Confidential Human Factors

Incident Reporting Programme

MFB 70

Single Points of Failure

Welcome to the Spring edition of FEEDBACK, our free safety newsletter for the global maritime community. We’re delighted to report that we’re now publishing in Arabic as well as the other seven existing languages, all of which can be found on our website or via our mobile app, which you can download using the QR codes printed on the back page of this newsletter.

Readers will detect that all of the reports in this edition share a common theme: single points of [safety] failure. Whether it is the pilot who undertakes the burden of night navigation unaided, the rope through which every fender on the ship’s side is secured, or the single safe walkway to the forecastle which gets blocked by the timber cargo stored on deck, recognising and addressing potential ‘single points of failure’ greatly reduces the risk of an incident occurring.

As ever, CHIRP publishes these reports to raise awareness of the safety learning that arises from these incidents, and where possible, we always try to highlight simple and practical safety measures that you can implement in your daily routines. In this edition, we encourage you to adopt the PACE (Probe, Alert, Challenge, Emergency) system, which improves group decision-making. You can also read a fuller description in our Making Critical Decisions at Sea publication (available on our website under the ‘Resources’ tab). Let us know what you think about this system – we’d be delighted to hear if this helps you and your teams on board. And we’re always keen to receive your incident and near-miss reports that help others learn from your experiences too.

Until the next edition – stay safe!