Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2206
Initial Report
The OOW spotted a faulty navigation masthead light warning on the bridge’s navigation light control alarm system while the vessel was at sea. The issue was reported to the chief engineer and master, but due to the sea state, the decision was made to wait until the vessel was alongside before going aloft.
Immediately upon coming alongside, while the rest of the crew were busy rigging the gangway, the chief engineer climbed up the mast without completing the permit to work for working aloft or wearing a safety harness. While the CE was up the mast, the wake of a passing vessel caused the vessel to roll violently, causing the CE to fall and break their arm.
CHIRP Comment
The decision to delay attending to the light while underway at sea was correct. Once alongside, vessel motion can still be affected on both large and small ships, especially as the shipâs stability can change significantly during cargo, bunkering and ballasting operations. Contacting the port authority to check on vessel movement for the time the work is carried out is standard practice.
The fact that the Chief Engineer went aloft so swiftly indicates a self-imposed time pressure to get the task done as soon as possible. Similarly, not following safety procedures before going aloft suggests that the chief engineer succumbed to optimism bias (also known as the âIt wonât happen to meâ syndrome). More concerningly, it points to poor safety culture and safety leadership: if others see the chief engineer (who is very often the shipâs safety officer) taking safety shortcuts, how does this incentivise the more junior crewmembers to follow safety procedures?
Key Issues relating to this report
Culture- When it comes to safety culture, senior officers must lead by example and model the safety behaviours they want their team to adopt. As the saying goes, it is better to set an example than to be one!
 Alerting- Making sure that the master/safety officer and crew were aware that the light was going to be fixed would have alerted everyone to the requirement to use the permit to work for going aloft. Does your vessel operate a permit-to-work system when going aloft?
Situational awareness- Being aware that even in a port where conditions are not affected so much by environmental factors, you can sometimes overlook the dynamic action on your vessel by passing vessels.
Pressure- There appeared to be pressure to get the work done. This work should have been allocated to crew members who are more used to working aloft. The permit to work for going aloft could have been supervised by the chief engineer. How do you control your permits to work? Do you know the rank of your safety officer?