Situational Awareness – The defect in the hull plating was not recognised as a serious threat to seaworthiness at the time. The absence of permanent command and limited oversight during refit reduced collective awareness of the vessel’s true condition and the associated risks.

Communication – Although the Chief Officer raised a valid safety concern, the information was not passed beyond the ship. Communication became one-way, with no opportunity for open discussion or escalation. This breakdown prevented essential parties, management, class, and flag, from providing oversight, and led to them unknowingly carrying undefined risks in the long term.

Teamwork – The team dynamic was weakened by the absence of the permanent Masters and unclear authority among temporary officers.
This created uncertainty over roles and responsibilities, allowing unsafe decisions to go unchallenged.

Capability – There was an apparent lack of competence in assessing the structural implications of hull corrosion and repair requirements.

Performing a weld repair without verification or class input demonstrated a limited understanding of safety standards and statutory obligations.

Alerting – Early warning signs—such as the discovered corrosion and the Chief Officer’s recommendation- were ignored. This indicates a breakdown in the alerting process where individuals either did not recognise or did not act upon safety signals.

Local Practices – Poor repair yard practices were carried out, leading to fragmented refit and supervision and unevenly distributed workloads. Without the permanent Masters, key safety oversight functions were lost. Shipyard work continued without consistent monitoring or clear interface management.

Culture – A “keep it quiet” attitude discouraged transparency and reporting.
This culture of concealment undermined safety management and trust and placed both personnel and the vessel at risk.

Key Takeaways

Regulators – Culture is as important as compliance.
Regulators should look beyond paperwork and evaluate the culture that influences behaviour. When reporting systems are bypassed, the ISM Code becomes just a formality. Oversight during refits and temporary command periods should ensure that safety reporting, hot-work control, and class notifications are being adhered to. Promoting transparency and supporting confidential reporting will help uncover risks before they lead to incidents.

Managers – Leadership shapes the safety climate.
Management must set clear expectations that defects and safety issues are always reported, regardless of operational pressure. Temporary command arrangements require strict supervision and documented accountability. A culture that values honesty over convenience safeguards both reputation and personnel. Repairs impacting hull integrity must always involve class and flag—taking shortcuts risks far more than delays.

Crew – Speak out, even when it feels uncomfortable.
Every seafarer has a responsibility to protect the safety of the vessel, the crew, and the environment by questioning unsafe decisions and ensuring procedures are properly followed. If you find yourself in a difficult situation, take practical steps to protect both safety and yourself. Keep a written record of your concerns, either in an official logbook or by sharing them with a trusted person using email or another method that provides a clear time stamp. This creates an objective record if the situation later escalates. You can also contact CHIRP for confidential advice and support.

Raising concerns through the correct channels, even when they are not welcomed, is a mark of professionalism. Maintaining situational awareness, using the permit-to-work system correctly, and verifying that repairs are properly completed all help prevent a “temporary fix” from becoming a long-term hazard.

While speaking up can be morally uncomfortable, the potential safety and legal consequences of staying silent can be far more serious.

Safety Culture – The organisation had not fully identified or communicated the atmospheric risks linked to solvent cleaning during refits.

Capability – The task lacked a specific assessment that considered chemical behaviour, confined-space characteristics, and the required controls. Knowledge of solvent-related oxygen displacement was not part of regular training or toolbox talks.

Communication – The crewmember was isolated from other crew members, so no communication could take place.

Teamwork – No designated standby person or two-way check-in process for potentially hazardous work. The crew is working independently without support.

Design and engineering control – Lack of integrated ventilation/gas detection for small, confined compartments.

Local Practice- Procedures and work-as-done did not align with the real risks and relied heavily on PPE rather than higher-order controls.

Key Takeaways

“You can’t smell missing oxygen—so plan for the hazard you can’t sense.”

