M2261 - Critical safety failures and crew fatigue on cruise ship during passenger excursions

Initial Report

A crew member on an expeditionary cruise vessel reported serious safety concerns following a recent passenger excursion.

The vessel planned to land passengers at a remote location known for its impressive wildlife. There was a considerable onshore swell, so the vessel anchored a mile offshore. The captain assessed that the distance to shore, the sea state and the surf conditions on the beach exceeded the safe operating limits for the vessel’s own inflatable passenger launches, and a local, larger, ferry was commissioned to move passengers ashore.  Unfortunately, however, the ferry ran aground on its way out of harbour. To avoid cancelling the trip, and without consulting with the captain, the expedition leaders directed that the passenger launches be used, and nominated several of the crew members as helmsmen, even though not all of them were qualified to do so.

Our reporter was one of several people who expressed concerns to the expedition leaders, pointing out that this went against the captain’s earlier orders, and the weather had further deteriorated. These concerns were over-ruled.

The launch crews then worked from 8am to 7pm without breaks or meals, in tropical heat and high humidity. The considerable sea state, surf, and lengthy transits were uncomfortable for the passengers and highly stressful for the crews, who were aware that they were operating in unsafe conditions, which were further exacerbated by the lack of reliable communication equipment. Several safety incidents occurred, including a man overboard incident, and passengers left on a beach near wild animals.

Following the day’s operations, one crew member experienced severe psychological and mental stress, which the onboard doctor later assessed. After submitting an official report to the captain detailing these safety concerns, the crew member was summoned to a meeting with the cruise director and was asked to disembark at the next port of call.

CHIRP Comment

This report raises important safety concerns, particularly for expedition cruise ships that emphasize excursions. The pressure to meet passenger expectations can lead expedition leaders to prioritize the delivery of excursions at all costs. In this case, delays caused by a grounded ferry likely created additional time pressure, which may have pushed the leaders to use the ship’s launches without consulting the captain. Without deck experience, they may not have fully understood the safety risks, especially if the crew operating the launches were not properly trained. Ignoring the captain’s earlier orders also undermined the captain’s authority, which was further weakened when the captain failed to reassert control after discovering the launches were in use. CHIRP has ascertained that there is no industry SOP for the transfer of passengers from cruise liners other than individual company Safety Management System (SMS) guidelines and procedures.

A ship’s launch has both design limits (such as maximum passenger capacity or sea conditions) and operational limits, which take into account passenger mobility, safety, and comfort. To help make better decisions on board, companies are encouraged to define these operational limits in their SMS. This should include not just weather and sea conditions, but also passenger mobility requirements. Some companies use a simple ‘step test’ to assess if passengers can safely board or disembark.

Using the ship’s launches with unqualified personnel and without proper communication equipment should have been an obvious safety risk and a clear violation of the company’s SMS. However, the expedition leaders overlooked these concerns in their focus on satisfying their passengers cruise experience. Several passengers reported safety concerns to CHIRP.

The crew’s high workload, along with insufficient rest and food, further compromised safety. The 11-hour work shifts left tender operators fatigued, leading to risks that were not minimized to acceptable levels (As Low As Reasonably Practicable, or ALARP).

Additionally, the cruise director did not properly care for a crew member suffering from work-related stress, which raises concerns about ethical working practices.

CHIRP brought these issues to the attention of the company, which dismissed them, so the matter has been escalated to the vessel’s flag state and classification society, both of which are now investigating.

Culture- The company was dismissive when contacted by CHIRP, suggesting its safety culture is lacking. The practical consequences were a series of safety violations including the captain’s orders being ignored and the crew’s concerns rejected. Despite objective evidence with two serious incidents, risky behaviour was allowed to continue and there was no intervention by the master.

Fit for purpose– Neither the launches nor the communication equipment were suitable for the task.

Capability— Some crew members were not qualified to operate the launches, and their capability was further eroded by fatigue in the difficult weather conditions.

 Communication– There was a breakdown of communication between the captain, expedition leaders and launch crews.

Teamwork- Members of the team were focused on different goals and there was no shared understanding of the risks nor the importance of safety. Collective challenge was ignored, and the crew did not have ‘stop work’ authority despite the hazards.

Local practices– Local practices are clearly stressful and should be reviewed by the company’s HR team at the earliest opportunity.