Culture – The dominant issue. The crew described a poor safety culture, a lack of trust, and fear of raising concerns. A culture that discourages speaking up erodes morale and increases risk.

Communication – Failures in information flow, both within the vessel and between the ship and shore, were evident. Poor communication leads to misunderstanding, confusion, and missed hazards.

Teamwork – The lack of supportive leadership undermines teamwork. A crew that does not feel united or supported is less effective and less safe.

Fatigue – While not explicitly stated, the poor working conditions likely contributed to fatigue or a high workload. Fatigue reduces alertness, reaction time, and judgment.

Alerting – the reluctance to contact the Flag State directly and the need to use CHIRP indicates a failure of systems that should enable safe, anonymous reporting. Seafarers felt they had no safe route to raise concerns internally or externally.

Key Takeaways

 Seafarers – Speak up, even when it is difficult. Your voice matters. If you are working in unsafe or unsupportive conditions, reporting through trusted channels like CHIRP can help drive change. A strong safety culture begins with individuals who care enough to raise concerns, even when the system appears not to listen.

Managers – Culture is built, or broken, by leadership. Poor on-board culture and weak leadership directly harm safety, trust, and performance. Create conditions where the crew feel respected, heard, and supported. Empower teams to report concerns without fear. Safety is not just compliance — it is behaviour, values, and consistency.

Regulators – Confidential reporting needs absolute protection. Seafarers will not report concerns if they fear being exposed. Confidentiality and follow-up action are critical. Regulators must ensure that reporting systems are genuinely safe and trusted and that companies are held accountable when systemic issues are raised.

Culture – Inconsistent use of safety harnesses suggests either a weak safety culture or poor enforcement of safety procedures. If some crew members do not feel obliged or expected to follow basic safety practices, the culture is not functioning correctly.

Capability – The use of an inappropriate waist belt instead of proper fall protection indicates a lack of knowledge or training about the appropriate equipment for working aloft. Correct practices would be better highlighted if a Permit to Work were used.

Teamwork – If one crew member is correctly equipped but does not intervene when others are not, it suggests a lack of shared responsibility and poor team cohesion. Good teams look out for each other.

Fit for Duty – Safety covers not only the physical but also the psychological aspects.

Key Takeaways

Seafarers – If one person needs a harness, all do. Inconsistent use of safety gear puts everyone at risk. If a task requires fall protection, ensure that every crew member is adequately equipped. Don’t assume someone else’s risk is different from yours — safety must be a standard, not an option.

Managers – Supply the gear and set the standard. Ensure there are enough adequately certified fall protection systems on board, and make it clear that unsafe alternatives, such as waist belts, are not acceptable. A transparent, enforced safety standard prevents improvisation and protects your crew.

Regulators – Support safety with visibility and clarity. CHIRP welcomes collaboration with Flag States to raise awareness and promote consistent safety standards. Sharing best practices through initiatives like the ‘Working Aloft Safety Flyer’ helps turn guidance into action on board.

Culture – The dismissive attitude toward the pilot’s safety — prioritising paintwork over people — reflects a poor on board safety culture. A culture that does not respect external personnel or reporting lines weakens trust and increases risk.

Communication – The Master’s refusal to remove the fenders and the failure to explain or resolve the issue collaboratively suggest a lack of effective communication between the ship and the pilot. Effective communication is crucial for achieving shared situational awareness and making informed, coordinated decisions.

Alerting – The pilot raised a safety concern, which was initially ignored; this constitutes a failure to act on an alert. Ignoring or dismissing raised concerns discourages others from speaking up and undermines the effectiveness of safety systems.

Teamwork – Boarding a vessel is a collaborative effort between the ship and the pilot. Filming the event and failing to help shows a breakdown in cooperative behaviour and mutual respect, key elements of effective teamwork.

Situational Awareness – The lack of recognition that the pilot had been injured, and the absence of any first aid or welfare check indicate poor situational awareness. The crew was not entirely focused on what was happening around them or the seriousness of the event.