Regulators – this report reinforces the need to ensure that guidance on confined-space entry and hazardous-substance use explicitly covers the oxygen-displacement risks of common solvents such as acetone. Regulatory frameworks may already mandate atmospheric testing and ventilation for enclosed-space work, but this incident shows how everyday maintenance tasks can fall outside formal definitions while presenting identical hazards. Clearer expectations around gas detection, task-specific risk assessments and solvent-handling protocols during refit periods would help close this gap.

Managers – the key takeaway is that work planning must account for both the environment and the chemical properties of the substances being used. Procedures that rely solely on PPE, without ventilation or atmospheric monitoring, create a false sense of security. Ensuring that Safety Data Sheets are incorporated into pre-task briefings, making gas detectors readily available and verifying that confined-space precautions are applied even in small spaces like bilge sumps are essential steps. Refit periods require heightened vigilance because non-routine work often involves equipment isolation, restricted access and chemical hazards that may not be part of everyday operations.

Crew – the lesson is that familiarity with a product does not guarantee safety. Solvents can behave unpredictably in confined areas, and symptoms of oxygen depletion may be subtle until they become dangerous. Relying on PPE alone is not enough; ventilation, monitoring and having someone aware of the task are critical safeguards. Trusting instinct and acting early, as the reporter did, can prevent severe outcomes.

Situational awareness – Failure to re-assess conditions before manoeuvring; uncharted hazards not anticipated.

Teamwork/communications – Decision-making may not have been challenged; lack of cross-checks reduced safety margin.

Capability & Culture – Risk assumptions influenced by prior experience; organisational norms may have reinforced shortcut thinking.

 Overconfidence/Complacency – Extended anchoring without incident led to an underestimation of risk near uncharted coral.

Key Takeaways

Even after safe anchoring, familiar waters can turn into hazards—pause, reassess, and navigate cautiously.

Regulators – Embed human factors such as complacency, fatigue, and communication in regulations and inspections—safety isn’t just about charts and machinery.

Managers – Encourage a safety culture where crew pause, reassess, and speak up; operational convenience should never override risk awareness.  Management companies could greatly assist vessels by developing a ‘quick plan’ procedure for short passages that retains all the key elements required for any passage.

Crew – Treat every manoeuvre after inactivity as a new navigational task—assume nothing, verify everything, and safeguard yourself and others.

Pressure – The approach to an anchorage often creates time pressure. The first mate may have felt rushed to “get the anchor ready” before the vessel reached the drop position, increasing the likelihood of an error.

Complacency – Anchor preparation is a routine task. Familiarity with the operation can reduce vigilance, particularly regarding the risk of premature release while the vessel is still making way.

Lack of Communication – There appears to have been no clear confirmation between the bridge and forecastle on vessel speed, readiness, or the command to let go. This is a critical barrier that failed.

Lack of Teamwork – Safe anchoring depends on coordinated actions between the bridge and the deck. The incident suggests the operation was not being managed as a shared task with clearly defined roles and checks.

Distraction – The premature release may indicate the first mate’s attention was divided, possibly by concurrent tasks, environmental factors, or monitoring the vessel’s approach.

Lack of Situational Awareness – Releasing the anchor while the vessel was still making 10 knots shows a breakdown in awareness of vessel speed and the consequences of letting go at that moment.

Key Takeaways 

“Rushing routine work leads to accidents—slow down, focus, and follow the steps.”

Regulators – This incident demonstrates how routine anchoring operations can become dangerous when workload and time pressure are poorly managed. It emphasises the need for regulatory focus on how procedures are practically applied during arrival phases, not just their existence.

Managers – The event highlights the risk of starting safety-critical tasks too early under perceived time pressure. Managers should ensure anchoring procedures, training, and supervision clearly align with vessel speed, task sequencing, and workload during approaches.

Crew – This incident shows how rushing and distraction during routine tasks can cause unintended outcomes. It highlights the importance of avoiding time pressure, staying aware, and ensuring conditions are safe before handling.