An independent and confidential Issue 78

MARITIME FEEDBACK reporting system for the Maritime industry Spring 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.

Safety takes time: Do we give ships enough time to stay safe? Flag State, because contraventions of the Maritime Adam Parnell Labour Convention are disgraceful, if sadly all Director (Maritime) too common. On a brighter note, it is encouraging that several of the incidents reported in this edition were resolved successfully by the crews involved. The benefits of

W e have a wide range of reports in this edition, and we thank all our reporters for contacting us. It strikes me that, despite the variety of vessel thorough training are readily apparent. Among the most common factors identified in these reports are situational awareness, capability, types involved, most of these reports apply to almost culture, teamwork, alerting and communication. every ship. How would your ship manage if you found We learn of a momentary loss of concentration on yourselves in similar situations? But the common a Search and Rescue craft, a fire in a cargo of charcoal theme in all reports is time: without it, many and another on a motor yacht recently out of drydock. checks and preventative measures are missed, a An inoperable CO2 system was also discovered following nd safety gets compromised. a period of maintenance. Once again we learn about a Finally, we commend the suggestion that pilot ladder which was improperly rigged, and we also vessels should adopt the use of ‘REMOVE BEFORE have reports about a corroded walkway on deck and an SAILING’ tags when equipment is rendered eye injury caused by a caustic cleaning agent. inoperative during maintenance periods. It is a simple One report which should not apply to and inexpensive idea which could potentially save any vessel, ever, concerns unacceptable living many lives. conditions. We are following this up with the 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.

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 78 | Spring 2025

M2354 CHIRP Comments The quickest way to motivate the industry to address this

Non-compliant pilot ladder common issue properly is to refuse to board. This also ensures pilots’ safety. Do not take chances – there is no such thing as a ‘safe’ non-compliant ladder. Initial report SOLAS requires that a responsible deck officer Our reporter sent pictures of a pilot ladder that did not meet supervises the rigging of ladders. Unfortunately, there is SOLAS regulations. No handholds were securely fastened some ambiguity in using the word ‘officer’ because ISO to the ship’s bulwarks, preventing the pilot from stepping 799 says that a deck officer can be any suitably trained safely and comfortably from the top of the ladder onto the deck crew, and many companies thus delegate the role to ship’s deck. The accommodation ladder platform did not a deck hand rather than a ship’s officer. This has obvious have stanchions, and the ropework and securing hitches safety implications. were substandard. The pilot ladder was not correctly CHIRP calls on Flag States to mandate that ladder secured at deck level. rigging be supervised by a ship’s officer and that this activity This was reported to the master when the pilot boarded be included within the Permit to Work system because of the vessel. The master was informed about the proper the potential risk to life. securing of the combination rig and has given assurances that corrective action will be taken. Port state authorities Factors relating to this report were alerted to this incident. Culture – A poor safety culture is evident, which is shown by the lack of care to a pilot boarding the vessel. Management must provide guidance and practical training to the crew.

Situational Awareness – There is a false sense of safety that the pilot can manage this transfer safely when it is clearly dangerous.

Capability –There are clear procedures for rigging a pilot ladder combination rig, but they were not followed in this incident.

M2310

Eye injury Initial report The ship’s cook used an oven cleaner containing sodium hydroxide while cleaning the galley after a mealtime. The cleaner was sprayed onto all greasy areas, including the extractor hood over the cooker (which was above head height) and left for some time to dissolve the grease. When the cook returned to inspect the sprayed area, the chemical cleaner dripped from the cooker hood into the cook’s eye, causing severe irritation and a burning sensation to the eyeball. A crewmember called the master who irrigated the eye with a sterile eye wash to flush the chemical from the cook’s eye. The coastguard doctor was contacted as a precautionary measure; they advised that the crewmember be airlifted to a local hospital for further treatment.

CHIRP Comments The correct PPE must be worn when working with caustic or other hazardous materials, especially above head height, as risks of personal injury significantly increase. The PPE should cover the entire body to prevent caustic burns. A full-face shield is better than eye goggles as it protects the whole face from caustic burns. It was also inadvisable to leave the area unattended after the chemical had been sprayed onto the galley surfaces because another crewmember might have entered and suffered a severe injury.

