Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2700
Initial Report
“The master instructed me to issue a Permit to Work (PTW) for the ETO to enter a fuel tank while the vessel was at sea to repair an underwater light.
A risk assessment was carried out, which confirmed that it was not possible to fully remove the fuel or ventilate the space to safe levels. On this basis, the task was rejected.
Despite this, the master insisted the work should proceed. I refused to issue the PTW, as the request was contrary to COSWP and established guidance on enclosed space entry. The master stated that I had no authority to refuse, despite my role as the vessel’s Safety Officer.
I stuck to my original decision, and the work did not take place.”
CHIRP Comment
This report highlights a maintenance situation in which established safety barriers functioned as intended. The outcome was achieved, not by chance, but through the exemplary actions of the vessel’s Safety Officer, who correctly applied the safety management system and upheld the permit-to-work (PTW) process in the face of pressure.
The proposed work involved entry into a fuel tank while the vessel was at sea. The Safety Officer correctly identified that the tank could not be fully drained or adequately ventilated, and that the conditions did not meet the requirements of COSWP or accepted enclosed-space entry guidance. On this basis, the Permit to Work was refused, and the task did not proceed. CHIRP considers this to be an appropriate, proportionate, and professionally sound safety decision.
Of concern, however, is the apparent challenge to both the PTW process and the Safety Officer’s authority. The PTW system is intended to serve as a formal safety barrier, particularly for high-risk activities such as entering enclosed spaces. Its effectiveness relies on a shared understanding that permits may be refused when risks cannot be adequately controlled, regardless of operational or commercial pressures.
CHIRP notes that entry into enclosed spaces within fuel tanks remains a significant cause of serious maritime accidents and fatalities. Industry guidance is clear that such entries must not be undertaken unless the space has been properly prepared, tested, and confirmed safe. Attempts to override these controls undermine the purpose of the safety management system and increase the risk of serious outcomes. A valid question for the naval architects is why a light fitting should be accessed via a fuel tank?
This case also reinforces the importance of clearly defined roles and authority on board. When the Safety Officer’s responsibilities are not fully understood or supported at the command level, safety decisions risk becoming negotiable rather than mandatory.
CHIRP 100% strongly endorses the Safety Officer’s professionalism in upholding their decision and submitting a confidential report. Operators may wish to use this case to review their understanding of enclosed space entry requirements, the authority and responsibilities associated with the Permit to Work system, and how differences of opinion on safety matters are resolved within the vessel’s command structure.
Maintaining an environment where safety concerns can be raised, supported, and respected without challenge is fundamental to effective safety management, and CHIRP will work to provide support for those who find themselves in a similar situation.
Key Issues relating to this report
Communication – The situation involved a clear conflict between authority and safety responsibilities. While the Safety Officer communicated their refusal, the incident highlights the importance of assertiveness in enforcing safety rules.
Pressure – The report directly demonstrates the challenge of resisting unsafe instructions from a superior, which is explicitly covered in the Deadly Dozen as a factor that can lead to accidents if ignored.
Local practice – The master attempted to override established safety procedures and COSWP guidance.
Culture – The master showed no safety culture, whereas the Safety Officer upheld the company’s values. It is possible that this type of override of a safety barrier, the PTW, is commonplace.
Key Takeaways
“Safety systems are only effective when the authority to stop unsafe work is understood, respected and supported at every level on board.”
For regulators – This report reinforces that compliance cannot be assumed simply because procedures exist. Effective safety management depends on authority, role clarity and cultural reinforcement on board. Regulators may wish to continue emphasising that Permit to Work systems are safety barriers, not administrative tools, and that Safety Officers must be explicitly empowered to stop unsafe work without fear of challenge or reprisal.
For managers – Company leadership – the incident highlights the gap between work as imagined and work as done. Clear policies on enclosed space entry and PTW authority must be supported by consistent messaging to masters and senior officers. Training should address the authority gradient directly and reinforce the point that rejecting unsafe work is a leadership responsibility, not an obstacle to operations.
For crew – The report demonstrates the importance of speaking up and adhering to established safety processes, even when under pressure. It also shows that refusing unsafe work is a legitimate and necessary part of professional seamanship. Safety systems only protect crews when individuals trust them and are supportive when they are used.