Adam Parnell
Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
FEEDBACK
FISH01
Ensuring Safety in Fishing Operations
Welcome to the first edition of our safety newsletter for the commercial fishing industry. For over 2 decades, CHIRP Maritime has empowered seafarers worldwide by raising awareness of safety lessons learned from real-life scenarios. Because we recognise the unique circumstances and challenges faced by the commercial fishing sector, we are proud to introduce a new publication specifically for fishers, based on reports submitted by fishers. We hope to create a safe and non-judgemental learning environment where fishers can share, and learn from, the experiences of others. This helps to prevent similar incidents in the future and contributes to a safer maritime environment overall.
In this edition, we explore a series of recent fishing incident reports sent to CHIRP. The failure to communicate maintenance intentions led to a grievous accident. In another, we showcase the
hidden dangers that can arise from historical conflicts – in this case, unexploded ordnance.
A collision between a fishing vessel and a ferry within a port highlights the cascading effects of deviating from local communication protocols.
Maintenance-related incidents also feature prominently. In one report, a fisher sustained a serious hand injury while undertaking unplanned maintenance. In another, a fishing vessel’s gear
collapsed while being hoisted due to a parted steel wire rope, highlighting the significance of regular equipment inspection.
Lastly, an incident involving a fisher falling overboard underlines the importance of personal safety equipment and self-rescue measures. Carrying a waterproof handheld VHF radio or a Personal Locator Beacon (PLB) and rigging self-rescue ladders are crucial steps in ensuring fishers’ safety, especially when operating single-handedly.
These incidents share a common thread: proper communication, situational awareness, and adherence to safety protocols are paramount. Vessel operators, crew members, and port authorities must collectively uphold these principles to mitigate risks and prevent accidents. Safety is a shared responsibility, and it is essential to stay informed, follow guidelines, and
continuously reassess and improve practices to foster a safer fishing environment for everyone involved. Please let us know your thoughts about this new publication, both good and bad, so that we can make future editions even better. And do please keep your reports coming!
Yours in Safety,
The CHIRP Maritime team
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M2159
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Propellor fouls on pot line
Propellor fouls on pot lineInitial Report
Shortly after a fishing vessel entered the main channel at the harbour entrance, the engine’s revolutions unexpectedly slowed, and the engine temperature rose. A quick investigation revealed that a poorly marked floating line attached to a line of pots had become wrapped around the prop shaft. The line was cut free, but the engine would not restart, and the vessel had to be towed into the harbour by another fishing vessel which was, fortunately, passing close by.
Further investigation proved that the gearbox had been severely damaged and needed to be replaced, costing over £10,000 and two weeks’ lost fishing time. Although the insurance covered the gearbox cost, the loss of income over the two weeks was significant.
CHIRP Comment
Laying pots near a main channel can be attractive because the areas are rarely fished, usually in sheltered water, and are easy to access. However, CHIRP frequently receives reports about vessels becoming snagged on pot lines which have been poorly marked. In this case, the marker was an empty 2-litre plastic milk carton.
Fishers sometimes use floating line because even if the marker buoy is lost, the string of pots can often be recovered. However, it presents a snagging hazard, particularly at low tide, which is why port authorities prohibit it. Where the laying of pots within harbour limits is allowed, they should be laid away from the main channel so that the riser is kept well away from the channel.
Losing control of a vessel inside a busy harbour can easily cause collision into moored or passing boats or an uncontrolled grounding. Both can result in a pollution incident which would close the port. For these reasons, CHIRP discourages laying pots near main navigational routes
Key Issues relating to this report
Local practices – Check whether your harbour allows pots to be laid inside the harbour. Where it is permissible, lay away from navigational routes or among lines of moorings. Where practicable, ensure the riser is at the end furthest away from the channel, and avoid using a floating line.
Design – Be aware of any local requirements regarding the design and size of marker buoys, and in any case follow local ‘best practice’ to avoid dangerous situations and to minimize the risk of losing fishing gear.
Situational awareness – Keep a close watch out for poorly marked lines inside the harbour and navigate with caution. Have an emergency plan to react quickly to an unexpected loss of control or steering. Report poorly marked lines inside harbours to the harbour master so that they can inform the owner to take appropriate measures.
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M2102
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Caution: Short-Cuts Can Bite!Caution: Short-Cuts Can Bite!Initial Report
The engineer on a fish processing vessel needed to conduct maintenance on a conveyor belt used for moving boxes of fish. When work on the processing deck was temporarily stopped for a crew break, the engineer activated the emergency stop so that the conveyor belt would not be reactivated while they worked on it. They should have informed the crew of their maintenance intentions.
