Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
Propellor fouls on pot line
Inadequate supervision and Risk Assessment
Collision with a Yacht in a busy traffic lane
Incorrect response to fuel leaks results in an unintentional power shutdown
Communications difficulties hinder understanding
Incorrect Information Provided during Master-Pilot Exchange
Engine status not known
Collison with bridge and barge after moorings parted in high winds
Anchoring Angst!
Permit to work checks not thoroughly completed
Inappropriate risk assessment
Lifting eyebolts failed while launching a Tender.
No gas detection equipment carried on board
Caution: Short-Cuts Can Bite!
Workload distractions lead to a high-speed collision
Unsafe access for the crew on a logger
Fouled Towing Line Bridle
Loss of steering control on a bulk carrier approaching a berth
Unsafe Fendering Arrangement for Ship-to-Ship Operations
Vessel grounds in harbour
Tender capsize when towing inflatable places 4 in lethal danger
Lithium-ion Battery Fire
Near miss during lifting of a tender
Near miss due to distractions
Near miss approaching port
A shortcut they’ll remember for a long time
Maintain control … right to the bitter end
Pressurised to make a fatal decision
Dangerous recovery of a person in the water
Lack of familiarity with equipment puts the vessel in danger
Tender grounding
Entrapment in running equipment causes serious personal injury
Sailing yacht grounds at marina entrance
Contingency action to avoid a close quarter incident with a passenger Ferry
Failure to communicate a change for the pilot boarding arrangement
Collision between power driven vessel and yacht narrowly avoided
Mooring launch crushed against the side of a container vessel
Bridge Resource Management- Issues concerning helm execution
Enforcement of safety regulations – is it adequate?
Failure to challenge authority leads to dangerous occurrence
Main Engine failure exposes maintenance deficiencies
Collision between passenger ferry and tug results in fatalities
Open hatches lead to tug sinking
Multiple crew burns in Engine Room
Eye injury!
Breach of TSS regulations
Fatality – falling from height
Danger! Working at height!