CHIRP Maritime FEEDBACK 81

An independent and confidential

MARITIME FEEDBACK reporting system for the Maritime industry

Edition MFB 81 GENERAL MARITIME November 2025

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Stand up, Speak out, Stay safe! Contents

2 M2591 - Severe injury cased by a fall 4 M2576 - Close quarters situation from pilot ladder 6 M2558 - Pilot transfer arrangement 3 M2561 - Illegal disposal of waste at sea (PTA) - significant safety concerns 3 M2590 - Near miss between an 7 M2613 - Bullying ship manager – safety uncrewed surface vessel (USV) and a and leadership culture ashore? large number of yachts

Adam Parnell

Don’t let silence endanger safety at sea. Each report reflects a deeper truth: safety culture is shaped by the actions of individuals, and sustained Maritime safety is built not just on regulations and by the systems that support them. Whether it’s a procedures, but on the everyday courage of those pilot refusing to board an improperly rigged ladder who speak up when something isn’t right. This or a crew member resisting pressure to violate edition contains powerful examples of moral MARPOL rules, these stories remind us that bravery, from sounding the alarm on illegal waste compliance is not just about ticking boxes; it’s about disposal at sea, to challenging unsafe pilot transfer protecting lives, the environment, and professional arrangements in harbour, to confronting bullying integrity. leadership ashore.

CHIRP depends on the voices of seafarers and maritime workers This creates a conflict between 2 competing risks: that of falling worldwide to raise safety concerns in their environments. Every from height onto a pilot vessel already at the bottom of the report, regardless of size, helps us identify trends, challenge ladder, and the chance that the pilot vessel could snag the complacency, and foster learning across the industry. Your bottom of the ladder as it manoeuvres alongside, causing the experiences are important; in fact, they can literally save lives. pilot to be thrown off the ladder by the violent motion.

If you have witnessed a safety issue, faced pressure to cut There is no ‘best’ answer that can be universally applied. corners, or want to share a lesson learned, we encourage you to However, the Standard Operating Procedures (SOPs) of many submit a confidential report. Together, we can maintain pilot authorities will favour the positioning of the pilot vessel at momentum and foster a maritime culture where courage is the bottom of the ladder before the pilot arrives at the top of the celebrated, compliance is standard, and safety is everyone’s pilot ladder and begins their descent. CHIRP suggests that pilot responsibility. authorities augment their SOPs by permitting the pilot some discretion if their dynamic risk assessment (conducted in coordination with the ship and the pilot vessel) indicates that, in that specific circumstance, the balance of risk favours the pilot Reports descending partway down the ladder before the pilot vessel approaches the bottom of the ladder.

Report No1 - M2591 – Severe injury cased by a In all instances, the IMO guidance posters (MSC.1/Circ 1428) can fall from pilot ladder reinforce good coordination and shared expectations. Clear communication, mutual awareness, and precise timing remain Initial Report the most effective ways to ensure every pilot transfer ends While descending a pilot ladder, a pilot fell approximately 5m safely. onto the pilot launch and was severely injured. The standard operating procedure for this pilotage authority was for the pilot vessel to position itself at the foot of the ladder and remain there Key Issues relating to this report while the pilot or other personnel descended. Situational Awareness – Be aware of the factors that can cause a pilot to fall. These include the weather and sea state, the Our reporter was concerned that this procedure may conflict relative movement of the two vessels, the height of climb and with best practice, as falls from even moderate heights onto a the efficacy of the ‘lee’ created by the larger vessel, among pilot vessel can be fatal. They prefer to be partway down a other factors. ladder before the pilot vessel approaches alongside.

