CHIRP Maritime FEEDBACK 80 (Autumn 2025)

An independent and confidential Issue 80

MARITIME FEEDBACK reporting system for the Maritime industry Autumn 2025

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Built to Break? Design decisions shape safety outcomes at sea

Adam Parnell Director (Maritime) A predominant theme in this edition is that mistakes are often made at the design and construction stages of a ship’s lifecycle. It is therefore Once again, our excellent reporters have shared a vital that practical mariners are involved at the building wide range of incident reports, and we thank them yard, so they can spot any practical difficulties and all. In this edition, we move from ‘traditional’ incidents ensure they are corrected before the vessel enters such as pilot boarding mishaps and enclosed spaces, service. It is normally more difficult, and more to a cutting-edge report about the capsize of an expensive, to correct mistakes later. Unmanned Survey Vessel (USV), and, as always, Murphy’s law states, “anything that can go wrong there are valuable lessons to be learned by anyone will go wrong”. This is not rocket science, although Mr. involved in shipping. Murphy was an American rocket scientist who coined You will also find a worrying report about a ship the epigram in the 1940s. It is worth bearing in mind which suffered a serious pest infestation and was as you go about your business on board, because if subject to a botched fumigation, and another about you think about what might go wrong in any set of aerial plans which were inaccurate. In a similar vein, circumstances, you have a much better chance of another reporter tells us about an escape hatch which taking steps to prevent it and ensure you get safely could not be opened if a mooring rope was turned up home at the end of every voyage. on the adjacent bitts. Until next time, stay safe!

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.

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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 80 | Autumn 2025

M2494 Third Attempt – Boarding completed – Conditions had eased, and the pilot was able to transfer via the lower deck.

Unacceptable design for However, several safety issues were observed with the rigged pilot ladder (see image above):

pilot boarding and crew The ladder was not resting against the ship’s hull. It was secured to the handrail, not to strong points on deck.

attendance There was an obstruction at the top – the ladder rope did not sit flush with the deck, creating a tripping and entanglement hazard. Initial report Pilot Boarding Report – Learning Points from Repeated Transfer Attempts Some vessels continue to be unable Weather Conditions (First Attempt): to provide safe and compliant pilot Wind: 33 knots SW Sea: 1.7 – 2.5m swell transfer arrangements, particularly Swell breaking over the lower deck, making it inaccessible. in adverse weather conditions First Attempt – Boarding aborted – The crew was observed standing on the hatch cover above a fixed yellow CHIRP Comments metal ladder (see attached image), appearing to expect the Boarding eventually took place some 48 hrs after the first pilot to board via this structure. No pilot ladder was rigged. attempt, and CHIRP commends the strong safety stance The pilotage act was aborted due to the absence of a taken by the pilots. This report highlights a persistent compliant ladder. The Master was informed, and a second issue: some vessels continue to be unable to provide safe attempt was planned for the following morning. and compliant pilot transfer arrangements, particularly in adverse weather conditions. In this case, two boarding Second Attempt – Boarding aborted – Weather conditions attempts were aborted due to unsafe setups and the remained similar to those of the first attempt. absence of a properly rigged pilot ladder. Crew members The pilot was directed to board near the were seen using vertical fixed ladders and standing on accommodation area at the vessel’s stern, at the lower deck hatch covers, neither of which is safe or compliant in level. However, this area was repeatedly overtopped by dynamic sea conditions. swell, making it unsafe for transfer. Although the third attempt succeeded in calmer weather, Two crew members were again stationed at the top of the the pilot ladder rigged was still unsafe, with poor securing, fixed vertical metal steps. This arrangement is non-compliant gaps between the ladder and hull, and obstructions at the and places both pilots and crew at unnecessary risk. top. This raises serious concerns. Improvised boarding The crew attempted to open a gate amidships as an methods, however well-intentioned, expose pilots and crew alternative boarding position, but the vessel was shipping to unacceptable risk. SOLAS and IMO regulations are not seas on deck and clearly unsafe (see image above). optional; they are the minimum standard.

