An independent and confidential Issue 82

MARITIME FEEDBACK reporting system for the Maritime industry Spring 2026

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.

When ‘Routine’ Becomes Risky We also examine a pilot-ladder arrangement Adam Parnell that concealed a serious design flaw, and an unusual Director (Maritime) report in which a remote update to a galley fridge triggered a partial electrical failure during port entry, which exposed how seemingly disconnected events can have significant safety implications. Routine tasks feature heavily in this edition, and each Finally, two reports highlight how pressure one shows how familiar practices can hide serious influences decisions: one officer was criticised for risks. A navigation audit graded as “medium risk” complying with COLREGs because it affected ETA, while identified multiple missing defences, which, when another Safety Officer resisted demands to permit entry combined, pointed to far more serious vulnerabilities. to a fueltank that contravened enclosed space rules. In We also feature a case in which contractors dismissed both cases, standing firm prevented unsafe outcomes. sound safety advice, highlighting how difficult it can These reports offer sharp lessons in vigilance, be for junior crew to challenge authority, especially challenge, and the need to remember that ‘routine’ when it matters most. does not mean ‘risk-free’. One reporter narrowly avoided collapse after Each of these reports came from a reader just like acetone vapour displaced oxygen in a confined space, you, and we are very grateful to those who had the despite following the vessel’s SMS, illustrating how courage to report to us. We encourage you all to report everyday substances can create unseen hazards anything that threatens your own or others’ safety so when used in restrictive environments. that together, we can prevent harm.

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 82 | Spring 2026

M2642 Task risk assessments should explicitly consider the chemical properties of substances used, as documented in

Near miss - potential their safety data sheets, including their vapour behaviour, ventilation arrangements, and the need for atmospheric

poisoning and asphyxiation monitoring. Standard enclosed-space precautions, including portable gas detectors, effective mechanical ventilation, and

of a crew member using a designated standby person, should always be applied. This is particularly important during refit or maintenance periods,

a chemical for cleaning a when resources can be reduced due to additional workload. This report also underlines the importance of crews having access to and understanding Safety Data Sheets confined space (SDS) in the correct working language. Pre-task planning should ensure that all personnel are aware of the risks of Initial report vapour expansion and oxygen displacement, as well as the I was on a vessel during an extensive refit and was limitations of PPE. responsible for cleaning and painting the engine room bilges. CHIRP strongly recommends that solvent-based cleaners, The main bilge sump was 6 ft deep, just enough to crouch such as acetone, should not be used for bilge cleaning. in, and I was at the bottom, using acetone to degrease the surfaces in preparation for painting. Unbeknownst to anyone Factors relating to this report in the crew, acetone expands to over 300% of its original Safety Culture – The organisation had not fully identified volume and is heavier than air. As a result, oxygen was or communicated the atmospheric risks linked to solvent rapidly displaced, and the vapour had nowhere to escape. I cleaning during refits. was wearing a VOC (Volatile Organic Compound) mask, in line with the company’s operating procedures, so I had no Capability – The task lacked a specific assessment way to sense what was happening. I didn’t have a ventilation that considered chemical behaviour, confined space system set up, a body-worn gas detector, or a lookout posted. characteristics, and required controls. Knowledge of solvent- The first sign of trouble was not light-headedness or nausea, related oxygen displacement was not part of regular training but a deep sense of ‘fight or flight’ in my chest. I scrambled or toolbox talks. out of the bilge sump and just caught my breath enough to call on the radio. Luckily, I escaped without needing medical Communication – The crewmember was isolated from the treatment, but it could have been much worse. It’s a lesson other crew, so no communication could take place. I’ve carried throughout my career. Teamwork – No designated standby person or two- CHIRP Comments way check-in process for potentially hazardous work. The Bilges are enclosed spaces as defined in the Code of crewmember was working independently without support. Safe Working Practices Section 15, MGN 659, and MSC A.1050(27). Vessels should clearly identify and record which Design and engineering control – Lack of integrated compartments onboard are considered enclosed spaces ventilation/gas detection for small, confined compartments. (ES), or confined spaces (CS) and ensure this information is reflected in the SMS and risk assessments. While the Local Practice – Procedures and work-as-done did not reporter was following the vessel’s SMS, the VOC mask used align with the real risks and relied heavily on PPE rather than was not suitable for the hazard encountered. higher-order controls. This report highlights an important and often under- appreciated chemical hazard associated with routine Key Takeaways tasks such as bilge cleaning. The reporter was working You can’t smell missing oxygen — so plan for the during a refit period, when ventilation arrangements and hazard you can’t sense. system configurations may differ from normal operations. The use of acetone in the confined geometry of a bilge Regulators sump, combined with poor ventilation and no atmospheric This report reinforces the need to ensure that guidance monitoring, created a potentially life-threatening on confined-space entry and hazardous-substance use, situation. A personal oxygen meter should be worn. It is explicitly covers the oxygen-displacement risks of common commendable that the reporter recognised the symptoms solvents such as acetone. Regulatory frameworks may early and exited the space promptly, thereby preventing a already mandate atmospheric testing and ventilation for more serious outcome. enclosed-space work, but this incident shows how everyday A key learning point is that many common solvents maintenance tasks can fall outside formal definitions while produce vapours that can rapidly displace oxygen because presenting identical hazards. Clearer expectations around gas they have higher vapour densities, particularly in enclosed, detection, task-specific risk assessments and solvent-handling confined, and poorly ventilated spaces. VOC masks protect protocols during refit periods would help close this gap. against the inhalation of certain substances but do not provide notification that oxygen depletion is occurring. Managers Carrying gas-detection equipment is essential, not only for The key takeaway is that work planning must account formally designated enclosed spaces or confined spaces for both the environment and the chemical properties of but also when using oxygen-displacing chemicals in any the substances being used. Procedures that rely solely restricted area. on PPE, without ventilation or atmospheric monitoring,