Key Takeaways

Seafarers – Every visitor is your responsibility. Pilots and contractors are part of your extended team. They deserve the same duty of care as your crew. Ensure safe boarding arrangements, treat visitors with respect, and help without hesitation. A clean deck is no excuse for a dirty attitude.

Managers – Safe access is not optional – it’s the law. Boarding arrangements must meet SOLAS requirements — every time. Pressure to protect paintwork cannot outweigh the safety of personnel. Set clear expectations with your crews: all visitors, especially pilots, must be welcomed safely and professionally.

Regulators – Standards must protect people, not paint. Incidents like this show how operational decisions can put reputations — and lives — at risk. Regulators must reinforce the message that duty of care extends to all personnel boarding a vessel and that non-compliant setups or dismissive behaviour are unacceptable.

Communications – Crew concerns were often ignored or dismissed, and formal complaints were needed to prompt basic responses (e.g., mattress and toilet seat replacement). Are your concerns truly heard when you raise them?

Pressure – The crew were placed under pressure to remain in unsafe and unfit conditions without repatriation or protection of their welfare.

Complacency – The continued operation of the vessel despite expired fire extinguishers, the absence of lifejackets, and the lack of flares indicates a command that does not appreciate the risks regarding practical safety and compliance with safety regulations.

Local Practices – Unacceptable standards appear to have become normalised (e.g., operating with no lifejackets or uninhabitable cabins).

Key Takeaways

Seafarers – Know your rights, speak up and retain supporting documents.
Seafarers should document unsafe conditions and report them through formal channels. Understanding your rights under MLC is vital, especially regarding health, safety, and repatriation. If internal reporting fails, seek help from unions or ITF inspectors without delay.

Managers – Safety concerns are not insubordination.
Dismissing a crew member for raising valid concerns undermines the safety culture and breaches international obligations. Managers must ensure compliant living conditions, maintain safety equipment, and respond constructively to crew feedback.

Regulators – Where there is smoke, act fast.
This case highlights serious SOLAS and MLC violations. Regulators should prioritise oversight of vessels with combined owner-captain roles and act swiftly on signs of abandonment, poor habitability, or safety equipment failure.

Local Practices (Deviation) – The use of a short ground line and messenger workaround indicates a normalised departure from the standard procedure—a workaround that became routine under operational pressure.

Situational Awareness – There was a failure to maintain an accurate awareness of line tension and the risk of the ground line parting while negotiating with the shore.

Communication – Although concerns were raised, there was no effective closed-loop communication between the person in charge and the capstan operator.

Alerting – Repeated requests by the mooring station went unheeded, indicating a breakdown in the system of alerting and assertive challenge.

Teamwork – Lack of a shared mental model and coordination between shore personnel, the mooring leader, and the capstan operator.

Pressure – implicit in the fact that they continued the operations, potentially from schedule or routine expectations, and this overrode safety concerns.

Key Takeaways

Seafarers – If it doesn’t feel safe, stop.
Don’t continue unsafe work—stop and speak up clearly. Know the risks, don’t normalise shortcuts, and act on warning signs.

Managers – Unsafe workarounds reveal unsafe systems.
Workarounds mean something’s wrong. Fix procedures, empower crews to halt unsafe tasks, and learn from close calls.

Regulators – Deviations are symptoms, not root causes.
Focus on systems, not just actions. Promote human factors reporting and ensure procedures align with real-world demands.

Local practices – unless cases like this are highlighted, they can become the norm.

Complacency – the risk of underestimating liquid chemicals is potentially very hazardous.

Capability – training in the safe use of chemicals should be part of all crew familiarisation. Until familiarised, the crew should not be handling them.

Key Takeaways

For Seafarers, Shortcuts hurt; safety is part of the job.
Follow the procedures, wear the PPE, and don’t guess with chemicals. If in doubt, ask. Reporting protects everyone, including you.

For Managers, What gets supervised gets done safely.
Embed procedures into daily practice, not just paperwork. Reinforce safety behaviour through presence, guidance, and learning from incidents.

For Regulators, Policy is potential, practice is protection.
Focus on how rules work onboard, not just in manuals. Support training, reporting, and visible follow-through to keep learning alive.