Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2576
Initial Report
“I was aboard a large sailing super yacht, under power motoring on a south-westerly course at 9 knots and around 1.5nm from a navigational strait/passage. I noted a ferry steaming almost north, clearly visible, showing her starboard bow aspect. Visibility was very good, and both radars were operating with a lookout on the bridge.
The CPA was causing concern, and it was a clear crossing situation (Rule15 ColRegs).
In this situation, my vessel was the stand-on vessel. I maintained my course and speed. I expected the ferry to turn slightly to starboard (about 10-15 degrees) as there was plenty of sea-room and no immediate traffic, and the ferry had cleared the strait, so there were no depth restrictions. Then both vessels would have passed port to port.
The ferry maintained her course and speed, crossing my bow at a range of less than 2 cables. We then passed starboard to starboard, close enough (about 70 metres) that I could clearly see the Master/watchkeeper on the bridge, who gestured that I was in the wrong, which surprised me, as there was no doubt about the situation, or which vessel should take what action.
Although ferries operate on regular routes, they must still comply with the COLREGS. This potentially close-quarters situation could have been avoided with better application of the COLREGS.”
CHIRP Comment
While both vessels had clear obligations to act to avoid collision, this case reinforces a simple truth: being righteous and right is not the same as being safe and compliant.
CHIRP followed up with the master of the sailing yacht to clarify and obtain additional information. The account indicates that neither vessel fully complied with the applicable COLREGs (Rules 2, 7, 8, 16, and 17), resulting in a close-quarters situation.
Expectancy bias may have played a role, with an assumption that the larger motor yacht would give way, as is sometimes seen in congested coastal waters. Such assumptions, however, undermine the clarity which COLREGs are designed to provide.
Commercial pressure may also have been a contributory factor. Tight schedules and routine crossings can subtly influence decision-making, leading mariners to favour efficiency over strict compliance. Passing at a distance of only 70 metres is hazardous, regardless of vessel size or route familiarity. In some areas with frequent ferry operations, local custom may develop whereby ferries maintain course with the expectation that other vessels will keep clear, even when this conflicts with the COLREGs.
Risk tolerance is another consideration. The ferry may have assessed 70 metres as an acceptable passing distance, which could explain the lack of avoiding action.
This event highlights the importance of adhering to the COLREGs to remove uncertainty. Expecting other vessels to deviate from them increases risk. Challenging assumptions, maintaining situational awareness, and using early and unambiguous communication are essential. A timely signal of five short flashes or sound blasts can often interrupt a developing misunderstanding before it escalates.
For ferry operators, there is also a wider organisational lesson. Operators working to demanding schedules should ensure passage plans and bridge practices are regularly reviewed, through marine manager visits or independent navigational audits, to confirm ongoing compliance with the COLREGs. Encouraging open, blame-free reporting and discussion of near misses helps identify trends and reinforce safe practices before incidents occur.
Key Issues 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.
Complacency – Familiarity with regular route traffic may have led to underestimating the risk, assuming no deviation or hazard would arise so not challenging the crossing scenario.
Alerting – Despite the yacht’s clear expectation of port-to-port passing, there was no challenge or signal to the ferry indicating concern, nor was there any cross-check or speaking up.
Pressure – Operational pressures, such as maintaining schedules, could have influenced the ferry crew’s decision-making; insufficient personnel or workload management may have contributed.
Key Takeaways
Regulators: Spot the patterns, close the gaps, enforce the COLREGS. Monitor patterns of repeated close-quarters incidents involving scheduled ferries and other traffic. Encourage systematic use of human factors frameworks (MGN 520 Deadly Dozen and SHIELD taxonomy) in investigations. Strengthen oversight of operator practices, where local or habitual shortcuts undermine COLREG compliance, and consider promulgating additional guidance on proactive VHF use and bridge resource management for congested or routine routes.
Managers: Culture and training must take precedence over schedule pressure. Maintain strict adherence to the COLREGS, regardless of familiarity with local routes or schedules. Do not assume the other vessel will act correctly. Proactively monitor CPA/TCPA, using all available means (radar, AIS, visual), and clarify intentions early via VHF when the risk of collision exists. Always be ready to challenge, alert, and speak up if a developing situation does not align with expectations.
Crew: Don’t assume – confirm and communicate to keep clear. Maintain strict adherence to the COLREGS, regardless of familiarity with local routes or schedules. Do not assume the other vessel will act correctly – proactively monitor CPA/TCPA, using all available means (radar, AIS, visual), and clarify intentions early via VHF when risk of collision exists. Always be ready to challenge, alert, and speak up if a developing situation does not align with expectations.