Local Practices (Shortcuts/Deviation) – The operating procedures of this pilotage authority are contrary to global best CHIRP Comment practice. However, as written, this pilot’s descent of the ladder Pilot Transfer Arrangement (PTA) incidents often reflect broader before the pilot vessel is at the foot of the ladder is also a systemic issues, such as inconsistent onboard training, deviation from documented practice. The pilotage authority is insufficient supervision, or a lack of shared understanding of encouraged to reconcile these different perspectives to ensure procedures. Ensuring all parties know what to expect and when that risks are as low as reasonably practicable (ALARP). is crucial for safety. Communication/Alerting – The pilotage authority did not An educational video by the Federation Francaise des Pilotes address the reporter’s concerns. Maritimes highlights that a fall from 3m onto a pilot vessel can cause serious injury, a fall from 5m can cause permanent Pressure – There was implicit pressure from the pilotage disability, and a fall from 8m can be fatal.[1] This underscores the authority for the pilots to adhere to a rigid operating procedure, importance of clear communication and coordination between despite this being contrary to industry best practice. the ship’s bridge team, the pilot, and the pilot launch crew. Key Takeaways When a pilot is embarking, it is generally safer for the launch to move away from the vessel once the pilot is secure on the Regulators: Enforce best practice before tradition becomes a ladder and has started to climb. However, when the pilot hazard. is disembarking and still at the top of the ladder, the risk of fatal injury should they fall onto the pilot vessel is at its greatest. Strengthen oversight to ensure disembarkation practices comply with international guidance and address cultural tolerance of unsafe methods.

Managers: Are risks “As Low As Reasonably Practicable” duty to act, plays a key role in ensuring that those who raise (ALARP)? concerns are supported, not silenced.

Review and align local procedures with international best CHIRP commends the reporter’s moral courage. This incident practice to prevent normalisation of unsafe shortcuts. reinforces why CHIRP exists: to provide a safe, independent route for seafarers to speak up when something is wrong, and Pilots/Contractors/Seafarers: Your safety comes first – to drive learning that protects people and the environment. don’t ascend or descend the ladder until agreed safety practices are in place. Key Issues relating to this report Always verify the launch’s safe positioning before committing to Culture – The vessel’s safety and environmental culture was the ladder, and challenge unsafe instructions if necessary. weak, and it took significant moral courage from the crew to speak up and challenge harmful environmental practices.

Alerting – Alerting is a crucial skill, and it takes courage to speak Report No2 - M2561 – Illegal disposal of waste at up when there is a risk of emotional or professional retaliation. sea Local Practices – Illegal dumping at sea had become Initial Report normalised on board until someone spoke out and reported it to A reporter informed CHIRP about the illegal disposal of oily the authorities. waste and plastic while the vessel was en route to its next port. They provided photographs and videos showing oily waste Key takeaways from the engine room being discharged into the sea under the instruction of senior officers. Regulators: Protect the sea, and those who also attempt to protect it. CHIRP alerted the flag state and, soon after, a flag state Flags and authorities should respond promptly to reports of inspector arrived on board to conduct an inspection. The illegal discharges and investigate thoroughly. Visible action, reporter and CHIRP maintained close communication including meaningful sanctions, helps prevent recurrence and throughout. The reporter’s primary motivation was simple: to strengthens compliance culture. Guidance and enforcement stop environmental pollution and ensure accountability. must emphasise both environmental protection and protection for reporters.

CHIRP Comment Managers: Protecting reporters ensures safety for everyone. The reporter initially raised the issue internally, with other crew members supporting concerns about the environmental impact. When seafarers feel safe enough to raise safety and When no action followed, they contacted CHIRP to ensure the environmental reports confidently, it leads to positive safety matter was adequately addressed. Their moral courage and changes. Managers have an obligation to champion a positive sense of responsibility are commendable. reporting culture. Clear procedures should ensure swift action and strong support for those raising concerns. Although the experience left the reporter feeling isolated at times, they remained convinced that protecting the marine Seafarers: CHIRP is here to help you. environment was the right thing to do. CHIRP shared the Reporting environmental violations is vital to protecting the evidence with the flag state, the company’s designated person marine environment. When you don’t feel safe reporting ashore (DPA), their insurers, and the classification society to through your company’s normal channels, CHIRP is here to understand why oily waste and sediment had accumulated and listen and help. to help prevent similar incidents in the future.

