CHIRP Maritime Annual Digest 2020

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This publication contains summaries of all cases published by CHIRP (Confidential Human Factors Incident Reporting Programme) during 2020.

CHIRP Maritime aims to improve maritime safety by providing an independent and confidential reporting system for all individuals employed in or associated with the industry, analysing data and identifying safety trends and informing the community of safety related reports and trends.

The Digest categorises incidents according to human factors, deck safety, engineering, technological, environmental, pilotage, COLREGs/navigation, safety culture and health.

Welcome to the fifth annual review of CHIRP Maritime reports, covering all the cases we published during 2020 and including a number of in-depth articles specially commissioned to highlight important safety topics.

This has been a strange and disturbing year, dominated by Covid-19 and the global disruptions it has caused.

The impact upon shipping has been particularly severe, both as a result of infections and outbreaks at sea and because it has been so difficult to arrange crew changes.

Many seafarers are still at sea months after they should have been relieved – they are continuing to shoulder their burdens with courage and fortitude. As I write this, our crew change problems have still not been resolved, and it is a tribute to the world’s seafarers that they have continued sending us their reports despite all the difficulties they are facing.

At CHIRP Maritime we tried to do something for our colleagues at sea, and commissioned experts to produce guidance for serving seafarers. The guidance was published as a booklet entitled ‘Seafarer wellbeing during the Covid-19 pandemic’ which was widely circulated within the maritime community and the papers, including medical advice, are reproduced in this Annual Digest – where our Health section appears first to reflect its importance.

We salute all the world’s seafarers who have kept trade moving despite the difficulties, and hope you will all soon make it home to your families. The pressures on mariners who are forced to spend more than a year at sea, working every day and having no prospect of shore leave, are immense. Add to this their constant worry about the safety of their friends and families ashore and it is guaranteed to result in increased levels of stress and fatigue. Whether it will also lead to an increase in accidents and incidents remains to be seen but, if it does, we hope the people who investigate such cases will bear in mind the almost intolerable pressures on our seafarers.

Fortunately for CHIRP Maritime, our small and compact team has remained intact during 2020. Jeff Parfitt (Director, Maritime), Ian Shields and Howard Nightingale, ably assisted by Stephanie Dykes in the United Kingdom are still supported by two Maritime Advisors – Ranjith Cheerath in Singapore and me in Hong Kong – so our services have not been disrupted. Stephanie is currently on maternity

leave, so we send our congratulations and best wishes, and look forward to seeing her again before too long.

Meanwhile, Howard Nightingale is retiring early in 2021, so the search is on for his successor. It has been a pleasure working with him and he will be a hard act to follow. We wish him a long and happy retirement. As always, we are guided by our Maritime Advisory Board (MAB) who are an outstanding group of men and women with over 700 years of combined shipping experience. They volunteer to vet our reports and provide comments and expertise, and also contribute many of the Insight articles which appear in the Annual Digest. All our work is overseen by the Trust, Executive Director Robert Robson and a distinguished team of Trustees, while our Ambassadors continue to promote our work around the globe. We were delighted to welcome Capt. Kumar from Chennai to our team of Ambassadors during the year, and he has already developed useful links for us in this important maritime nation.

Our Maritime FEEDBACK magazine is now published in English, Chinese, Filipino and Portuguese, so we are most grateful to all the sponsors and translators who help make this happen. Please let us know if there are other languages you would like to receive or, even better, if you would like to sponsor a version in another language. We have again been fortunate in finding generous sponsors who have made it possible to produce this Annual Digest. They are listed at the end of the publication and we are extremely grateful for their support and their ongoing commitment to safety.

The generosity of all our sponsors is acknowledged in our publications, and we could not function without them, but our reporters (both individuals and companies) remain anonymous for obvious reasons. It is a pleasure for me to once again acknowledge them all and thank them for their support, without which we would not exist. The usefulness of their reports is demonstrated by the increasing amount of feedback and comment which we receive as a result of the published reports, and we are delighted that we have been able to publish many of these comments in Maritime FEEDBACK and in this Digest.

We continue to receive approaches from organisations around the world who wish to cooperate with us, which is proof that we are contributing to safety in many ways.

