Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2460
Initial Report
During a routine inspection, the team found that an emergency escape hatch from the engine room to the deck could not be opened. The hatch, located near the aft mooring bits, was obstructed by the turned-up mooring lines. Just 2 to 3 centimetres of rope extending beyond the edge of the bitts was enough to prevent the hatch from opening — a small detail that could have had serious consequences in an emergency.
CHIRP Comment
This issue stems from the vessel’s design phase. Mooring arrangements and emergency escape routes were developed using CAD software and approved as compliant with the relevant regulations. However, it seems no one physically checked how these systems would work together in real-life conditions. CHIRP is aware of several such incidents, as reported to the International Marine Contractors Association (IMCA) and has written to the International Association of Classification Societies (IACS) to raise awareness.
The problem only becomes evident when the vessel is alongside or under tow, but that is precisely when escape routes must be fully functional. Being unable to open an emergency hatch because of a few centimetres of mooring line is a critical design oversight with potentially severe consequences. Blocked emergency escape hatches have led to deaths in the past, e.g. the Marchioness on the River Thames.
This highlights the need for practical, operational checks during the design and approval stages of newbuilds, not just digital validations. Safety depends not only on compliance but on proven functionality. It underlines the need for integrated risk thinking across routine operations, design layout, and inspection regimes.
Emergency systems must be constantly validated against the realities of onboard work practices. Incorporating escape routes during your familiarisation process, particularly when joining a different type of ship, is vital. Additionally, emergency escape hatches and their access ways should be incorporated into contingency exercises so that their use can be part of both egress and access during an exercise.
During a vessel’s quarterly inspection, the function and securing of escape hatches should be reviewed by an officer and crew from a different department.
Key Issues relating to this report
Situational Awareness – The design and approval teams failed to anticipate that the mooring operation would obstruct an emergency route. This suggests limited foresight regarding how the vessel would be used, particularly in an emergency scenario where every second counts.
Communication – There may have been insufficient communication between designers, builders, and operational stakeholders. Without input from those with lived experience on board, subtle but serious flaws like this can go unnoticed until it is too late.
Teamwork – The design process lacked interdisciplinary coordination. Engineers, naval architects, shipyard teams, and operational staff all play a role in ensuring systems function safely. Here, the lack of collaborative review meant a potential emergency hazard was built in from day one.
Key Takeaways
Seafarers – Don’t assume safety systems work as designed. Regularly inspect and test escape routes under real-world conditions, including when the vessel is moored, to ensure they are functional and practical. Speak up if something isn’t right, even if it complies with the  ship’s plans.
Managers – Engage operational staff early in the design process. Crews bring essential insight into how systems are used on a day-to-day basis. Build in practical walk-throughs and validation steps to catch risks before they become built-in hazards.
Regulators – Verify compliance against reality – not just design. Design compliance must be matched by functional performance. Safety-critical access points must function reliably under all operational conditions, particularly in emergencies.