M2762

This report highlights a common but significant safety concern: the inconsistent application of established risk controls during routine operations. The fact that one crew member undertaking a similar task was correctly using a harness and attachment point demonstrates that the necessary equipment was available, the procedure was understood, and the task could be carried out safely. The vessel also had an external access plan identifying suitable attachment points for this type of work. These arrangements indicate that the risks had already been recognised, yet the required safeguards were not consistently applied at the point of work.

When safety measures are applied selectively, it often reflects a gradual erosion of standards during routine operations. Tasks such as washdowns can become normalised, leading to the systematic underestimation of risks, particularly when they are perceived as quick or low consequence. However, any work undertaken near exposed edges or over the ship’s side requires rigorous adherence to the external access plan and associated control measures. In the absence of fall protection, suitable attachment arrangements, and effective supervision, risk management becomes dependent on individual judgement, which is neither reliable nor sustainable.

The presence of other crew members in the vicinity, without intervention, suggests that unsafe practices were either not recognised or not challenged. This raises broader concerns about onboard safety culture, particularly about whether individuals feel both responsible for and empowered to speak up when they observe unsafe behaviour. Effective teams maintain shared situational awareness and actively monitor not only their own safety but also the safety of those around them.

There is also a clear gap in supervision. Visible and engaged supervision plays a critical role in reinforcing expectations and addressing deviations in real time. When unsafe practices occur in plain sight, it suggests that supervisory oversight may not have been sufficiently present or actively engaged.

CHIRP is also concerned by indications that working close to exposed edges without appropriate controls may have become normalised. A key lesson identified by contributors is that not all unsafe behaviour is deliberate or reckless. It is important to distinguish between intentional violations and actions that arise when individuals underestimate risk, become task-focused, or follow accepted but unsafe routines. There is a risk in assuming that behaviour which appears unsafe is inherently negligent when it may, in fact, reflect wider cultural or procedural weaknesses.

A further issue relates to the practical difficulties faced by crew members working alone. This case reinforces the need for robust lone-working arrangements, particularly where there is limited supervision or opportunity for peer challenge, and where tasks involve exposure to significant hazards. CHIRP notes with concern the recommendation of a national investigation authority that the company and vessel manager review their permit-to-work arrangements to ensure they are not only correctly issued but also meaningful, clearly understood, and actively used to control risk. The report also highlights the value of collaboration with flag states and industry organisations to strengthen oversight and improve safety standards across the sector.

This case demonstrates that having procedures, plans and equipment in place is only one part of an effective safety system. Their consistent application, supported by active supervision and a culture in which individuals are willing to challenge unsafe practices, remains essential to preventing serious incidents. Consistency, not availability, determines the effectiveness of safety controls.