Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2702
Initial Report
The captain was distracted while chatting to the steward during anchoring operations and left the engines in astern after instructing the OOW to lay out the anchor using the windlass. The stress caused the chain to jump off the gypsy, startling the bosun, who was very close to the designated viewing platform for the operation. The captain blamed the bosun, but ECDIS data showed he was making 4 knots astern.
This was written as a near miss and submitted to the safety meeting, but it was rejected for inclusion in the minutes. This happened again at another location when the speed of the vessel was 3 knots astern while paying out the anchor cable using the windlass, the chain jumped, and again the crewmember, a lead deckhand, was blamed.
The reporter resigned from the ship and was summoned to the office to explain the reasons for their resignation. During this process, the reporter presented objective evidence—including ECDIS records, logbook entries, and witness statements—demonstrating that the master was responsible for poor and dangerous anchoring procedures. Based on the evidence provided, the master was dismissed from the company. Reflecting on the experience, the reporter noted: “It was a very hard time, and had I been more junior, my report may not have been accepted, or the matter may have gone unreported.”
The reporter suggests that the review of these examples could lead to a discussion about how to report serious safety breaches when the usual channels don’t work, or people are worried about losing their jobs or future opportunities if they do report.
CHIRP Comment
This report highlights several important human factors issues: distraction during a critical operation, unsafe anchoring practices, misuse of authority, and failures in the onboard reporting culture.
Anchoring operations require full concentration from both the bridge and forecastle teams. The reported astern speeds while paying out cable using the windlass created excessive load on the anchor chain, causing it to jump on the gypsy and placing personnel at serious risk of injury. The fact that the event occurred twice suggests that unsafe practices had become normalised.
The captain’s distraction during the operation was concerning, but the subsequent response was equally significant. Blaming deck personnel rather than examining the operational factors prevented proper learning from the first incident and increased the likelihood of recurrence. The rejection of the near-miss report from the safety meeting minutes is also troubling, as safety reporting systems only
work when concerns are openly discussed, recorded, and acted upon.
CHIRP commends the reporter for preserving objective evidence, including ECDIS data, logbook entries, and witness accounts. This is particularly important where there is a strong authority gradient, as more junior crew members may feel unable to challenge senior officers or report unsafe behaviour. CHIRP also commends the management company for its thorough approach to investigating this incident.
This case also highlights the importance of alternative reporting routes when onboard processes fail. Seafarers must have confidence that serious safety concerns can be raised through company, confidential, or regulatory channels without fear of retaliation. The usual route is via the designated person ashore (DPA). The DPA should make themselves known to the ship’s staff and actively encourage reports of concern to be addressed directly to them if onboard reporting procedures are not working. The DPA should not remain in a passive role within the company but should become more actively involved by visiting the vessels whenever possible. The hiring and vetting of senior officers should ensure that appropriate due diligence is conducted to assess their willingness to report safety concerns, especially those raised by the crew during safety meetings and at other times.
The key lesson is that effective safety culture depends not only on procedures but also on creating an environment where concerns can be raised, investigated fairly, and learned from before someone gets hurt.
Key Issues relating to this report
Human Factors related to this report
Situational awareness – Failure to understand what is happening, what has changed, or what may happen next. Frequently caused by distractions, complacency and inadequate experience.
Distractions – Loss of attention during safety-critical tasks. Alerting – Failure to speak up or challenge unsafe acts, conditions, or assumptions.
Culture – Poor safety culture, weak reporting culture, fear of blame, or normalisation of unsafe behaviour.
Teamwork – Poor coordination, lack of shared mental models, weak supervision, or ineffective cooperation.
Capability – Possible that the dynamic forces were not properly understood by the master.
Key Takeaways
Regulators – Most maritime accidents aren’t single “human errors” but systemic failures shaped by culture, workload, supervision and fatigue. Effective regulation must assess reporting culture and non‑technical skills, not just technical compliance. The MLC has created a recognised reporting pathway, but it is too often not used due to fear of losing your job and intimidation. This must not be allowed to prevail.
Managers & Companies – Safety is set ashore before it’s tested at sea. Decisions on crewing, schedules and reporting culture shape risk onboard. When shortcuts and fatigue are normalised, incidents follow. Psychological safety and practical human factors training matter.
Seafarers – Speak up early — small concerns prevent big accidents. Routine tasks become risky with distraction, fatigue or complacency. Managing awareness, challenging assumptions and supporting each other are key defences at sea.