Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2459
Initial Report
What the reporter told us: “We are facing a severe infestation of pests on the ship, with cockroaches present throughout the vessel. They are found in food supplies, refrigerators, utensils, bedding, and other areas. This situation has caused significant psychological and emotional distress among the crew. We are unable to eat or sleep peacefully, constantly feeling anxious and stressed. The captain’s behaviour exacerbates our situation. He behaves erratically, making threats to ensure our silence regarding these issues. There is fear among the crew, and speaking out feels unsafe. During recent inspections, port inspectors did not inspect the onboard condition closely. This same behaviour by port officials also occurred at the last port and during the current inspection. The captain has warned us against saying anything.”
CHIRP Comment
CHIRP contacted the flag state, which in turn contacted the company, and arrangements were made to carry out fumigation of the vessel. However, the arrangements made to fumigate the ship did not follow the procedures outlined in the company’s safety management system. CHIRP was allowed to review the relevant sections of the safety management system, and none of the risk assessment controls were implemented.
This report highlights a breakdown in safety culture and procedural compliance on board.
No safety meetings were conducted, and there was no explanation of the fumigant’s chemical data sheet. Some crew members were reportedly asleep in their cabins when fumigation began; an unacceptable practice that exposed them to serious health risks. Video evidence supports the crew’s account. The psychological effect on the crew regarding the infestation and the lack of support by the master and company until intervention by CHIRP led to very high stress levels, according to the reporters.
CHIRP managed to obtain the Safety Data Sheet for the fumigant used, and the risk of health issues associated with inhalation was high. The crew was instructed to conduct a second round of fumigation en route to their next port but was left without hazmat gear or proper masks, rendering the fumigation unsafe.
The master’s behaviour reflects a person under severe stress and not capable of making informed decisions concerning the safety of the crew. The management company appears to be severely lacking in experience and support for the crew.
This case serves as a stark reminder that documentation alone does not guarantee safety. Procedures must be understood, implemented, and routinely verified. CHIRP has escalated this matter to the flag state and continues to engage with the crew to ensure their safety concerns are heard and addressed.
Superficial or weak auditing, whether internal or external, can miss serious risks, especially if the crew feel unable to speak openly during inspections. Such circumstances not only endanger seafarers but also erode trust in the regulatory framework meant to protect them.
 The presence of procedures means little if they are not being lived and enforced on board. This case is a textbook example of “paper compliance”, where documentation exists primarily to tick boxes rather than to drive real safety outcomes.
Key Issues relating to this report
Local Practices – management appears to have its own rules for managing the vessel, with no adherence to the safety management system, despite a specific reference to fumigation.
 Culture – There is no authentic safety culture, except for the fact that you should not get caught!
Capability- The vessel’s operational leadership appears incapable of operating a safety management system
Key takeaways
Seafarers: Silence endangers safety—speaking up saves lives.Â
A severe pest infestation, improper fumigation, and a captain’s threatening behaviour created a psychologically unsafe and physically hazardous environment. Despite formal procedures existing on paper, none were followed, placing the crew at significant health risk.
Managers: Leadership without listening breeds risk.
The breakdown in leadership, procedural enforcement, and crew wellbeing in this case reflects deep-rooted safety culture failures. Procedures were ignored, risks were unassessed, and the crew was left vulnerable. Managers must ensure that documented systems translate into lived practice and that masters and crews are empowered and psychologically feel safe to raise concerns. Leadership accountability and visible commitment to safety are non-negotiable.
Regulators: Regulation fails when crews cannot speak freely.
This case highlights how inspection regimes can overlook critical hazards when crews are too afraid to speak up. Despite clear procedural violations and health threats, port inspectors overlooked the issues on two separate occasions. Regulators must strengthen inspection protocols to uncover both technical noncompliance and suppressed reporting cultures, ensuring seafarers can safely disclose concerns and that just culture principles are allowed to flourish.