Representative image. Credit: Shutterstock

If the lower deck is the only viable transfer point, this Capability – Improper ladder rigging and repeated use must be clearly stated in the vessel’s pilot card and agreed of unsafe arrangements suggest a poor understanding of in advance. It is not helpful to inform the pilot when they are SOLAS Ch V Reg 23 and pilot transfer standards. on the bridge about the transfer arrangement. This raises the question: do ports have heavy weather boarding procedures Communication – Unclear coordination between the pilot in place, with weather and sea state limits established? and vessel on boarding points and conditions led to unsafe Only those conditions that fall within the criteria should be or aborted attempts. allowed for pilot boarding to take place. This case reminds us that if a vessel cannot provide a Key Takeaways safe and compliant means of pilot transfer under expected Seafarers – Know the rules, do not improvise conditions, it may not be suitable for pilotage operations Unsafe boarding improvisations aren’t just non-compliant without modification. CHIRP will raise this issue with the — they endanger lives. Always use properly rigged pilot relevant authorities to explore whether further action or ladders, never fixed ladders or hatch covers. If in doubt, stop guidance is necessary to prevent recurrence. and escalate the issue. The subject of creating a safe lee for boarding was discussed by our Maritime Advisory Board. Below this report Managers – If your ship cannot comply, it is not ready is a short article written by members of the board with Vessels must be physically and procedurally capable of expertise in this area of seamanship. safe pilot transfer in the expected weather conditions. Ensure that pilot cards accurately reflect the actual Factors relating to this report boarding arrangements and that crews are trained to meet Local Practice norms – The continued reliance on non- SOLAS standards. compliant methods implies that unsafe practices may have become informally accepted aboard this vessel. Regulators – Unsafe boarding is still too common Persistent non-compliance shows the need for Complacency – The crew appeared to accept unsafe enforcement, not just guidance. Strengthen oversight of methods (e.g., fixed ladders, hatch covers) as viable pilot transfer design and onboard practices, and ensure boarding options, indicating the normalisation of non- unsuitable vessels are forced to change their poor practices compliant practices. before incidents occur.

www.chirp.co.uk/maritime MFB 80 | Autumn 2025

M2460 Communication – There may have been insufficient communication between designers, builders, and

Near miss – escape operational stakeholders. Without input from those with lived experience on board, subtle but serious flaws like this

route blocked can go unnoticed until it is too late.

Teamwork – The design process lacked interdisciplinary Initial report coordination. Engineers, naval architects, shipyard teams, During a routine inspection, the team found that an and operational staff all play a role in ensuring systems emergency escape hatch from the engine room to the function safely. Here, the lack of collaborative review deck could not be opened. The hatch, located near the aft meant a potential emergency hazard was built in from mooring bits, was obstructed by the turned-up mooring day one. lines. Just 2 to 3 centimetres of rope extending beyond the edge of the bitts was enough to prevent the hatch Key Takeaways from opening — a small detail that could have had serious Seafarers – Don’t assume safety systems work consequences in an emergency. as designed Regularly inspect and test escape routes under real-world CHIRP Comments conditions, including when the vessel is moored, to ensure This issue stems from the vessel’s design phase. Mooring they are functional and practical. Speak up if something isn’t arrangements and emergency escape routes were developed right, even if it complies with the ship’s plans. using CAD software and approved as compliant with the relevant regulations. However, it seems no one physically Managers – Engage operational staff early in the checked how these systems would work together in real- design process life conditions. CHIRP is aware of several such incidents, as Crews bring essential insight into how systems are used reported to the International Marine Contractors Association on a day-to-day basis. Build in practical walk-throughs (IMCA) and has written to the International Association of and validation steps to catch risks before they become Classification Societies (IACS) to raise awareness. built-in hazards. The problem only becomes evident when the vessel is alongside or under tow, but that is precisely when Regulators – Approval processes must include practical escape routes must be fully functional. Being unable to verification, not just CAD-based assessments open an emergency hatch because of a few centimetres of Design compliance must be matched by functional mooring line is a critical design oversight with potentially performance. Safety-critical access points must function severe consequences. Blocked emergency escape hatches reliably under all operational conditions, particularly have led to deaths in the past, e.g. the Marchioness on the in emergencies. River Thames. This highlights the need for practical, operational checks during the design and approval stages of newbuilds, not just This highlights the need for practical, digital validations. Safety depends not only on compliance operational checks during the design but on proven functionality. It underlines the need for integrated risk thinking across routine operations, design and approval stages of newbuilds, layout, and inspection regimes. not just digital validations Emergency systems must be constantly validated against the realities of onboard work practices. Incorporating escape routes during your familiarisation process, particularly when joining a different type of ship, is vital. Additionally, M2433 emergency escape hatches and their access ways should be

The ship’s aerial plans incorporated into contingency exercises so that their use can be part of both egress and access during an exercise.

