Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M1796
Initial Report
This report was first issued in August 2021 and reissued in June 2025.
The reporter informed CHIRP of serious mental health issues due to fatigue and high levels of stress concerning a chief officer who was working on an LPGÂ vessel.
The vessel was trading on a coastal voyage route with very short distances between ports. The contract time for the chief officer was 3 months but the chief officer had worked an additional 4 months while awaiting a relief. A deck officer had been repatriated on medical and disciplinary grounds, leaving the chief officer with only two other deck officers.
The reporter stated that cargo operations were extremely demanding due to the short port times and fast loading and unloading operations. The port rotations, and the grades and quantities of cargo, were never known until the last moment which made planning uncertain and stressful. Crew numbers were insufficient (the chief officer frequently had to take the helm due to the lack of crew), there was a lack of personal protective equipment and consumable stores on board, and mooring winch failures that could not be fixed by the shipâs staff.
These issues had been raised in the monthly safety meetings but had not been addressed by the management company. On board discipline was being affected by the managementâs lack of concern about issues being raised by the ship.
The chief officer eventually had to leave the ship due to poor mental health and see a doctor for an unlimited time. The company was asked to replace the third deck officer, increase the number of crew and develop a long-term recruitment strategy for all ranks. The charterers had also been requested to plan further ahead so that proper work/rest hours could be achieved. Shore management was asked to monitor crew discipline and appraisals, and to respond appropriately to issues raised during monthly safety committee meetings.
The reporter stated that he left his job 2 years previously due to similar health issues and suggested that extra care should be taken regarding seafarers having a mental health breakdown as there is no compensation for health or job loss.
CHIRP Comment
At what point do fatigue and stress lead to ill health? Was pressure a factor in this case, or were the crew just busy or dangerously overloaded?
Tankers are subject to SIRE inspections, given the manning levels, it is likely that there would have been a focus on the chief officerâs hours of work and rest,
particularly given the fast turnarounds and short voyage lengths. Breaches of work and rest hours would easily be identified providing they had been correctly recorded. SIRE evaluation reports should include a comment on fatigue and mental health in the context of crewing levels.
Demanding work which is sustained over a long period without any respite will lead to high stress and a possible breakdown in the ability to perform that work. This is especially so if the person has a high personal standard for the work and high attention to detail. If this cannot be achieved, then a mental breakdown is possible.
In this case, the situation was made worse by the lack of management support and exacerbated by the resulting breakdown of crew discipline, which further increased the mental workload for the chief officer. Regrettably, a proactive preventative intervention was not undertaken prior to the chief officer being landed on grounds of ill health.
CHIRP is willing to engage with shipping organisations to promote seafarersâ mental health issues more widely so that they are understood and supported throughout the industry, and proposes that consideration should be given to making provisions for seafarers mental health in the ISM Code. This would provide some focus on this area of wellbeing and codify minimum standards regarding seafaring mental health (see A Standard for Seafarersâ Mental Health Awareness and Wellbeing Training, published in 2020 by Witherby Publishing group). The Maritime Labour Convention (MLC) is the minimum standard, not the target!
CHIRP is willing to engage with shipping organisations to promote seafarersâ mental health issues more widely so that they are understood and supported throughout the industry, and proposes that consideration should be given to making provisions for seafarers mental health in the ISM Code
Key Issues relating to this report
Pressure: Does your charterer understand the workload you are operating under? Has anyone from shore management explained to the charterers the extent of the pressure being placed on the crew? Does your management company provide more crew when the workload increases beyond the existing crewâs capacity?
Teamwork: Why did the master with overriding authority not demand that the company support the officers and crew given the issues identified in the report? This matter should have been identified much earlier if there was an active teamwork spirit on board.
Fatigue: Was anyone taking any action to help the chief officer, or was nobody able to recognise the signs of failing mental health? The high workload on board, combined with other operational and behaviour issues affecting the crew, caused an officer to suffer severe fatigue and eventually a mental breakdown.
Does your company or vessel have a Fatigue Management Plan that spells out the management and crew responsibilities to reduce the risk of fatigue?
Capability: Does your shipping company have the necessary competence to manage the mental health issues of its seafarers? Until ship managers understand the factors associated with mental health and receive the necessary training for themselves and their crews, then cases such as this one will continue to occur.
Culture: Given what has been reported, do you feel that there is a poor culture of safety in your ship/shore management teams? Is this something that you have experienced and voiced concerns about but have not been listened to?