CHIRP contacted the flag state, which in turn contacted the company, and arrangements were made to carry out fumigation of the vessel. However, the arrangements made to fumigate the ship did not follow the procedures outlined in the company’s safety management system. CHIRP was allowed to review the relevant sections of the safety management system, and none of the risk assessment controls were implemented.

This report highlights a breakdown in safety culture and procedural compliance on board.

No safety meetings were conducted, and there was no explanation of the fumigant’s chemical data sheet. Some crew members were reportedly asleep in their cabins when fumigation began; an unacceptable practice that exposed them to serious health risks. Video evidence supports the crew’s account. The psychological effect on the crew regarding the infestation and the lack of support by the master and company until intervention by CHIRP led to very high stress levels, according to the reporters.

CHIRP managed to obtain the Safety Data Sheet for the fumigant used, and the risk of health issues associated with inhalation was high. The crew was instructed to conduct a second round of fumigation en route to their next port but was left without hazmat gear or proper masks, rendering the fumigation unsafe.

The master’s behaviour reflects a person under severe stress and not capable of making informed decisions concerning the safety of the crew. The management company appears to be severely lacking in experience and support for the crew.

This case serves as a stark reminder that documentation alone does not guarantee safety. Procedures must be understood, implemented, and routinely verified. CHIRP has escalated this matter to the flag state and continues to engage with the crew to ensure their safety concerns are heard and addressed.

Superficial or weak auditing, whether internal or external, can miss serious risks, especially if the crew feel unable to speak openly during inspections. Such circumstances not only endanger seafarers but also erode trust in the regulatory framework meant to protect them.

 The presence of procedures means little if they are not being lived and enforced on board. This case is a textbook example of “paper compliance”, where documentation exists primarily to tick boxes rather than to drive real safety outcomes.

This report illustrates how a minor error, such as incorrect labelling, can lead to significant issues. The GPS 1 and GPS 2 antennas were wrongly marked on both the bridge plan and the compass deck. If a fault had occurred, the crew might have checked the wrong antenna, wasted time, and possibly overlooked the real issue.

The antennas were installed in the correct place, but the signs and drawings did not match. This indicates that no one properly checked the labels after installation was completed.

For something as crucial as GPS, all information, including markings and drawings, must be clear and precise. If the crew cannot trust what they see, it can cause delays or mistakes during fault-finding.

This case serves as a reminder that when antennae are installed during the new build phase or at dry dock, any new equipment must be rigorously checked. The area/antenna plan should also be updated and cross-checked to ensure accuracy.

On a critical and operationally practical note, an antenna position must be correctly marked and located so that the navigation system can apply the correct offset from the vessel’s centre line. e.g. on a 60-meter beam vessel, a 20-meter error in recording can put you outside of a navigable channel!

It is essential that, during the annual or five-year radio survey, aerial verification of all bridge equipment is physically carried out. This also applies after any refits at dry dock, where bridge equipment is renewed or replaced.

This capsize highlights the dangers of operational decisions that override environmental limits, particularly under commercial pressure. Weather risks were known, but the operation was continued despite this, pushing the vessel beyond safe operating parameters.

As USVs and MASS become more common, there must be clear lines of responsibility. It is essential to identify who has ultimate authority over their deployment and recovery. Without this clarity, confusion or misjudgement could have serious consequences.

Both the owner and operator are legally responsible for the safety of their vessel and any other vessels nearby. Going beyond documented operational limits could make them legally liable. Moreover, a recent IMO decision confirms that state-funded rescue services are not required to recover unmanned vessels. This raises important questions about the environmental damage and navigational risks posed by disabled or capsized USVs left adrift.

Damaged USVs may also present a physical hazard. They can behave unpredictably, may have moving parts, or contain active electrical systems. Without specific knowledge of the vessel, approaching it could be dangerous. This incident also raises the question of whether the owners and decision-makers accepted a higher risk of an incident simply because the vessel was uncrewed. While there may be no immediate human risk, the broader operational, legal, and environmental consequences remain significant.

Current training and certification standards are struggling to keep pace with technological advancements. Remote operations teams often consist of highly experienced professionals with qualifications such as OOW Unlimited, Chief Mate, Master, and Yachtmaster. However, there is an urgent need to revise STCW and related regulatory frameworks to reflect the operational realities of USVs and MASS. Regulations also vary considerably between countries, which adds further complexity when these vessels operate across borders or in international waters.

This event acts as a warning to the maritime industry: as autonomy advances, so must foresight, training, and responsibility. Commercial pressure must never outweigh safety. The maritime community, regulators, and operators must collaborate to ensure that safety standards evolve in tandem with innovation.

This incident demonstrates how a single missed communication, resulting from a radio channel change, can undermine even well-planned procedures for enclosed spaces. A critical instruction about the designated exit route was not received by the lone crew member still inside the void space. This led to confusion and a dangerous attempt to exit.

The AB acted sensibly when their multi-gas detector issued a low battery warning, thinking it might be a gas alert. However, a Permit to Work and toolbox talk could have helped clarify the types of alarms, ensured the device was fully charged, and confirmed that the correct PPE, such as a hard hat, was worn.

The unexpected alarm caused a moment of panic, a “startled effect”. While putting on an escape hood, the AB’s visibility was reduced, and they dropped their radio, leaving them disoriented and unable to communicate.

Meanwhile, the team outside began closing one of the exit hatches, while someone was still inside. This action should never happen during entry operations. It delayed the AB’s escape and caused a head injury when they struck the closed hatch.

The root issue appears to be a lack of a shared mental model among the team. Other activities, such as bilge testing and ongoing engine room communications, added to the distraction, as a conflicting work activity was taking place, thereby increasing the AB’s cognitive workload.

Although procedures and permits were in place, this case shows why they must be supported by clear, confirmed communication and effective task coordination. Most importantly, exit routes must never be blocked while anyone remains inside an enclosed space.