Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2361
Initial Report
In the month leading up to the incident, the deck crew, including the reporter, had been extremely busy, often exceeding the required hours of rest. Fatigue was a persistent issue. The reporter, a relatively new
deckhand on the vessel, had only dropped anchor once or twice.
On this occasion, the crew hurried to anchor. Due to inexperience with the vessel’s anchor markings, the reporter misjudged the length of the deployed chain, thinking that four shackles had been dropped when, in fact, there were five. The final warning markings were very short and close to the chain’s end, making them unclear. As a result, the bitter end unexpectedly emerged from the chain locker. At that moment, the reporter was positioned near the brake wheel, and their hand was nearly crushed as the chain ran out. It was later discovered that the bitter-end shackle lacked a safety pin for securing it—this was on a new vessel.
CHIRP Comment
This incident raises several safety concerns—not just regarding the equipment itself but also in howe we manage fatigue, training, and supervision during critical operations like anchoring. The crew member’s
unfamiliarity with the vessel’s anchor markings significantly contributed to the misjudgement, serving as a reminder of the importance of proper familiarisation training—especially when handling essential equipment.
Securing the bitter end of the anchor should be a part of the mindset for any anchor operation — it’s the last line of defence to prevent it from running free if something goes wrong. Therefore, discovering that a brand-new vessel was delivered without a safety pin raises serious questions about quality control and oversight during the building and commissioning process.
Supervision is crucial, especially during high-risk tasks like anchoring, where even a moment’s inattention or confusion can result in significant consequences. CHIRP strongly encourages vessel operators to prioritise thorough familiarisation for all crew, ensure clear and consistent marking systems, and maintain robust oversight of critical procedures.
It’s not about assigning blame; it’s about learning and improving. These issues are preventable, and with the
proper focus, they can be resolved.
Key Issues relating to this report
Fatigue – Long hours and pressurised work can lead to a loss of clear thinking, as cognitive ability is lessened and risk-taking increases.
Situational awareness – Standing near anchor equipment during an anchor operation is hazardous, and the risk of injury can be severe. This was a close call for the operator and should alert management to current working practices.
Alerting – Given the inexperience and fatigued operator, having another crew member available for the anchoring would provide a cross-check.