Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2450
Initial Report
During a company fleet-wide navigational audit, several discrepancies and procedural gaps were identified after comparing the passage plans, bridge logbooks, and Voyage Data Recorder (VDR) data. A significant observation was that passage plans lacked an anchor plan, which is required by the Bridge Procedures Guide (BPG). Additionally, there was no objective evidence to verify the frequency of position fixing or proof that radar was used to plot the ship’s position to ensure secure anchorage.
Although supported by radar recordings, parallel indexing was not observable during critical wheel-over manoeuvres. There was also no indication of regular checks at frequent intervals to confirm that the vessel remained securely anchored by taking bearings of fixed navigational marks. In several instances, only the X-band radar was operational during anchorage, and essential data points such as the actual date and time were absent from the passage plan.
The method of obtaining the ship’s position was not specified, and parallel indexing was not utilised while the vessel was underway in coastal waters. Although connected to the VDR, the echo sounder was not monitored, and the rudder angle indicator was absent from the VDR live player. The passage plan was not updated to reflect changes in circumstances, such as drifting, and the anemometer, despite being connected to the VDR, displayed data only on the radar screen.
The X-band radar was found to be switched off at a critical point during anchorage, and the depth indicator was not visible on the VDR live player, even though the Echo Sounder was connected. Furthermore, the ECDIS voyage log contained an incorrect year, and the master approved the standing orders and passage plan. However, despite the SMS checklist indicating that the ship’s position was verified through bearings of fixed navigational marks, the VDR data provided no supporting evidence.
During the voyage, radar playback identified nearby vessels, with the closest point of approach breaching the master’s requirement in the standing orders. Not all targets were acquired, and only radar trails were monitored throughout the passage.
CHIRP Comment
The significant discrepancies in passage planning procedures raised serious concerns about the vessel’s navigational safety. These issues were uncovered during an internal audit rather than by external authorities.
Key failures included the lack of parallel indexing, the absence of position verification, no anchor plan, and inadequate use of radar plotting during critical stages of the voyage and at anchorage. Additionally, the master who approved the passage plan did not directly oversee the planning process. This highlights a fundamental breakdown in compliance that requires immediate corrective action to maintain safety standards.
A fleet-wide audit by the company found similar issues across all vessels, suggesting that this was a systemic issue rather than isolated non-compliance.
CHIRP cautions all companies to take a closer look at their navigational procedures to ensure that they meet the requirements of the company SMS and the bridge procedures guide (BPG).
Key Issues relating to this report
Culture: Unsafe norms have developed, making non-compliance routine and accepted. Complacency, norms, and lack of knowledge create a dangerous environment. Training, leadership, and culture play critical roles, indicating systemic issues beyond individual lapses.
Communication: Insufficient communication between the bridge team members and the master led to gaps in the execution and understanding of the approved passage plan.
Complacency: Repeated non-compliance across the fleet suggests unsafe norms have become accepted, such as not updating the VDR or omitting radar plotting. This indicates a dangerous level of complacency.
Capability: Deck officers lacked the training and knowledge to properly maintain the VDR and conduct thorough passage planning, including anchor plans and radar usage.
Alerting: Junior officers may not feel empowered to question inadequate plans or voice concerns, perpetuating unsafe practices due to a culture of silence.
Situational Awareness: Poor understanding of critical navigational steps, from radar use to anchoring procedures, indicates a broader issue of a lack of situational awareness and risk appreciation.
Teamwork: The bridge team’s lack of coordination, proper monitoring, verification, and shared responsibility in navigation and data logging points to systemic failures in internal communication and a culture discouraging speaking up.
Key Takeaways
Seafarers, “Feeling normal doesn’t mean it is safe.”
Just because something feels routine, like skipping radar checks or not updating the VDR, does not mean it is safe. Speak up. You are the eyes and ears of safety onboard. Do not stay silent. Raise concerns, look out for each other, and practice solid seamanship. Your voice matters and can save lives.
Ship managers, “Same problem, many ships? That is a management issue.”
If crews repeatedly cut corners, look at the training, leadership, and support they are getting. Make sure crews know what is expected and feel confident speaking up. Safety culture starts ashore, and it is your responsibility to build it.
Regulators, “Administrative compliance cannot mask operational risk.”
When critical tasks like radar plotting or passage plan checks are skipped across a fleet, it is a sign that the system, not the sailor, may be broken. Regulators must look beyond paperwork and into practice. Targeted SMS audits, anonymous crew feedback, and follow-up visits can reveal where safety culture fails.