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Web Alert: Lessons learned from near-miss reports

News & Insights 28 February 2017

This first bulletin of 2017 looks at three hazards which put seafarers in danger, and features Eric Murdoch, Chief Surveyor, offering his advice on how to mitigate incidents.

The Standard Club is working with the Confidential Hazardous Incident Reporting Programme (CHIRP) to promote safety at sea and accident prevention. CHIRP receives reports of hazardous incidents which they investigate with the ship's owner. The case studies and lessons learnt are published in their quarterly bulletin Maritime Feedback in both written and video form. These videos provide excellent material for discussion during a ship's safety committee meeting.

Read more on the first four bulletins in the series here.

This first bulletin of 2017 looks at three hazards which put seafarers in danger, and features Eric Murdoch, Chief Surveyor, offering his advice on how to mitigate incidents. 

In the first case study, a compressed air bottle from a life boat was being recharged. Suddenly, the union adaptor between the breathing apparatus compressor and the air bottle disconnected, despite not having reached the maximum design pressure of the bottle. The adaptor shot off at high speed and could have caused fatal injury if it had hit anyone. It is likely the incident was caused by either the misfit of a replacement part created by a different manufacturer, or damaged or worn threads. This highlights the grave damage that can be caused by small faults. The video suggests ways in which this incident could have been prevented and explains how simple precautions during maintenance could stop a minor error becoming a major incident.

Case study two features a blocked drain pipe. Attempts to free it with air and water were unsuccessful. Heat was a more successful method, so successful in fact that the blockage shot out and hit a bulkhead opposite. This was because the water in the pipe had heated to form steam and drove the blockage to evacuate at high pressure. The assistant had previously been standing at the end of the pipe and only by chance had moved out of the way and therefore avoided being hit and injured. While the obvious resolution to this incident is to ensure crew stand away from the end of a blocked pipe being cleared, this near-miss raises some important points for ensuring the success of a toolbox talk. These should not just be about how to get the job done quickly, and should encompass discussions of safety, hazard and risk assessment. Eric Murdoch, Chief Surveyor, has some helpful advice on how to get the best out of these meetings.

The third near-miss involves a close encounter in a TSS after a ferry altered course to starboard to make a bow crossing when on passage between two ports. The course alteration left the closest point of approach (CPA) and bow crossing range of 0.2 miles. The ferry communicated that they wished the other ship to slow down and give way by moving to starboard, without considering a second ship whose path they were also crossing. Fortunately, the ship was able to slow and avoid an incident but the situation should have been avoided by not carrying out this inappropriate manoeuvre. The company responsible took a positive and constructive position, and will follow up with the bridge team to avoid a similar incident occurring in future.

This edition closes with a discussion of ship design and the ways in which this can be the cause of incidents. Good ship design should minimise the chances of personal injury and reports to CHIRP of examples where this is not the case can help them to lobby for change.

The bulletin is available here.

These safety bulletins rely on reports to be submitted from all sectors of the maritime industry. There is room for improvement in all shipping sectors, and CHIRP can use these reports to escalate problems to people who can make a difference, such as naval architects, classification societies and flag state authorities. Reports can be submitted at

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