Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2640
Initial Report
The vessel had been anchored for three days to support guest excursions. The owner requested that the vessel move closer to the dock to allow easier pick-up for a tour.
After weighing anchor, the vessel ran aground about 10 minutes later. It struck uncharted coral and was damaged, including the sacrificial rudder tip. One crew member sustained bruising after falling inside the vessel when it grounded.
The presence of uncharted coral was subsequently reported to the hydrographic office. The incident highlighted a degree of overconfidence, as the vessel had been anchored in the same bay for several days without incident.
CHIRP Comment
This report highlights the risks that can arise when a vessel changes from a prolonged period of static operations back into manoeuvring, particularly in areas where hydrographic data may be incomplete.
Short voyages decided at short notice and under time pressure can be just as hazardous as longer passages and require the same level of planning. In poorly charted areas, practical precautions may include using a tender to check depths, ensuring echo sounders are active, and avoiding assumptions that conditions will be uniform across an anchorage. The Master retains the authority to say “no” on safety grounds, and a clear explanation is often accepted.
The vessel had been safely anchored for several days, which may have reduced the perceived risk when repositioning closer to the dock. Experience shows that extended periods without incident can lead to overconfidence and assumptions about the safety of surrounding waters. The presence of uncharted coral demonstrates that hazards can exist over very short distances, even in familiar locations.
Operational or guest-driven requests can introduce subtle pressure to act quickly. This underlines the importance of pausing to re-establish situational awareness and conduct a fresh risk assessment before manoeuvring, particularly after a period of inactivity.
The injury to a crewmember during the grounding reminds us that sudden vessel movements can create secondary risks to personnel, even at low speed.
CHIRP commends the reporting of the uncharted coral to the hydrographic office. Mariners are encouraged to treat manoeuvring after extended anchoring as a new navigational task, to challenge assumptions formed during benign operations, and to adopt a conservative approach when operating close to shore or reef systems.
Key Issues relating to this report
Situational awareness – Failure to re-assess conditions before manoeuvring; uncharted hazards not anticipated.
Teamwork/communications – Decision-making may not have been challenged; lack of cross-checks reduced safety margin.
Capability & Culture – Risk assumptions influenced by prior experience; organisational norms may have reinforced shortcut thinking.
Overconfidence/Complacency – Extended anchoring without incident led to an underestimation of risk near uncharted coral.
Key Takeaways
Even after safe anchoring, familiar waters can turn into hazards—pause, reassess, and navigate cautiously.
Regulators – Embed human factors such as complacency, fatigue, and communication in regulations and inspections—safety isn’t just about charts and machinery.
Managers – Encourage a safety culture where crew pause, reassess, and speak up; operational convenience should never override risk awareness. Management companies could greatly assist vessels by developing a ‘quick plan’ procedure for short passages that retains all the key elements required for any passage.
Crew – Treat every manoeuvre after inactivity as a new navigational task—assume nothing, verify everything, and safeguard yourself and others.