After the coffee break and once processing had restarted, the engineer wanted to check whether the tension on the chain was correct. While the engineer was checking the chain’s tension by hand, an approaching box of fish activated a sensor that instantly switched on the conveyor belt, causing the sprockets and chain to start moving. The engineer’s startled reaction was to pull their hand back because their fingers were trapped under the belt, tearing off part of a fingertip.
CHIRP Comment
The engineer failed to isolate the system completely and thought activating the emergency stop would prevent the system from operating. CHIRP contacted the company and received very positive feedback on how they would ensure that this type of incident would be prevented from happening again.
CHIRP was informed that the risk had been identified in the risk assessment for this work; it did not include Lock Out, Tag on, Tag off (LOTOTO) procedures which were only available for work on electrical systems and not on equipment with moving parts. The company have made changes to include this safety procedure for all equipment with moving parts.
Everyone must be briefed on planned maintenance work at the daily work planning meeting to ensure that conflicting work activities can be rescheduled and that adequate time and resource is allocated to the task. Because no one else was aware of the engineer’s intentions, the incident outcomes could potentially be even more severe.
Key Issues relating to this report
Communications – Does your vessel have daily and weekly work planning meetings and is the work communicated to the rest of the crew? Would you display a notice board showing daily and weekly work activities?
Pressure – Self-imposed time pressure led to shortcuts being taken. Planned maintenance should not be rushed.
Design – It should have been impossible for the conveyor to restart until the emergency stop button was reset. Emergency cut-off systems are not an acceptable alternative to the established pre-work isolation routines.
Everyone must be briefed on planned maintenance work at the daily work planning meeting to ensure that conflicting work activities can be rescheduled
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M2161
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Lone fisher falls overboardLone fisher falls overboardInitial Report
During the early evening, a single-handed inshore fishing vessel under 10m was working pots just outside the harbour’s mouth. The fisher lost their balance and fell overboard, and could not self-rescue. Although they wore their flotation device, they could not summon help because their radio was still on the boat. They were in the water for over an hour before they were spotted and recovered by a passing sailing vessel.
Although they were extremely hypothermic, they made a full recovery. Their fishing vessel was recovered the following day.
CHIRP Comment
In this scenario, the fisher was fortunate to be spotted by a passing sailing vessel. Wearing a flotation device was crucial because it reduced the effort required to remain afloat so that they could conserve energy.
When fishing single-handed, CHIRP advises that a ladder is rigged to aid self-rescue or a floating messenger line attached to a lifebuoy streamed from the stern and next to the ladder. Fishers are also strongly encouraged to wear a waterproof hand-held VHF radio or (even better) a Personal Locator Beacon (PLB), which can alert the emergency services if you fall in.
Key Issues relating to this report
Local practices – Rig a ladder or another means of getting back on board if you fall over the side.
Communication – Carrying a means of summoning emergency assistance on your person can save your life. In some regions, fishers operate a regular radio check-in call with someone ashore to alert the authorities if they fail to check in when due.
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M2166
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Potentially fatal near missPotentially fatal near missInitial Report
Our reporter told CHIRP that their 27m beam trawler was alongside, port side too, in the harbour for maintenance. They hoisted the port (inboard) trawl so that they could stand on the quayside and fix the nets. Just before they started work, the steel wire rope (SWR) parted, and the beam, stone mat and net fell at great speed over the side between the vessel and the quay, only narrowly missing several of the crew. A new rope was reeved, and, with the help of a diver, the gear was safely recovered.
In subsequent correspondence, the reporter stated that the ropes were regularly greased and checked for signs of wear. Ropes were also ordinarily end-for-ended approximately halfway through their estimated service life to further reduce the effects of wear on any one part of a rope. There was no indication that the rope had been overloaded or worn.
CHIRP Comment
This near miss highlights the potential risks that can arise during maintenance and hoisting operations: even when good inspection and upkeep routines are in place, equipment can fail, and incidents can happen. Proper equipment inspection is crucial to identify worn parts early to minimise the risks of unexpected failures. Signs of wear include dark or rusty parts of the rope, breaking strands (‘hairy rope’), or the rope’s diameter narrowing. Keep the crew clear while the equipment is hoisted or lowered to minimise crushing, entrapment, or wire ‘snap-back’ risks.
Use the required PPE during hoisting operations, like safety helmets. When lifting, avoid the sudden onset or release of tension: either can cause high shock dynamic loading, causing rope failure. Be aware of the maximum load that is allowed for the hoisting equipment in use
Key Issues relating to this report
Communication – Use clear and effective communication during the toolbox talk to highlight the hazards so that everyone involved knows the maintenance procedures and understands the potential risks. Do you have an emergency response plan to react to accidents or incidents?