CHIRP encourages readers to report concerns, even if feedback from authorities appears limited. Every submission helps reveal Report No3 - M2590 – Near miss between an systemic issues and promotes positive change. uncrewed surface vessel (USV) and a large number of yachts This case also illustrates that protection for those who speak up is not only a shipboard issue; it reflects the company’s safety Initial Report culture ashore. The DPA, with both the authority and the moral While departing from a fuelling jetty within a harbour, a USV and its support vessel were surrounded by a large number of

sailing vessels entering the harbour. Due to the high density of habit can reduce safety margins and increase the risk of traffic, both vessels were unable to manoeuvre safely, resulting incidents. in a near miss. The situation posed a significant risk to life and property, as several vessels were at risk of collision or damage.

Key Takeaways CHIRP Comment This near miss highlights the challenges of operating uncrewed Regulators and Authorities: Regulate for future vessel types , surface vessels (USVs) in busy ports alongside conventional not just the existing ones. craft. Even well-planned operations can create risk when there is limited room to manoeuvre and many other vessels are Mixed crewed and uncrewed vessel operations demand present. updated procedures and oversight. Integrating USVs into port and VTS systems, strengthening coordination requirements, All vessels, whether crewed or uncrewed, must comply fully and refining training and guidance are essential steps to with the COLREGs. USVs are to be treated the same as any manage future traffic safely. other craft, and other water users have an equal responsibility to maintain lookout and take early, effective action to avoid Managers and Operators: Plan for the crowd — not for the collision (Rules 2, 5 and 6). Likewise, USV operators must calm. comply with Rules 8(e) and 8(f), as well as all other applicable regulations. The event underlines the need for realistic risk assessment and pre-departure coordination that reflect actual traffic conditions, The master and remote operator of a USV must be formally not just the operational plan. Human oversight remains vital, nominated and are usually ashore. On small vessels, one person and effective workload management between USV control may hold both roles, but a remote operator can control only one teams and support craft is key. Safety should never be vessel at a time, while a master may have several under compromised by schedule or commercial pressure. command. Seafarers: If the picture isn’t clear, don’t move. Seafarers should anticipate congested areas and maintain heightened awareness, particularly during arrival and departure. This incident highlights the importance of maintaining Port operators and vessel managers should ensure clear traffic situational awareness when operating in congested waters and management and communication plans are in place whenever recognising that uncrewed systems may have limitations in USVs are active. perception and manoeuvrability. Clear, early communication remains essential, and it is always safer to delay departure than Port authorities may wish to review local regulations and to risk escalation in confusion or congestion. consider guidance for USV operations in areas of dense leisure or commercial traffic, including requirements for signalling, monitoring, and coordination with port control. Report No4 - M2576 – Close quarters situation

Key Issues relating to this report Initial Report Situational Awareness – The traffic density overwhelmed the “We are a large sailing yacht under power, motoring on a south- USV/support team’s ability to maintain a clear mental picture of westerly course at 9 knots and around 1.5nm from a all contacts and their intentions. navigational strait/passage. I noted the ferry steaming almost north, clearly visible, showing her starboard bow. Visibility was Communications – With multiple vessels, tight spacing, and very good, and both radars were operating with a lookout on the perhaps different operators (yachts, marina control), bridge. miscommunication or ambiguity in intentions could lead to misunderstandings. The CPA was causing concern, and it was a clear crossing situation (R15 COLREGs). Complacency – Because departures are routine, operators may have underestimated collision risk, assuming that vessels would In this situation, my vessel was the stand-on vessel, as “give way” or that traffic would self-resolve. confirmed by the lookout. I maintained my course and speed. I expected the ferry to turn slightly to starboard (about 10-15 Local practices – In some ports, it is common practice to depart degrees) as there was plenty of sea-room and no immediate into busy traffic without clear sequencing or control. This local traffic, and the ferry had cleared the strait, so there were no