create a false sense of security. Ensuring that Safety Data incident occurred, but several key defences were absent or Sheets are incorporated into pre-task briefings, making gas unverifiable. We consider some of the findings to be well detectors readily available and verifying that confined-space above “Medium Risk”, and our analysis is as follows: precautions are applied, even in small spaces like bilge The findings are accurate, but there are too many sumps, are essential steps. Refit periods require heightened passive phrases, such as “no objective evidence”, which vigilance because non-routine work often involves softens the operational reality. In safety-critical operations, equipment isolation, restricted access and chemical hazards if something cannot be demonstrated, it cannot be that may not be part of everyday operations. relied upon. The use of mixed time standards (UTC and local Crew time) undermines shared situational awareness The lesson is that familiarity with a product does not and complicates decision-making during anchoring, guarantee safety. Solvents can behave unpredictably in emergencies, and incident review. The use of correct times confined areas, and symptoms of oxygen depletion may be is a fundamental requirement in bridge management, not subtle until they become dangerous. Relying on PPE alone an administrative detail. is not enough; ventilation, monitoring and having someone Failure to amend the anchoring plan suggests the aware of the task are critical safeguards. Trusting instinct and operation was treated as routine rather than as planned acting early, as the reporter did, can prevent severe outcomes navigation. This often leads to informal watchkeeping and reduced vigilance once the anchor is down. Across several observations, there was no verifiable evidence of effective monitoring - no visual bearings, no M2621 plotted positions, limited radar use, and one radar switched off. In effect, the vessel was anchored without reliable

Navigational audit quality position awareness. An anchor watch without monitoring is not a watch – it is an assumption. Radar redundancy is a deliberate safety feature. Initial report Switching off a radar removes or reduces early warning of The reporter has shared an example of a navigational anchor dragging, traffic, or unexpected movement. Radar audit they consider below standard and representative use at anchor should be considered essential. of the quality observed during some inspections. The While each issue was assessed as medium risk in findings shown below relate to the Company SMS and isolation, their combined effect significantly increased the Bridge Procedures Guide and illustrate how auditors are likelihood of an undetected dragging anchor or a close- recording observations. This example is shared to encourage quarters situation. No accident occurred, but normal reflection on audit quality, consistency, and whether such defences had eroded. Monitoring, documentation, and findings effectively support safe navigation and meaningful radar use are core safety controls, not optional tasks. CHIRP improvement on board. members expressed concerns that there was an excessive The reporter sent the following report to CHIRP, emphasis on documentation requirements rather than on highlighting a typical example of a navigational audit. real navigational performance. The advisory board wants to Navigational audits – independent inspection highlight the need for auditors to receive training in bridge findings. The findings relate specifically to the Company behaviour, situational awareness, and anchoring practices. SMS and Bridge Procedures Guide. 1. The passage plan and bridge logbook were in local time but the VDR was in UTC. 2. The passage plan was NOT amended to include the Anchoring Plan, creating ambiguity. 3. During anchor watch, there was no objective evidence of frequent intervals check that the ship remained securely at anchor by taking bearings of fixed navigational marks. 4. During anchorage, there was no objective evidence that both radars were in use, which impaired situational awareness. 5. Radar recordings do not support the use of parallel indexing, again impairing situational awareness. 6. Radar recordings do not support the use of radar to determine and plot the ship’s position to ensure that the vessel remains secure at anchor. Another reduction of situational awareness. 7. During anchor watch, the X-band radar was Representative image. Credit: Shutterstock switched off. Factors relating to this report CHIRP Comments Situational Awareness – Reduced electronic verification of Although each finding was recorded as a “Medium Risk” position likely hinders a true understanding of the vessel’s observation, their number and consistency point to a location. Without standard timeframes, the team may not broader breakdown in anchoring watch discipline. No know what is happening in real time.