were incorrectly labelled During a vessel’s quarterly inspection, the function and securing of escape hatches should be reviewed by an officer and crew from a different department. Initial report Indications and markings for the GPS 1 and GPS 2 antennas It seems no one physically checked were incorrectly displayed on both the bridge antenna how these systems would work arrangement plan and the compass deck. Incorrect markings, in the event of specific issues, can lead to misunderstandings together in real-life conditions regarding which equipment needs checking and repair. A complete survey of the ship’s antennae was conducted and Factors relating to this report the plans were updated accordingly. Situational Awareness – The design and approval teams failed to anticipate that the mooring operation would CHIRP Comments obstruct an emergency route. This suggests limited foresight This report illustrates how a minor error, such as incorrect regarding how the vessel would be used, particularly in an labelling, can lead to significant issues. The GPS 1 and GPS 2 emergency scenario where every second counts. antennas were wrongly marked on both the bridge plan and

the compass deck. If a fault had occurred, the crew might M2459 have checked the wrong antenna, wasted time, and possibly overlooked the real issue. The antennas were installed in the correct place, but the Pest infestation signs and drawings did not match. This indicates that no one properly checked the labels after installation was completed. Initial report For something as crucial as GPS, all information, We are facing a severe infestation of pests on the ship, including markings and drawings, must be clear and precise. with cockroaches present throughout the vessel. They are If the crew cannot trust what they see, it can cause delays or found in food supplies, refrigerators, utensils, bedding, mistakes during fault-finding. and other areas. This situation has caused significant This case serves as a reminder that when antennae are psychological and emotional distress among the crew. installed during the new build phase or at dry dock, any new We are unable to eat or sleep peacefully, constantly equipment must be rigorously checked. The area/antenna plan feeling anxious and stressed. The captain’s behaviour should also be updated and cross-checked to ensure accuracy. exacerbates our situation. He behaves erratically, making On a critical and operationally practical note, an antenna threats to ensure our silence regarding these issues. There position must be correctly marked and located so that is fear among the crew, and speaking out feels unsafe. the navigation system can apply the correct offset from During recent inspections, port inspectors did not inspect the vessel’s centre line. E.g. on a 60-meter beam vessel, the onboard condition closely. This same behaviour by a 20-meter error in recording can put you outside of a port officials also occurred at the last port and during the navigable channel! current inspection. The captain has warned us against It is essential that, during the annual or five-year saying anything. radio survey, aerial verification of all bridge equipment is physically carried out. This also applies after any refits at dry dock, where bridge equipment is renewed or replaced.

For something as crucial as GPS, all information, including markings and drawings, must be clear and precise Factors relating to this report Situational Awareness – During technical troubleshooting, bridge teams rely on plans and labels to quickly isolate faults. Incorrect markings can easily mislead the operator and prolong a problem that requires urgent attention.

Communication – Poor information flow between design, installation, and operations teams likely contributed to this discrepancy. Without effective feedback loops, errors can persist unnoticed until they lead to failure.

Teamwork – The eventual resolution required a coordinated review of all antenna locations and documents. This highlights the importance of collaboration across departments in identifying and addressing safety risks.

Key Takeaways Representative image. Credit: Shutterstock Seafarers – Check, do not assume Don’t rely unthinkingly on diagrams or deck markings — CHIRP Comments especially during fault-finding. Visually confirm the actual CHIRP contacted the flag state, which in turn contacted installation and speak up if you notice any discrepancies. the company, and arrangements were made to carry out fumigation of the vessel. However, the arrangements made Managers – Mistakes hide in small details to fumigate the ship did not follow the procedures outlined Include signage and documentation checks in post- in the company’s safety management system. CHIRP installation and maintenance routines. Even minor labelling was allowed to review the relevant sections of the safety errors can cause significant operational delays. management system, and none of the risk assessment controls were implemented. Regulators – Do not simply test systems — test This report highlights a breakdown in safety culture and assumptions, too procedural compliance on board. Ensure that commissioning and inspection processes No safety meetings were conducted, and there was no verify not only the functionality of equipment but also the explanation of the fumigant’s chemical data sheet. Some accuracy of associated markings and plans, particularly for crew members were reportedly asleep in their cabins when critical systems such as GPS. fumigation began; an unacceptable practice that exposed

www.chirp.co.uk/maritime MFB 80 | Autumn 2025

them to serious health risks. Video evidence supports Regulators: Silent crew resulted in missed signals— the crew’s account. The psychological effect on the crew regulation fails when crews cannot speak freely regarding the infestation and the lack of support by the This case highlights how inspection regimes can overlook master and company until intervention by CHIRP led to very critical hazards when crews are too afraid to speak up. high stress levels, according to the reporters. Despite clear procedural violations and health threats, port CHIRP managed to obtain the Safety Data Sheet for the inspectors overlooked the issues on two separate occasions. fumigant used, and the risk of health issues associated with Regulators must strengthen inspection protocols to uncover inhalation was high. The crew was instructed to conduct a both technical noncompliance and suppressed reporting second round of fumigation en route to their next port but cultures, ensuring seafarers can safely disclose concerns was left without hazmat gear or proper masks, rendering the and that just culture principles are allowed to flourish. fumigation unsafe. The master’s behaviour reflects a person under severe stress and not capable of