depth restrictions. Then both vessels would have passed port to port. Key Issues relating to this report Local Practices – The ferry’s failure to alter course reflects a The ferry maintained her course and speed, crossing my bow at potentially ingrained local practice of prioritising routes and a range of less than 2 cables. We then passed starboard to schedules over safe crossing protocols. starboard, close enough (about 70 metres) that I could clearly see the master/watchkeeper on the bridge, who gestured that I Communication – No VHF call or signal exchange occurred, was in the wrong, which surprised me, as there was no doubt even when intentions were unclear, which denotes a about the situation, or which vessel should take what action. breakdown in clear communication.

Although ferries operate on regular routes, they must still Situational Awareness – No/wrong/late visual detection: The comply with the COLREGs. This potentially close-quarters close crossing suggests the ferry didn’t adequately gauge the situation could have been avoided with better application of the yacht’s trajectory in time. Even though radars were operating, COLREGs.” the impending crossing wasn’t detected or acted upon sufficiently early.

Complacency – Familiarity with regular route traffic may have led to underestimating the risk, assuming no deviation or hazard CHIRP Comment would arise, and failing to challenge the crossing scenario. CHIRP followed up with the master of the motor yacht to clarify and obtain additional information. Alerting – Despite the yacht’s clear expectation of port-to-port passing, there was no challenge or signal to the ferry indicating The account suggests that both vessels failed to follow the concern, nor was there any cross-check or speaking up. appropriate rules (2, 7, 8, 16, and 17) of the COLREGs, leading to a close-quarters situation. Expectancy bias may have influenced Pressure – Operational pressures, such as maintaining their actions, as the ferry assumed the large motor yacht would schedules, could have influenced the ferry crew’s decision- give way, which is sometimes the norm in busy coastal waters. making; insufficient personnel or workload management may have contributed. A further factor may have been commercial pressure. Tight schedules and repetitive crossings can subtly influence Key Takeaways decisions, sometimes leading mariners to prioritise efficiency over compliance. However, passing at only 70 metres is clearly Regulators: Spot the patterns, close the gaps, enforce the hazardous, regardless of vessel type or familiarity with the COLREGs. route. Track recurring close-quarters incidents involving scheduled ferries and other vessels. Apply human factors frameworks This event serves as a reminder that the COLREGs exist to (MGN 520 Deadly Dozen, SHIELD taxonomy) to identify remove uncertainty. Expecting other vessels to deviate from systemic issues. Strengthen oversight to address shortcuts or them introduces unnecessary risk. Challenging assumptions and local habits that undermine COLREGs compliance, and promote maintaining situational awareness are critical, as is early and clearer guidance on proactive VHF use and bridge team unambiguous communication; a timely signal of five short light management in congested waters. flashes/sound blasts can often break the chain of misunderstanding before it leads to danger. Managers: Culture and training must take precedence over schedule pressure. For ferry operators, there is also an essential organisational Ensure bridge teams are empowered to follow the COLREGs, lesson. Companies operating to tight schedules should ensure even under time pressure or on familiar routes. Build a culture that management regularly reviews passage plans, either that values challenge and open communication. Reinforce that through marine manager visits or independent navigational safety decisions are supported, even when they delay audits, to confirm that bridge practices remain compliant with schedules. the COLREGs. Encouraging crews to report and discuss near misses openly and without blame helps to identify patterns and Seafarers: Don’t assume, check, communicate, and act early. reinforce safe behaviour before incidents occur. Use every available tool, radar, AIS, and visual bearings, to confirm other vessels’ intentions. If in doubt, clarify via VHF While both vessels had clear obligations to act to avoid collision, before the situation escalates. Never rely on what “should” this case reinforces a simple truth: being righteous and right is happen; anticipate, question, and take early action to stay clear not the same as being safe and compliant. and stay safe.

have since noted improvements in PTA safety. While this