A recent analysis of over 750 safety incident reports received by CHIRP between 2021 and 2025 has revealed a striking consistency in causal factors, which is mainly independent of vessel type, operating pattern, or location. The dataset spanned 31 different vessel types, with separate detailed analyses conducted on bulk cargo vessels, container ships, tankers, and superyachts. For each of these, the top three contributory factors were identified across four levels of the SHIELD taxonomy: Acts, Preconditions, Operational Leadership, and Organisation.

Although many sectors often view their challenges as unique, the findings suggest that the underlying human factors are almost identical, making safety lessons highly transferable across industry sectors. This consistency indicates that the root causes of safety incidents are not limited to specific vessel types or operations. They are systemic and often originate ashore, rather than on board the vessel itself.

Organisational Decisions: The Hand on the Tiller of Safety

At the organisational level, decisions made ashore contributed to many of the most persistent safety issues. Procurement of poorly or inadequately designed equipment was very frequently cited as a contributory cause in incident reports. Examples include pilot transfer arrangement designs that could not comply with regulations; poorly placed or missing attachment points for working aloft safely; or sub-optimal mooring bollard locations that compromise line handling.

In many cases, risk assessments were either not conducted or failed to identify critical hazards, particularly those arising from the interaction between people, equipment, and the environment. Even when documentation existed, it was often insufficient to support the safe execution of tasks.

However, underlying many of these failures is a critical and often uncomfortable truth: hat resources (financial, human, and technical) are not always allocated in a way that supports safety as a strategic priority.

Safety cannot be delivered on intent alone. Board-level decisions that underfund maintenance, delay crew change cycles, or prioritise operational efficiency over fatigue management will ultimately ripple down to the deck plates. When budgets are tight, it is often training, supervision, and procedural development that are quietly sacrificed, despite their essential role in risk management.

Importantly, this is not a problem that organisations face in isolation. Regulatory bodies, flag states, classification societies, and port state control authorities set the baseline conditions for maritime safety. While these frameworks are designed to safeguard operations, incident reports have shown that compliance with regulations does not always translate into real-world safety.

Several reports referenced equipment or procedures that passed inspections yet proved unsuitable in practice. This disconnect highlights that compliance does not always equal safety. Regulatory inspections often focus on documentation and visible conditions rather than on usability, human factors, or the real operational environment. Design standards, too, can fall short when they don’t fully consider how equipment is used on board.

Moreover, regulators often react to incidents rather than anticipate latent risks such as understaffing, fatigue, or alarm overload; all of which are factors that precede unsafe acts. To close this gap, regulators must move beyond enforcing minimum standards and towards enabling resilient, human-centred safety frameworks that involve end users in setting standards and emphasise learning over blame.

When organisations and regulators align by integrating safety as a shared priority rather than a checklist, the ripple effects are clear. Investments made in the boardroom, supported by forward-thinking regulation, create resilient conditions that support safe operations on board.

As Captain John Lloyd, CEO of The Nautical Institute, has noted:

“Many accidents that occur on ships have their roots in decisions made far from the vessel, often in the boardroom.”

The CHIRP analysis reinforces this perspective: seafarers are better supported in managing the complex, high-risk environments they operate in when safety is embedded into budgeting, procurement, staffing levels, vessel design, and procedural development.

Too often, safety is seen as a cost centre rather than a core enabler of continuity, reputation, and performance. But the evidence is clear: investments made in the boardroom are felt directly and immediately on the bridge, in the engine room, and on deck in terms of safety outcomes.

Operational Leadership: the critical layer of influence

The analysis highlights the critical role of operational leadership in translating organisational intent into safe and effective action on board. This is the level at which strategic decisions such as risk tolerances, procedural expectations, and resource allocations are either enabled or hindered by the support structures put in place ashore.

Across vessel types, the data reveals recurring challenges: operational risks are not always fully evaluated before tasks begin; supervision may lack the depth or presence needed to match the complexity of the operation; and known unsafe practices are sometimes left unaddressed, even when observed.

These issues often stem not from indifference but from a lack of resources and empowerment. Shipboard leaders are frequently left managing complex operations with:

• limited crew numbers and skills mix, which stretches safe manning beyond sustainable limits.
• incomplete or outdated procedures that do not reflect actual work conditions.
• conflicting pressures to maintain commercial schedules despite known fatigue risks.
• training that focuses on compliance rather than critical decision-making or human performance.

Whether through cost-saving decisions, inefficient structures, or unclear accountability, when organisations restrict access to these critical enablers, they create conditions in which even the most committed onboard leaders can struggle to maintain a safe operation.

The boardroom may never see the moment when a fatigued officer is expected to oversee a high-risk task shorthanded, or when a supervisor lacks the confidence to stop a job due to ambiguous procedures. But those moments are the downstream impact of upstream choices.

To close this gap, investment in leadership must extend beyond titles; it must encompass the time, tools, training, and trust necessary to act decisively. A strong safety culture does not trickle down on its own; it must be actively supported from the top, with resources that reflect the realities of operational life.

Preconditions: the conditions that shape performance

A consistent theme across vessel types was the absence of robust cross-checking and challenge within teams. In many cases, critical tasks were carried out without a multi-person approach or open communication of concerns. This is rarely due to cultural shortcomings alone—it often reflects the reality of limited crew numbers, time pressures, and insufficient training in assertive communication. These conditions are not accidental; they result from upstream decisions regarding manning models, training investments, and task allocation.

Complacency also emerged as a recurring factor. When operations are stripped to their most efficient form—with minimal redundancy, no time for structured reviews, and high workloads—complacency isn’t just a human failing; it becomes an organisational symptom. Crew members are often left to perform complex tasks under the assumption of normality, with little bandwidth for proactive challenge or reflective thinking.

In addition, the design and performance of technical systems were frequently cited as contributing factors. Unintuitive interfaces, alarms that are poorly prioritised, or automation that behaves unpredictably can all degrade human performance, especially under pressure. Too often, these design flaws are inherited from procurement decisions made with little end-user input or selected based on short-term commercial factors rather than usability or maintainability.

Acts: the final link in the chain

These are the most visible moments in incident reports, but they are rarely isolated failures of individual judgment. Instead, they are often the result of accumulated pressures, unclear procedures, or cognitive overload in complex environments.

In some cases, the operator may not have had access to the correct information at the right time. In others, the decision-making environment may have been shaped by fatigue, distraction, or conflicting priorities. These are not abstract conditions; they are often the result of tight rotations, deferred maintenance, overlapping responsibilities, or under-resourced departments ashore. When organisations stretch their people thin, they increase the likelihood that the last link in the chain will fail.

We must stop treating unsafe Acts as the origin of failure. They are the last visible symptom of invisible constraints placed much earlier in the system, often long before the vessel left port.

A Call to Action: safety starts at the top

The consistency of findings across vessel types and over a five-year period should be a Red Flag for industry. The human factors contributing to safety incidents are not anomalies, they are systemic and shaped by the structures, decisions, and resourcing strategies within organisations.

This is not a call to fix individuals. Rather, we should follow the advice of Professor Sydney Dekker, the author of “Safety Differently”:

“We should not be trying to fix the human but rather fix the system to account for human limitations.”

It behoves us all to ask ourselves:

• are our risk assessments identifying the hazards that crews actually face, or only those that fit into policy frameworks?
• are our procedures reflect the lived realities of shipboard life, not just ideal conditions imagined ashore?
• do we give our operational leaders the time, tools, and training to manage risk, not just maintain output?
• are budgetary decisions made with a clear understanding of their downstream safety impact?
• are we focussing on safety, or merely compliance?