Factors related to this incident CHIRP Comments Communications – The head of the department needed to The armed guard is to be praised for raising this report be informed about this hazardous work so that proper safety because the crew were too afraid of reprisals to do precautions could be taken. so themselves. This raises worrying questions about the company’s safety culture. Many seafarers are Overconfidence – Because cleaning the galley is a routine unaware of their rights, set out in the Maritime Labour task and has been done many times before without incident, Convention, regulation 3.1 (page 43). The vessel in this the risk of the chemical cleaner has been overlooked. If report is breaching many of these legal requirements. you routinely work with chemicals, be alert to any signs of CHIRP contacted the vessel’s Flag State, which has a complacency in yourself or others. legal obligation to ensure that the vessel addresses these shortcomings immediately.

M2317 Factors relating to this report Culture – Management has very little regard for safety, MLC compliance and contractor welfare. Unacceptable living Alerting – CHIRP notes that this report comes from conditions embarked contractors, suggesting that the crew does not feel safe reporting these obvious failings. Initial report During a recent deployment, a temporarily embarked armed security guard reported that the ship’s material condition and M2329 living conditions were deplorable. The potable drinking water system was inoperative, and the crew relied on outdated bottled water. The water used for showering, brushing teeth, and laundering clothes was rusty. There was no air Container fire conditioning, and the toilet system was broken. Additionally, Initial report the living quarters were unhygienic, and the crew While on passage, a container full of charcoal spontaneously experienced numerous bed bug bites all over their bodies. ignited and a severe fire ensued. Food was also unsatisfactory: meals were monotonous, A special exemption existed at the time of the incident, with limited meat or fish options. Fruit was rarely available meaning that the cargo did not need to be declared and tasted of rust. dangerous goods. This significantly delayed efforts to identify the location of other charcoal-filled containers when the fire erupted. Thanks to the crew’s swift and decisive actions and exceptional teamwork during the emergency, personal injuries were prevented, and the ship sustained no structural damage. The crew’s coordinated efforts in boundary cooling and fire suppression were critical despite the challenges posed by the fully enclosed containers, which made firefighting operations more difficult.

CHIRP Comments This report echoes a similar incident (M2253) published by CHIRP in 2024. CINS (the Cargo Incident Notification System) has published their Guidelines for the Safe Carriage of Charcoal in Containers which is available online. Charcoal is categorised as ‘UN1361 CARBON animal or vegetable origin’ and presents unique risks because it can spontaneously ignite if not stored or packed correctly. From 1 January 2026, charcoal must always be labelled as dangerous goods, and transitional arrangements commenced from 1 January 2025. It is worth noting that 68 container fires were reported from 2015 to 2022, highlighting the potential risk to all carriers. While this new requirement will promote the safer carriage of charcoal in containers, shippers must still exercise due diligence to ensure that all requirements are fulfilled before loading. Carriers are encouraged to review their cargo management and know-your-customer procedures. Ship management and chartering departments are crucial in ensuring that shippers comply with the new regulations.

www.chirp.co.uk/maritime MFB 78 | Spring 2025

The crew’s ability to prevent this fire from escalating M2319 largely depended on strong onboard emergency

Fire on a large motor yacht preparedness, which is founded on a robust safety culture within the company. This report highlights the outcomes of practical training provided both on board and by the company. Initial report Factors relating to this report After a period of maintenance in dry dock, a motor yacht Local Practices – When packing charcoal into containers, was moved to a repair berth. Shore power was unavailable, strong local oversight and supervision is required to and one of the yacht’s generators was started. The captain ensure that the risks of oxidisation and spontaneous was not made aware that shore power was lacking, nor told ignition are minimised. that the generator had been started. During a pre-sail survey, the engine room (ER) Alerting – Charcoal must now be declared a dangerous ventilation dampers had been shut by the contractors. In the good. The local exemption has been revoked. haste to move out of the dry-dock, the crew did not have enough time to fully check the condition of these, so failed to Situational Awareness – Packers are encouraged to notice that they were still closed. This raised the temperature provide photographs of loaded containers to shipping in the ER, and an emergency escape hatch was opened to companies to improve their situational awareness of improve ventilation. A while later, the ER fire alarm sounded. container contents in the event of an emergency. The captain briefly checked the ER, observed haziness but no strong odour or visible fire source, and closed the door. The engineer and deckhand donned breathing Packers are encouraged apparatus and entered the ER. They discovered smoke near the running generator, which was shut down to minimise to provide photographs fire risk. However, this left the vessel without power. The emergency hatch was also closed. of loaded containers While attempting to respond to the incident, several issues were discovered: the emergency fire pump was difficult to operate, the emergency generator was inoperative, M2355 smoke detectors and atmosphere testing equipment were unavailable, and the fire system’s uninterruptible power

