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Web Alert: Three further lessons from near-miss reports

26 May 2016

The ‘Confidential Hazardous Incident Reporting Programme’ (CHIRP) works to collect information regarding incidents or near-misses and distribute this knowledge to assist others to learn from these experiences. Its latest initiative, sponsored by The Standard Club, is the production of new ‘video maritime feedback bulletins’ which are released on a quarterly basis. Each eight minute production promotes good safety practices and provides opportunities for ship owners and operators to compare their organisation’s own performance in such matters, which aligns with The Standard Club’s own efforts to reduce losses and accidents in the international maritime industry.

Near misses and minor incidents should not go unreported as they allow companies to learn from hazardous incidents at sea and those occurring in port at the interface between the ship and the shore facilities. The information for these bulletins is gathered from seafarers reporting incidents they have witnessed, but each report is treated in strict confidence and used only to illustrate a hazard. Seaferers and shore managers should also report near-misses according to their company practices.  For the CHIRP scheme, reports can be submitted at
Read more on the first bulletin in the series here.
The second bulletin looks at another three reported events and the ways in which they could have been avoided. The first case study focuses on the collision regulations (COLREGS). The COLREGS apply to all safety at sea, the central maxim being: positive action, taken in ample time. This case looks at a dangerous close encounter in a traffic separation scheme (TSS) in the Dover Strait. A container ship moving at speed was overtaking a VLCC, using the Sandettie Deep Water route, despite being below the minimum draught. The ship refused to alter course despite communication and passed too close, and was later also close to entering the opposing traffic lane when avoiding a bulk carrier. The manouevre should not have taken place, given the danger of interaction between the two vessels and the severe consequences of disrupting the shipping route that would be caused by a collision in this location. Passage plans should comply with local guidance for a deep water route, and be put in place well prior to arrival at the TSS. General guidance should also be considered: slow down if in doubt, keep in mind the vessel astern, don’t overtake without ample time and space, and don’t rely on electronic aids alone.

The second and third case studies look at on-board operations.
During maintenance work, pipes serving the exhaust gas heater fire suppressant system were discovered to be thinned and virtually blocked, meaning the system would have failed in the event of fire. In this case, a comprehensive approach was taken to rectify the fault. However, this fault may not have been spotted had the maintenance work not been done. Stringent inspection regimes must be integrated into the ship’s planned maintenance system to check that these emergency systems which are not often used are still regularly maintained and not forgotten.

The third case study looks at entry into enclosed spaces, and discusses what should be considered an enclosed space and what constitutes actual entry, to determine when ventilation and safety equipment are required. If in doubt, seafarers should treat any space defined as ‘enclosed’ by the IMO resolution as an enclosed space and follow the procedures accordingly.

The bulletin is available here.