Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2612
Initial Report
During routine paint and corrosion repair on the bow, a hole was discovered in the hull plating approximately 0.5 meters above the waterline. Inspection revealed that the anchor pockets had not been properly sealed, allowing water ingress and corrosion to spread beneath the coating system over multiple seasons. This represented a clear compromise of hull integrity. Upon discovery, the defect was documented and reported to the permanent Masters, who were on leave at the time. The Chief Officer recommended formally notifying management, the class, and the flag authorities and following standard hot work procedures, including obtaining a permit.
The master instructed that the matter be handled internally and ordered a weld repair without a hot work permit, safety oversight, or post-repair testing. The repair was completed without verifying watertight integrity, hull thickness, or class approval. Despite these actions, the vessel was scheduled for an Atlantic crossing, with no assurance that the repair had restored the hull to safe operational standards.
Several factors contributed to this incident. The absence of the permanent command structure during the refit period resulted in poor oversight of shipyard activities. A culture of concealment and avoidance of reporting undermined procedural compliance and safety integrity. Conducting hot work without a permit exposed the vessel and personnel to serious fire and safety risks. Finally, the deliberate instruction to bypass reporting channels demonstrated a significant breach of professional and ethical standards.
The outcome of these events was a repaired hull with no formal verification or documentation, leaving uncertainty over the vessel’s seaworthiness. The failure to follow ISM Code reporting requirements, the lack of class involvement, and the avoidance of established safety procedures exposed both the crew and the shipyard personnel to unnecessary risk. This incident highlights the need for vigilance, transparency, and adherence to reporting protocols, especially during periods when temporary command arrangements are in place.
CHIRP Comment
Undermining a vessel’s safety culture is not acceptable. Creating situations where individuals carry responsibility without the authority to act, especially when they are deliberately undermined, significantly increases risk.
This report reinforces the importance of transparency and strict adherence to procedures, particularly during repair or yard periods when normal command structures may be disrupted. Bypassing reporting requirements and permit-to-work systems removes essential safety barriers designed to protect personnel and maintain hull integrity.
Treating yard periods as “low risk” is a dangerous assumption. During repairs, a vessel may be effectively out of class and uninsured if unrepaired or unreported damage later causes an incident. This risk is often poorly understood on board.
When vessels are under refit or managed by temporary personnel, obligations under the ISM Code remain unchanged. Any damage affecting watertight integrity must be formally reported, assessed, and verified by Class and Flag through established channels.
Unpermitted hot work remains a recurring concern in CHIRP reports. Regardless of intent, welding without a valid permit exposes crew and yard personnel to serious fire and explosion risk. It may also invalidate insurance cover should an incident occur. How hot work can be conducted in a yard environment without proper documentation should be questioned by all involved.
CHIRP encourages all mariners to maintain an open and professional safety culture, one where hazards are reported, not concealed. The integrity of the hull and the effectiveness of the safety management system depend on openness, accountability, and procedural discipline.
Key Issues relating to this report
Situational Awareness – The defect in the hull plating was not recognised as a serious threat to seaworthiness at the time. The absence of permanent command and limited oversight during refit reduced collective awareness of the vessel’s true condition and the associated risks.
Communication – Although the Chief Officer raised a valid safety concern, the information was not passed beyond the ship. Communication became one-way, with no opportunity for open discussion or escalation. This breakdown prevented essential parties, management, class, and flag, from providing oversight, and led to them unknowingly carrying undefined risks in the long term.
Teamwork – The team dynamic was weakened by the absence of the permanent Masters and unclear authority among temporary officers.
This created uncertainty over roles and responsibilities, allowing unsafe decisions to go unchallenged.
Capability – There was an apparent lack of competence in assessing the structural implications of hull corrosion and repair requirements.
Performing a weld repair without verification or class input demonstrated a limited understanding of safety standards and statutory obligations.
Alerting – Early warning signs—such as the discovered corrosion and the Chief Officer’s recommendation- were ignored. This indicates a breakdown in the alerting process where individuals either did not recognise or did not act upon safety signals.
Local Practices – Poor repair yard practices were carried out, leading to fragmented refit and supervision and unevenly distributed workloads. Without the permanent Masters, key safety oversight functions were lost. Shipyard work continued without consistent monitoring or clear interface management.
Culture – A “keep it quiet” attitude discouraged transparency and reporting.
This culture of concealment undermined safety management and trust and placed both personnel and the vessel at risk.
Key Takeaways
Regulators – Culture is as important as compliance.
Regulators should look beyond paperwork and evaluate the culture that influences behaviour. When reporting systems are bypassed, the ISM Code becomes just a formality. Oversight during refits and temporary command periods should ensure that safety reporting, hot-work control, and class notifications are being adhered to. Promoting transparency and supporting confidential reporting will help uncover risks before they lead to incidents.
Managers – Leadership shapes the safety climate.
Management must set clear expectations that defects and safety issues are always reported, regardless of operational pressure. Temporary command arrangements require strict supervision and documented accountability. A culture that values honesty over convenience safeguards both reputation and personnel. Repairs impacting hull integrity must always involve class and flag—taking shortcuts risks far more than delays.
Crew – Speak out, even when it feels uncomfortable.
Every seafarer has a responsibility to protect the safety of the vessel, the crew, and the environment by questioning unsafe decisions and ensuring procedures are properly followed. If you find yourself in a difficult situation, take practical steps to protect both safety and yourself. Keep a written record of your concerns, either in an official logbook or by sharing them with a trusted person using email or another method that provides a clear time stamp. This creates an objective record if the situation later escalates. You can also contact CHIRP for confidential advice and support.
Raising concerns through the correct channels, even when they are not welcomed, is a mark of professionalism. Maintaining situational awareness, using the permit-to-work system correctly, and verifying that repairs are properly completed all help prevent a “temporary fix” from becoming a long-term hazard.
While speaking up can be morally uncomfortable, the potential safety and legal consequences of staying silent can be far more serious.