Corroded walkways supply battery had failed. Unable to monitor the ER, the master activated the CO2 system, which did not operate properly because it had been incorrectly configured. The over deck pipes captain and crew were unaware that the CO2 cylinder valves had to be held open until they were fully discharged. Initial report The local emergency services intervened and made While walking between holds 2 and 3 on a bulk carrier, the the space safe for re-entry. Subsequent investigation bosun observed that the platform made a crackling sound revealed that hot exhaust gas leaking from a malfunctioning under load. The metal plate was found to be significantly exhaust valve caused the fire, which was made worse worn and no longer capable of safely supporting the weight because the closed ventilation dampers limited air circulation of a single crew member. The bosun reported the issue to in the compartment. the master, who ordered an inspection of other walkways, which were found to be in a similar state. CHIRP Comments Taking vessels into and out of dry dock is a complex CHIRP Comments and high-risk operation that requires very clear Cross-deck walkways are often made of steel plates, but communications between contractors, dockyards, these can be corroded by seawater or chemicals carried as and vessel crews. This is particularly true when the cargo. Although the upper surface of these plates is usually responsibility for maintaining or operating the vessel, its well-painted, the underside is frequently overlooked or fixtures, and other equipment is transferred. inaccessible for painting, allowing undetected corrosion to It is essential that the schedule for bringing a vessel out develop until failure occurs, potentially resulting in serious of dry dock allows sufficient time for the crew to conduct injuries like leg fractures and lacerations. thorough inspections of their assigned equipment and spaces. CHIRP recommends replacing these steel plates with open They must also be able to re-check systems if external grating made from composite materials, which are resistant surveyors make modifications, as with the ventilation dampers. to corrosion. An open grating also exposes the underlying While owners may prefer to prioritise hotel services, pipework, making leak detection considerably easier. safety systems must take precedence. Beneath the polished exterior of a large superyacht, it remains a seagoing vessel Factors relating to this report where safety is paramount. A significant cultural shift in Situational Awareness – The condition of the walkway management is needed to ensure safety is consistently the could not be assessed because inspecting the underside of top priority. the steel plate was difficult. Time is also needed for the crew to become familiar with the operation and maintenance of the equipment Design – Assessing the condition of the steel plate was and to become proficient in routine and emergency modes difficult due to accessibility issues, so gratings are preferred. of operation.

Equally important, they need time to learn how to The design of the pins is a contributing factor: they are a function as a team. The fact that the captain was not informed similar colour to other nearby items and CHIRP suggests that if of the power issues or the running of the generator suggests they had been painted, or had a label like the ‘Remove before that they had not had the opportunity to work as a single, Flying’ tags used in the aviation industry, it would have been efficient crew. This includes reviewing (or developing) suitable much easier to identify that the pins had not been removed. risk assessments for every stage of the vessel’s emergence from dry dock and return to seagoing operations.

Factors relating to this report Capability – After any maintenance period, the crew need time to identify emergent defects, ensure that equipment is configured correctly, and they are correctly trained to operate it safety.

Communications – Defects and changes in operational readiness must be reported to the captain.

Teamwork – Teams need time to gel as a coherent and effective unit. Management should plan so that the drydock crew have sufficient time to establish good teamwork.

Alerting – Given the situation on board with non- operational essential safety appliances, would you have alerted your head of department.

Beneath the polished exterior of a large superyacht, it remains a seagoing vessel where safety is paramount

M2311 Factors relating to this report: Pressure – Are your crew adequately qualified and resourced to withstand additional pressure that can come at Near miss: poor the end of a drydock?

configuration of CO2 Teamwork – It is crucial to have a shared mental model when re-entering service after a drydock period, as this

firefighting system encourages facing challenges together.

Situational awareness – Actively seek input from other Initial report crew members and update your awareness. Never assume Following a period of maintenance, a pre-sailing inspection other people’s intentions- ALWAYS CHECK. revealed that the safety pins which prevented the CO2 firefighting system from operating were still in place. A Local practices – Equipment hand-over checklists can be a contractor had inserted the safety pins to prevent accidental valuable tool in these circumstances and should be used. discharge while maintaining the system but had not removed them once the work was completed. Communications – ‘Remove before sailing’ tags are useful Had these remained in place, the system could not have to help crew and contractors identify the state of the system. been used in the event of an engine room fire.

CHIRP Comments M2333 There is always a pressure to get vessels out of dock and back to operational service as quickly as possible. However, similar to report M2319 (Fire on large motor yacht), this pressure resulted in several important steps Lifeboat capsize during a being missed. Whenever equipment is handed over to or from a contractor, it is best practice that a suitably capability demonstration qualified crewmember and the contractor