Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2083
Initial Report
âI was asked to take guests on a sunset cruise on a jet drive tender around the island in the South Pacific. I warned the captain that multiple shallow spots on the main yachtâs ECDIS were not shown on the Tenders. I was told to try, so we set off but halfway around the island, and as the sun went down, it became harder to see the unlit posts, which indicated the safe routes around the reef.
I decided to turn around, and on the return trip, we missed one post, and the tender went aground on a reef and could not refloat as the tender as the tide was dropping. We had no radio or phone signal, but a passing local fisher gave us a lift back to the yacht, and we returned with the fisher on the high tide that night to recover the tender.â
CHIRP Comment
The captain intentionally deviated from safety procedures in directing the tender trip to go ahead despite knowing that the charts were inadequate for safe navigation, particularly at night. This placed the reporter in a difficult âno winâ position: either to disobey their captain or undertake a trip against the rules of good seamanship. The reporter did challenge the captain, but the captain prioritised the guestsâ wishes ahead of theirs and the crewâs safety which suggests
a poor safety culture on board. It also means poor planning â had the trip been organised more thoroughly in advance, the inadequacy of the charts would have become known sooner, and an alternative route away from the reefs might have been possible, or the course reconnoitred by day and saved into the tenderâs ECDIS. The Masterâs standing orders should state that no tender should leave the mother ship without adequate communications equipment.
Similarly, a comprehensive risk assessment would have identified that VHF coverage would have been inadequate once out of sight of the parent vessel. A patchy phone signal should always be expected in remote areas.
Key Issues relating to this report
Culture: The captainâs order to launch with inadequate charts was a safety violation.
Pressure: the authority gradient between the captain and reporter meant that the latter probably couldnât refuse the order. Putting guestsâ wishes before their safety indicates that the captain had not developed a good working relationship with the guests. A formal brief upon their arrival that âsafety supersedes everything elseâ would have prevented the captain from putting themself under pressure to accede to the guestsâ wishes.
Teamwork/Planning: a thorough risk assessment, a better route choice, or a prior recce would all have prevented this incident.
Communications: When working remotely, assume that communications will be difficult. Does your vessel have a ‘tender overdue’ procedure? A tracking device fitted on the tender should be considered.