Situational awareness – Crews should be encouraged to continually think “What if…?’ and be alert to what is happening around them. Use the right PPE.
Teamwork – Working together and challenging the status quo during maintenance routines, especially ones not carried out frequently, is good practical safety management.
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M2073
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Collision between a fishing vessel and ferry in portCollision between a fishing vessel and ferry in portInitial Report
Shortly after a RO-RO ship left its berth, it collided with an inbound fishing vessel. The fishing vessel sank, but all 7 of the crew were safely recovered. In this port, vessels needed to request permission to enter or leave so that vessel movements could be deconflicted by the port’s traffic services to avoid potential collisions, although this rule was often ignored by smaller vessels. In this case, the fishing vessel did not have a working radio, so there was no communication between the vessel and the port, nor could it hear that the RO-RO vessel calling after it had left
its berth.CHIRP Comment
The causes of this incident were present a long time before it happened. By allowing smaller vessels to ignore the requirement to radio for permission to enter or leave, deficiencies in the ports monitoring or detection systems went unnoticed. Potentially, the reduced emphasis on radio communication from small vessels made it less likely that fishing vessels would carry a spare radio, and possibly meant that the failure of the primary radio went unnoticed. In any case. The port did not detect the inbound vessel and granted the RO-RO permission to leave its berth.
The activities involved in entering or leaving a harbour likely distracted the bridge teams on both from their primary task of keeping a good lookout to detect the risk of collision (Collision Regulations rule 5). In any event, even when risk of collision was determined, neither vessel took the correct action to avoid collision (rules 8 and 17).
Key Issues relating to this report
Situational Awareness – This report highlights the importance of effective monitoring and detection systems to be in place, especially in high-traffic areas. Port entry or exit is a high-risk operation, and vessel operators should be vigilant and maintain situational awareness to prevent collisions.
Communication – If the fishing vessel had carried a handheld VHF as a back-up, (which in any case is essential emergency equipment should you ever have to abandon ship) this incident might have been avoided. The fishing vessel’s inability to inform the port of their intention to enter or respond to the ferry’s attempts to contact them contributed to the collision. Timely and clear communication between vessels and port authorities is essential for safe navigation. A radio check before leaving or entering the harbour is good seamanship.
Local Practices – In this port, smaller vessels commonly ignored the requirement to request permission to enter or leave. The port authority should enforce the requirement to report because it hampers the port’s ability to operate a safe harbour. Are you aware of your reporting requirements when arriving or departing a port?
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M2160
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Danger!Unexploded ordnanceDanger!Unexploded ordnanceInitial Report
A fishing vessel entered the harbour to land its catch. It also landed some rusty metal objects that had become tangled in the ‘cod end’. A member of the harbour staff realised that these were items of historic ordnance and could contain explosive residue. The emergency services were called, and a bomb disposal team attended and took away the items, which were subsequently proven to be unexploded ordnance. Had the items entered a waste recycling plant, they would have posed a significant hazard to both people and equipment.
CHIRP Comment
Items of historic ordnance are occasionally caught in nets in many parts of the world that have experienced previous (or ongoing) conflicts, making the already hazardous work of commercial fishers even more dangerous.
While submerged in water, the components within explosives can separate and become extremely unstable if they dry out. Other chemicals, such as phosphorus, can spontaneously ignite in contact with air, creating toxic fumes.
In this instance, the ship’s crew were unaware they had unexploded explosives on board. But if you are in doubt, do not touch it or try to throw it back over the side. Keep the crew as far away as possible, increase your vessel’s watertight integrity by closing all weather-tight and water-tight accesses and contact your regional emergency services and follow their directions. Reduce your speed and steer a course that minimises boat movement. More guidance has been published by the UK’s Maritime and Coastguard Agency in MGN 323 (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/440107/323.pdf)
Key Issues relating to this report
Local practices – Ensure your fishing vessel has a plan to deal with suspected unexploded ordnance based on an appropriate risk assessment.
Situational awareness – Try to understand areas where unexploded ordnance is more likely to be encountered. Your local port authority or fishing association may be able to help with this. Do not trawl over or near areas of charted disposal sites.
Alerting – To increase awareness, try to take pictures of the unexploded ordinance and distribute them to other fishers. Update the safety folder with the Near Miss incident.
loss_of_awareness, lack_of_assertiveness, normalisation_of_deviation