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MARITIME FEEDBACK reporting system for the Maritime industry

Issue 11 SUPERYACHTS February 2026

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Silence isn’t safety Adam Parnell between crew members, we ignore it at our peril. The Director (Maritime) first two reports also raise the question of alerting, or speaking up when we see a potential problem. As we comment in one of the reports: ‘while speaking up

T his edition contains interesting and varied reports, and we are grateful to all our contributors for their support. It is noticeable that most cases are concerned can be morally uncomfortable, the potential safety and legal consequences of staying silent can be far more serious.’ with routine operations – collision avoidance, bilge A lack of teamwork also appears in several cleaning, shifting anchorage, bunkering and preparing reports, and in most cases could be avoided by to anchor – all things which we are familiar with, but holding proper briefings and discussion before a task perhaps this familiarity sometimes causes us to lower is undertaken. Better communication is likely to lead our guard at the wrong time. to better teamwork. Among the human factors we identify, We hope you will find the cases described in inadequate communication appears most often. this edition useful and, until next time, be careful Whether it is communication between vessels or out there!

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.

M2612 When vessels are under refit or managed by temporary personnel, obligations under the ISM Code remain

Hull integrity compromised unchanged. Any damage affecting watertight integrity must be formally reported, assessed, and verified by Class and

during refit Flag through established channels. Unpermitted hot work remains a recurring concern in CHIRP reports. Regardless of intent, welding without a valid Initial report permit exposes crew and yard personnel to serious fire and During routine paint and corrosion repair on the bow, a explosion risk. It may also invalidate insurance cover should hole was discovered in the hull plating approximately 0.5 an incident occur. How hot work can be conducted in a meters above the waterline. Inspection revealed that the yard environment without proper documentation should be anchor pockets had not been properly sealed, allowing questioned by all involved. water ingress and corrosion to spread beneath the coating CHIRP encourages all mariners to maintain an open and system over multiple seasons. This represented a clear professional safety culture, one where hazards are reported, compromise of hull integrity. Upon discovery, the defect was not concealed. The integrity of the hull and the effectiveness documented and reported to the permanent Masters, who of the safety management system depend on openness, were on leave at the time. The Chief Officer recommended accountability, and procedural discipline. formally notifying management, the class, and the flag authorities and following standard hot work procedures, Factors relating to this report including obtaining a permit. Situational Awareness – The defect in the hull The master instructed that the matter be handled plating was not recognised as a serious threat to internally and ordered a weld repair without a hot work seaworthiness at the time. The absence of permanent permit, safety oversight, or post-repair testing. The repair command and limited oversight during refit reduced was completed without verifying watertight integrity, hull collective awareness of the vessel’s true condition and thickness, or class approval. Despite these actions, the the associated risks. vessel was scheduled for an Atlantic crossing, with no assurance that the repair had restored the hull to safe Communication – Although the Chief Officer raised a valid operational standards. safety concern, the information was not passed beyond the Several factors contributed to this incident. The absence ship. Communication became one-way, with no opportunity of the permanent command structure during the refit period for open discussion or escalation. This breakdown prevented resulted in poor oversight of shipyard activities. A culture essential parties, management, class, and flag, from of concealment and avoidance of reporting undermined providing oversight, and led to them unknowingly carrying procedural compliance and safety integrity. Conducting hot undefined risks in the long term. work without a permit exposed the vessel and personnel to serious fire and safety risks. Finally, the deliberate Teamwork – The team dynamic was weakened by the instruction to bypass reporting channels demonstrated a absence of the permanent Masters and unclear authority significant breach of professional and ethical standards. among temporary officers. The outcome of these events was a repaired hull with This created uncertainty over roles and responsibilities, no formal verification or documentation, leaving uncertainty allowing unsafe decisions to go unchallenged. over the vessel’s seaworthiness. The failure to follow ISM Code reporting requirements, the lack of class involvement, Capability – There was an apparent lack of competence in and the avoidance of established safety procedures exposed assessing the structural implications of hull corrosion and both the crew and the shipyard personnel to unnecessary repair requirements. risk. This incident highlights the need for vigilance, Performing a weld repair without verification or class transparency, and adherence to reporting protocols, input demonstrated a limited understanding of safety especially during periods when temporary command standards and statutory obligations. arrangements are in place. Alerting – Early warning signs—such as the discovered CHIRP Comments corrosion and the Chief Officer’s recommendation- were Undermining a vessel’s safety culture is not acceptable. ignored. This indicates a breakdown in the alerting process Creating situations where individuals carry responsibility where individuals either did not recognise or did not act without the authority to act, especially when they are upon safety signals. deliberately undermined, significantly increases risk. This report reinforces the importance of transparency Local Practices – Poor repair yard practices were carried and strict adherence to procedures, particularly during repair out, leading to fragmented refit and supervision and or yard periods when normal command structures may be unevenly distributed workloads. Without the permanent disrupted. Bypassing reporting requirements and permit-to- Masters, key safety oversight functions were lost. Shipyard work systems removes essential safety barriers designed to work continued without consistent monitoring or clear protect personnel and maintain hull integrity. interface management. Treating yard periods as “low risk” is a dangerous assumption. During repairs, a vessel may be effectively out Culture – A “keep it quiet” attitude discouraged of class and uninsured if unrepaired or unreported damage transparency and reporting. This culture of concealment later causes an incident. This risk is often poorly understood undermined safety management and trust and placed both on board. personnel and the vessel at risk.