Once again, we have divided the Digest into themed sections to assist readers to find the topics which most interest them, but we seem to be receiving even more reports which could be allocated to several different sections. I am not sure whether this means incidents are becoming more complex, or whether our analysis is becoming more sophisticated, but we urge you to study all the sections because they all contain reports which will be of interest both to seafarers and people in shore positions.

One message which does come through, unfortunately, is that not all companies are able to demonstrate a robust safety culture, so there is still a great deal of work to do to reach our goal of ensuring that every seafarer returns home safely at the end of every tour of duty.

Within most sections you will also find Insight articles that illuminate topics covered in that section or provide additional information. They are written by experts and are well worth reading.

All our videos, publications and databases are easy to access through our website, so we hope you will look at them when time permits. For more detailed and focused research, we recommend the searchable database on the website. There is a useful guide in the banner on our home page which explains how to use our site if you are in any doubt.

We hope you will find this Annual Digest both interesting and informative, but please let us know. Your comments are important, and we read them all to ensure CHIRP Maritime continues to provide the information you need to make our industry safer.

Until next time, take care and may all your voyages lead you safely home.


COVID-19: Do you understand me?

Insight – Focus on seafarer wellbeing during COVID-19 pandemic

Insight – Trapped by COVID-19 – Highlighting the plight of seafarers on board vessels

Insight – COVID-19 – General advice to masters and crew


Unsuitable PPE for female seafarers

Communication is essential

Communication and language barriers

Working aloft

MCA Insight – Improving the mental health of seafarers’ worldwide

Insight – Achieving cost savings from learning opportunities


Fatigue in the harbour towage sector

Drug abuse on fishing vessels

Correspondence received – Drug abuse follow up

Wake wash and unsafe speed passing anchored vessels

Unmanned jet ski

FAO – their role in international fishing safety standards


When is a ship not a ship?

Defective rate of turn indicator

Echo sounder display and under keel clearance

ECDIS /AIS position data affecting a Portable Pilot Unit (PPU) positions

More main engine problems whilst arriving and sailing

Correspondence received – Minimum speed for going astern

Flooding of a superyacht


Lost crane load during cargo operations

Parting wires

A very near miss

Inflatable lifejacket – service tag fitted incorrectly

Mooring incident on an LPG tanker

Incorrect valve alignment

Correspondence received – Incorrect windlass brake band adjustment

Correspondence received – Overweight rescue boats


Failure to comply with Collision Regulations (Rule 15)

Learning opportunities from non–compliance reports (1)

Violation of PSSA restricted area

Conflict between aircraft and ships

Distraction results in allision

Insight – Anchoring and anchoring equipment – Revision 1


Poor communication and lack of command decision

Poor safety culture on board

Unsafe crew practices

Superyacht – crew working outboard without PPE

Defective winch brake on tug

Insight – Risk Assessment – Fit for purpose?


Unsecured ladder

Correspondence received – Discrepancies in the pilot ladder poster

Pilots Corner – Inaugural article

Learning opportunities from non-compliance reports (2)

Pilots Corner – A perspective from New Zealand

Pilots Corner – Non–compliant trap door pilot boarding arrangements

Pilots Corner – a lucky escape, consequences, and design issues

Insight – 1000 ways to secure a pilot ladder, and only one way is correct

Insight – CHIRP Maritime – 2019 Analysis of Pilot Ladder Failings


The aim of CHIRP is to contribute to the enhancement of aviation safety in the UK and maritime safety worldwide, by providing a totally independent confidential (not anonymous) reporting system for all individuals employed in or associated with these industries.

CHIRP has been in operation for aviation since 1982. In 1996 the Programme was restructured in the form of a charitable company limited by guarantee to enable it to make a more effective contribution to the resolution of important safety-related issues. This corporate structure was selected in order to provide a totally independent organisation, with management and fiscal responsibilities held by an Independent Board of Trustees. The Maritime programme has been operating since July 2003.

CHIRP welcomes safety-related reports from flight crew, air traffic control officers, licensed aircraft maintenance engineers, cabin crew and the general aviation community and people in the international maritime sector, including the shipping industry, fishing industry and leisure users.

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