Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2621
Initial Report
The reporter has shared an example of a navigational audit they consider below standard and representative of the quality observed during some inspections. The findings shown below relate to the Company SMS and Bridge Procedures Guide and illustrate how auditors are recording observations. This example is shared to encourage reflection on audit quality, consistency, and whether such findings effectively support safe navigation and meaningful improvement on board.
The reporter sent the following report to CHIRP, highlighting a typical example of a navigational audit.
Navigational audits- independent inspection findings. The findings relate specifically to the Company SMS and Bridge Procedures Guide.
- The passage plan and bridge logbook were in local time but the VDR was in UTC.
- The passage plan was NOT amended to include the Anchoring Plan, creating ambiguity.
- During anchor watch, there was no objective evidence of frequent intervals check that the ship remained securely at anchor by taking bearings of fixed navigational marks.
- During anchorage, there was no objective evidence that both radars were in use, which impaired situational awareness.
- Radar recordings do not support the use of parallel indexing, again impairing situational awareness.
- Radar recordings do not support the use of radar to determine and plot the ship’s position to ensure that the vessel remains secure at anchor. Another reduction of situational awareness.
- During anchor watch, the X-band radar was switched off.
CHIRP Comment
Although each finding was recorded as a “Medium Risk” observation, their number and consistency point to a broader breakdown in anchoring watch discipline. No incident occurred, but several key defences were absent or unverifiable. We consider some of the findings to be well above “Medium Risk”, and our analysis is as follows:
The findings are accurate, but there are too many passive phrases, such as “no objective evidence”, which softens the operational reality. In safety-critical operations, if something cannot be demonstrated, it cannot be relied upon.
The use of mixed time standards (UTC and local time) undermines shared situational awareness and complicates decision-making during anchoring, emergencies, and incident review. The use of correct times is a fundamental requirement in bridge management, not an administrative detail.
Failure to amend the anchoring plan suggests the operation was treated as routine rather than as planned navigation. This often leads to informal watchkeeping and reduced vigilance once the anchor is down.
Across several observations, there was no verifiable evidence of effective monitoring – no visual bearings, no plotted positions, limited radar use, and one radar switched off. In effect, the vessel was anchored without reliable position awareness. An anchor watch without monitoring is not a watch – it is an assumption.
Radar redundancy is a deliberate safety feature. Switching off a radar removes or reduces early warning of anchor dragging, traffic, or unexpected movement. Radar use at anchor should be considered essential.
While each issue was assessed as medium risk in isolation, their combined effect significantly increased the likelihood of an undetected dragging anchor or a close-quarters situation. No accident occurred, but normal defences had eroded. Monitoring, documentation, and radar use are core safety controls, not optional tasks. CHIRP members expressed concerns that there was an excessive emphasis on documentation requirements rather than on real navigational performance. The advisory board wants to highlight the need for auditors to receive training in bridge behaviour, situational awareness, and anchoring practices.
Key Issues relating to this report
Situational Awareness – Reduced electronic verification of position likely hinders a true understanding of the vessel’s location. Without standard timeframes, the team may not know what is happening in real time.
Local Practice – Not updating the plan reflects an informal practice that deviates from documented procedures.
Capability – The lack of use of available techniques suggests reduced monitoring capability. Radar should be used as part of best practice; not doing so may reflect gaps in competence.
Complacency – The decision to switch off the radar may reflect an overly relaxed attitude to risk. Routine behaviour can lead to assuming the plan does not need change or improvement.
Communications – Misaligned time references lead to misunderstandings and poor information exchange.
Distractions – Failing to maintain full situational awareness may indicate that focus is elsewhere.
Key takeaways
Regulators – Safety isn’t written on paper- it’s lived on the bridge. The audit demonstrates that even with modern systems and documented procedures, human factors and leadership profoundly influence outcomes. Oversight, guidance, and safety audits must address not only equipment and procedures but also crew behaviour, training, and organisational culture.
Managers – Lead with oversight, equip with knowledge, and culture follows compliance. The findings underline that leadership, supervision, and training are just as important as equipment. Ensuring procedures are enforced, crews are competent, and the safety culture is active helps prevent small lapses from becoming major risks.
Seafarers – Know your ship, trust your instruments, and do not assume- confirm. The inspection highlights the critical importance of vigilance and disciplined procedures. Always check positions, use all available instruments, and ensure your passage plan reflects reality. Your awareness and adherence to procedures are the frontline defence against incidents.