Representative image. Credit: Shutterstock

Key Takeaways M2576 Regulators – Culture is as important as compliance. Regulators should look beyond paperwork and evaluate the culture that influences behaviour. When reporting systems Close-quarter situation are bypassed, the ISM Code becomes just a formality. Oversight during refits and temporary command periods Initial report should ensure that safety reporting, hot-work control, “I was aboard a large sailing super yacht, under power and class notifications are being adhered to. Promoting motoring on a south-westerly course at 9 knots transparency and supporting confidential reporting will help and around 1.5nm from a navigational strait/passage. uncover risks before they lead to incidents. I noted a ferry steaming almost north, clearly visible, showing her starboard bow aspect. Visibility was very Managers – Leadership shapes the safety climate. good, and both radars were operating with a lookout on Management must set clear expectations that defects and the bridge. safety issues are always reported, regardless of operational The CPA was causing concern, and it was a clear pressure. Temporary command arrangements require crossing situation (Rule15 ColRegs). strict supervision and documented accountability. A culture In this situation, my vessel was the stand-on vessel. I that values honesty over convenience safeguards both maintained my course and speed. I expected the ferry to reputation and personnel. Repairs impacting hull integrity turn slightly to starboard (about 10-15 degrees) as there was must always involve class and flag—taking shortcuts risks far plenty of sea-room and no immediate traffic, and the ferry more than delays. had cleared the strait, so there were no depth restrictions. Then both vessels would have passed port to port. Crew – Speak out, even when it feels uncomfortable. The ferry maintained her course and speed, crossing Every seafarer has a responsibility to protect the safety my bow at a range of less than 2 cables. We then passed of the vessel, the crew, and the environment by starboard to starboard, close enough (about 70 metres) that questioning unsafe decisions and ensuring procedures I could clearly see the Master/watchkeeper on the bridge, are properly followed. If you find yourself in a difficult who gestured that I was in the wrong, which surprised me, situation, take practical steps to protect both safety and as there was no doubt about the situation, or which vessel yourself. Keep a written record of your concerns, either should take what action. in an official logbook or by sharing them with a trusted Although ferries operate on regular routes, they must person using email or another method that provides a clear still comply with the COLREGS. This potentially close- time stamp. This creates an objective record if the situation quarters situation could have been avoided with better later escalates. You can also contact CHIRP for confidential application of the COLREGS.” advice and support. Raising concerns through the correct channels, even CHIRP Comment when they are not welcomed, is a mark of professionalism. While both vessels had clear obligations to act to avoid Maintaining situational awareness, using the permit-to-work collision, this case reinforces a simple truth: being righteous system correctly, and verifying that repairs are properly and right is not the same as being safe and compliant. completed all help prevent a “temporary fix” from becoming CHIRP followed up with the master of the sailing a long-term hazard. yacht to clarify and obtain additional information. The While speaking up can be morally uncomfortable, the account indicates that neither vessel fully complied with the potential safety and legal consequences of staying silent applicable COLREGs (Rules 2, 7, 8, 16, and 17), resulting in a can be far more serious. close-quarters situation.

Expectancy bias may have played a role, with an Key Takeaways assumption that the larger motor yacht would give way, Regulators: Spot the patterns, close the gaps, enforce as is sometimes seen in congested coastal waters. Such the COLREGS assumptions, however, undermine the clarity which Monitor patterns of repeated close-quarters incidents COLREGs are designed to provide. involving scheduled ferries and other traffic. Encourage Commercial pressure may also have been a systematic use of human factors frameworks (MGN 520 contributory factor. Tight schedules and routine crossings Deadly Dozen and SHIELD taxonomy) in investigations. can subtly influence decision-making, leading mariners Strengthen oversight of operator practices, where local or to favour efficiency over strict compliance. Passing at a habitual shortcuts undermine COLREG compliance, and distance of only 70 metres is hazardous, regardless of consider promulgating additional guidance on proactive vessel size or route familiarity. In some areas with frequent VHF use and bridge resource management for congested or ferry operations, local custom may develop whereby routine routes. ferries maintain course with the expectation that other vessels will keep clear, even when this conflicts with Managers: Culture and training must take precedence the COLREGs. over schedule pressure Risk tolerance is another consideration. The ferry may Maintain strict adherence to the COLREGS, regardless of have assessed 70 metres as an acceptable passing distance, familiarity with local routes or schedules. Do not assume which could explain the lack of avoiding action. the other vessel will act correctly. Proactively monitor CPA/ This event highlights the importance of adhering to TCPA, using all available means (radar, AIS, visual), and the COLREGs to remove uncertainty. Expecting other clarify intentions early via VHF when the risk of collision vessels to deviate from them increases risk. Challenging exists. Always be ready to challenge, alert, and speak up if assumptions, maintaining situational awareness, and a developing situation does not align with expectations. using early and unambiguous communication are essential. A timely signal of five short flashes or sound blasts can Crew: Don’t assume – confirm and communicate often interrupt a developing misunderstanding before to keep clear it escalates. Maintain strict adherence to the COLREGS, regardless of For ferry operators, there is also a wider organisational familiarity with local routes or schedules. Do not assume lesson. Operators working to demanding schedules should the other vessel will act correctly - proactively monitor ensure passage plans and bridge practices are regularly CPA/TCPA, using all available means (radar, AIS, visual), reviewed, through marine manager visits or independent and clarify intentions early via VHF when risk of collision navigational audits, to confirm ongoing compliance with exists. Always be ready to challenge, alert, and speak up if the COLREGs. Encouraging open, blame-free reporting and a developing situation does not align with expectations. discussion of near misses helps identify trends and reinforce safe practices before incidents occur.

