Even if no one says it out loud, you feel it. But pressure should never override your training. The job is

Entanglement and fall important, but so are you.

from height during lifting Key Takeaways Seafarers, “If you are unsure, stop the lift.”

operations Before any lift, check your position and where your crewmates are. If something does not feel right, speak up. You are not alone—support each other and stop the job if Initial report needed. No task is worth a life. A crew transfer vessel was performing lifting operations at an offshore wind turbine. A deckhand and a trainee Ship managers, “Good training keeps crews safe under deckhand were assigned to receive four lifting bags attached pressure.” to a three-legged wire sling. The trainee lowered the load, High-pressure operations need high-quality, regular training. detached it from the slings, and signalled the crane operator Focus on real-life scenarios, not just checklists. Reinforce to raise the hook. what good looks like—and give crews the confidence to act As the hook and wire sling were raised, they became when things feel wrong. entangled with the trainee’s work restraint lanyard. The trainee immediately signalled an emergency stop, but the Regulators, “Look beyond the paperwork—watch how crane operator neither saw nor heard the signal. As a result, people work.” the trainee was lifted off the deck. While suspended, the Safe lifting depends on clear communication, awareness, trainee’s weight caused the entanglement to release, leading and confidence to speak up. Check if procedures work in to a fall of approximately one to two metres onto a pile of practice. Support systems where stopping a job is seen as bags on the deck. good seamanship, not failure. The trainee’s lanyard was worn loosely, increasing the risk of snagging. Additionally, the trainee was too close to the lifting equipment and did not use a tagline or maintain control of the equipment to prevent entanglement. The crane operator’s failure to respond to the emergency stop signal further exacerbated the situation.

CHIRP Comments While lifting operations can be undertaken by only two people, ideally, three people should be involved: a crane operator, a rigger, and a banksman/supervisor. In this incident, the trainee deckhand was acting as the rigger, and the more experienced deckhand was the banksman, who should have ensured that the trainee was correctly dressed (with no snagging hazards) before the work commenced. To be safe, all persons should remain in sight of one another, and operations should stop automatically if line of sight is lost.

Factors relating to this report Situational Awareness—Before starting any lifting operation, assess your position and that of the other crew members. Never begin the lift if you are uncertain.

Capability—Rigorous and reinforcement training should be given to the crew working in these high-pressure environments. How often do you carry out lifting operations training? Representative image. Credit: iStock

M2262 In this case, the pilot stepped from the stern of the pilot boat onto a bulwark ladder platform, which was not

Pilot falls into the water secured to the deck. This suggests a lack of supervision when the platform was rigged. The ladder moved as

while boarding the pilot grabbed a stanchion, causing him to lose balance and fall. Fortunately, the crew responded quickly and helped the Initial report pilot recover safely. While boarding a small tanker moored in port, a trainee pilot fell into the water when the bulwark ladder tipped over. Factors relating to this report The pilot boarded from the stern of the pilot boat onto the Communication—The pilot was not informed that the bulwark ladder platform without using a pilot ladder. This bulwark ladder was unsecured. This is a systemic issue that occurred because the tanker was fully loaded and had very operators and owners should address. little freeboard, and the shape of the hull made it difficult for the pilot boat to come alongside parallel. Situational Awareness- The pilot did not visually identify To climb onto the ship, the pilot held onto one of the the unsecured ladder. The simplicity of the arrangement ladder’s stanchions. The ladder was not fixed to the deck, may have led to a false sense of safety. something that only became clear after the fall. As the pilot pulled on the stanchion,