www.chirp.co.uk/maritime MFB 82 | Spring 2026

Representative image. Credit: Shutterstock

Local Practice – Not updating the plan reflects an informal Seafarers – Know your ship, trust your instruments, and practice that deviates from documented procedures. do not assume- confirm The inspection highlights the critical importance of vigilance Capability – The lack of use of available techniques and disciplined procedures. Always check positions, use all suggests reduced monitoring capability. Radar should be available instruments, and ensure your passage plan reflects used as part of best practice; not doing so may reflect gaps reality. Your awareness and adherence to procedures are the in competence. frontline defence against incidents.

Complacency – The decision to switch off the radar may reflect an overly relaxed attitude to risk. Routine behaviour can lead to assuming the plan does not need change or M2700 improvement.

Communications – Misaligned time references lead to Standing firm in the face of pressure from authority misunderstandings and poor information exchange.

Distractions – Failing to maintain full situational awareness may indicate that focus is elsewhere. Initial report The master instructed me to issue a Permit to Work (PTW) Key takeaways for the ETO to enter a fuel tank while the vessel was at sea Regulators – Safety isn’t written on paper- it’s lived on to repair an underwater light. the bridge A risk assessment was carried out, which confirmed that The audit demonstrates that even with modern systems it was not possible to fully remove the fuel or ventilate the and documented procedures, human factors and leadership space to safe levels. On this basis, the task was rejected. profoundly influence outcomes. Oversight, guidance, Despite this, the master insisted the work should and safety audits must address not only equipment proceed. I refused to issue the PTW, as the request was and procedures but also crew behaviour, training, and contrary to COSWP and established guidance on enclosed organisational culture. space entry. The master stated that I had no authority to refuse, despite my role as the vessel’s Safety Officer. Managers – Lead with oversight, equip with knowledge, I stuck to my original decision, and the work did not and culture follows compliance take place. The findings underline that leadership, supervision, and training are just as important as equipment. Ensuring CHIRP Comments procedures are enforced, crews are competent, and the This report highlights a maintenance situation in which safety culture is active helps prevent small lapses from established safety barriers functioned as intended. The becoming major risks. outcome was achieved, not by chance, but through the

exemplary actions of the vessel’s Safety Officer, who Culture – The master showed no safety culture, whereas correctly applied the safety management system and the Safety Officer upheld the company’s values. It is upheld the permit-to-work (PTW) process in the face possible that this type of override of a safety barrier, the of pressure. PTW, is commonplace. The proposed work involved entry into a fuel tank while the vessel was at sea. The Safety Officer correctly Key Takeaways identified that the tank could not be fully drained or “Safety systems are only effective when the authority adequately ventilated, and that the conditions did not meet to stop unsafe work is understood, respected and the requirements of COSWP or accepted enclosed-space supported at every level on board.” entry guidance. On this basis, the Permit to Work was refused, and the task did not proceed. CHIRP considers For regulators this to be an appropriate, proportionate, and professionally This report reinforces that compliance cannot be assumed sound safety decision. simply because procedures exist. Effective safety Of concern, however, is the apparent challenge to management depends on authority, role clarity and cultural both the PTW process and the Safety Officer’s authority. reinforcement on board. Regulators may wish to continue The PTW system is intended to serve as a formal safety emphasising that Permit to Work systems are safety barrier, particularly for high-risk activities such as entering barriers, not administrative tools, and that Safety Officers enclosed spaces. Its effectiveness relies on a shared must be explicitly empowered to stop unsafe work without understanding that permits may be refused when risks fear of challenge or reprisal. cannot be adequately controlled, regardless of operational or commercial pressures. For managers CHIRP notes that entry into enclosed spaces Company leadership - the incident highlights the gap within fuel tanks remains a significant cause of serious between work as imagined and work as done. Clear policies maritime accidents and fatalities. Industry guidance is on enclosed space entry and PTW authority must be clear that such entries must not be undertaken unless the supported by consistent messaging to masters and senior space has been properly prepared, tested, and confirmed officers. Training should address the authority gradient safe. Attempts to override these controls undermine the directly and reinforce the point that rejecting unsafe work is purpose of the safety management system and increase a leadership responsibility, not an obstacle to operations. the risk of serious outcomes. A valid question for the naval architects is why a light fitting should be accessed via a For crew fuel tank? The report demonstrates the importance of speaking up This case also reinforces the importance of clearly and adhering to established safety processes, even when defined roles and authority on board. When the Safety under pressure. It also shows that refusing unsafe work is a Officer’s responsibilities are not fully understood or legitimate and necessary part of professional seamanship. supported at the command level, safety decisions risk Safety