Factors relating to this report: Local Practices – The ferry’s failure to alter course reflects a potentially ingrained local practice of prioritising routes and schedules over safe crossing protocols.

Communication – No VHF call or signal exchange occurred, even when intentions were unclear, which denotes a breakdown in clear communication.

Situational Awareness – No/wrong/late visual detection: The close crossing suggests the ferry didn’t adequately gauge the yacht’s trajectory in time. Even though radars were operating, the impending crossing wasn’t detected or acted upon sufficiently early. Representative image. Credit: AdobeStock

Complacency – Familiarity with regular route traffic may have led to underestimating the risk, assuming no M2640 deviation or hazard would arise so not challenging the crossing scenario.

Alerting – Despite the yacht’s clear expectation of port- Grounding incident to-port passing, there was no challenge or signal to the Initial report ferry indicating concern, nor was there any cross-check or The vessel had been anchored for three days to support speaking up. guest excursions. The owner requested that the vessel move closer to the dock to allow easier pick-up for a tour. Pressure – Operational pressures, such as maintaining After weighing anchor, the vessel ran aground about 10 schedules, could have influenced the ferry crew’s decision- minutes later. It struck uncharted coral and was damaged, making; insufficient personnel or workload management including the sacrificial rudder tip. One crew member sustained may have contributed. bruising after falling inside the vessel when it grounded.

The presence of uncharted coral was subsequently Managers – Encourage a safety culture where crew pause, reported to the hydrographic office. The incident highlighted reassess, and speak up; operational convenience should a degree of overconfidence, as the vessel had been never override risk awareness. Management companies anchored in the same bay for several days without incident. could greatly assist vessels by developing a ‘quick plan’ procedure for short passages that retains all the key CHIRP Comments elements required for any passage. This report highlights the risks that can arise when a vessel changes from a prolonged period of static operations back Crew – Treat every manoeuvre after inactivity as a new into manoeuvring, particularly in areas where hydrographic navigational task—assume nothing, verify everything, and data may be incomplete. safeguard yourself and others. Short voyages decided at short notice and under time pressure can be just as hazardous as longer passages and require the same level of planning. In poorly charted areas, practical precautions may include using a tender M2639 to check depths, ensuring echo sounders are active, and avoiding assumptions that conditions will be uniform across an anchorage. The Master retains the authority to say “no” Poor fuel handling causes blackout on safety grounds, and a clear explanation is often accepted. The vessel had been safely anchored for several days, which may have reduced the perceived risk when repositioning closer to the dock. Experience shows Initial report that extended periods without incident can lead to The vessel received poor-quality fuel during bunkering, overconfidence and assumptions about the safety of which was not detected in the supplied samples. After surrounding waters. The presence of uncharted coral departure, the ship lost propulsion in the middle of the night. demonstrates that hazards can exist over very short This occurred because the fuel oil was supplied directly to distances, even in familiar locations. the fuel oil service tank (FOST/day tank), bypassing the Operational or guest-driven requests can introduce bunker, settling tanks, and purifier. subtle pressure to act quickly. This underlines the As a result, several fuel injectors required replacement, importance of pausing to re-establish situational awareness and all fuel had to be processed through the purifiers. This and conduct a fresh risk assessment before manoeuvring, caused five hours of downtime during which the vessel was particularly after a period of inactivity. unable to manoeuvre. Fortunately, the vessel had ample sea The injury to a crewmember during the grounding room and calm conditions; under different circumstances, reminds us that sudden vessel movements can create the situation could have led to serious consequences. secondary risks to personnel, even at low speed. CHIRP commends the reporting of the uncharted CHIRP Comments coral to the hydrographic office. Mariners are encouraged This incident was a fuel‑handling failure not a fuel‑quality to treat manoeuvring after extended anchoring as a new issue. Fuel was delivered directly to the service tank— navigational task, to challenge assumptions formed during bypassing the bunker, settling, and purification systems— benign operations, and to adopt a conservative approach resulting in a complete loss of propulsion. Several injectors when operating close to shore or reef systems. had to be replaced, and all fuel had to be reprocessed through purifiers, causing five hours of downtime. CHIRP Factors related to this report recommends the use of third‑party fuel analysis to verify Situational