Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2276
Initial Report
The company’s Head of Safety was conducting a tour of a vessel which had been laid up for over a year, accompanied by potential purchasers. They were witnessed opening and entering a void space, which was correctly labelled as an enclosed space, despite not having a permit to work to do so. They were not carrying an atmospheric gas analyser. They had not completed pre-entry activities, e.g., venting the compartment, having crew and emergency equipment standing by, and an enclosed space entry checklist thoroughly completed and signed off by the master. The reporters approached CHIRP about this matter because any report raised through their company system would have gone directly to the Head of Safety, and they feared reprisals. They did not speak up at the time because they did not want to embarrass a senior company member.
CHIRP Comment
Entering an enclosed space without completing the pre-entry activities is exceptionally hazardous. Last year, 16 seafarers were killed because they entered enclosed spaces where the air was not breathable.
Even if the Head of Safety did not have a seagoing maritime background, they ought to have been aware of these hazards and the safety protocols that should be followed.
We will not speculate on the reasons that led to this specific incident, but people generally deviate from safety protocols for one of several reasons. One is that they underestimate or are unaware of the risks or overestimate their abilities (arrogance). Another is that they feel (real or imagined) pressure to complete a task quickly or without the right resources (lack of time or equipment).
Officers and managers have a special responsibility to lead by example in safety. They set the standards for a company’s safety culture.
When CHIRP contacted the company, they immediately understood the seriousness of the incident and responded immediately to ensure that it could not happen again.
Key Issues relating to this report
Communication — In this case, actions speak louder than words. The manager’s actions destroyed any safety messaging the company may have communicated to its fleet.
Local practices — An enclosed space entry operation requires a significant number of crew members to be in attendance. Make sure that everyone knows that enclosed space entry is taking place. The permit to work must be distributed to all parts of the ship: the bridge, engine room, the master, and the entrance to the enclosed space. Is this what happens on your ship? How well are enclosed space entry work activities communicated?
Alerting – If you see a safety breach, even by a senior manager, speak up! It is better that they are embarrassed than dead!
Pressure — Be aware that real or perceived pressure can lead anyone to deviate from procedures if they think it will save them time. If you feel under pressure, pause for a moment, and re-evaluate the risks. If you see others taking shortcuts, call it out.
Complacency (under-estimation of risk) — Enclosed spaces can be lethal if incorrectly entered.
Culture — Managers’ actions set the tone and standard of a company’s safety culture. In this incident, the reporter did not feel safe raising this issue through the company’s reporting system. CHIRP exists to capture these reports and advocate for improved safety while protecting the reporter’s identity.