Incident Review

135 articles

Four Minutes: Why the Skipper Didn't Survive a Grounding Most Crews Would Have Walked Away From

MAIB's investigation into the loss of the creel fisher Lexi Rose found a 69-year-old skipper with 40+ years' experience, drowned in shallow…

5 min read
Three in the Hold: What the Deaths on Berge Mawson Tell Every Chief Officer About Stevedores, Coal Cargo, and the PTW System

MAIB Report 5/2025 — three stevedores died in a coal hold access space on bulk carrier Berge Mawson at Bunyu Island, Indonesia.…

5 min read
The Last Wave: What the Double Fatality on Calypso 2 Tells Every Excursion Skipper About Ground Seas, PFDs, and Saying No

MAIB Report 6/2025 — a tourist and a mate drowned when Calypso 2 was swamped by ground seas near West End, Anguilla.…

5 min read
In the Water for Twenty Minutes: What the Death of Elizabeth Wood on LimbItless Tells Every Skipper About MOB Planning for Disabled Sailors

MAIB Report 7/2025 — Elizabeth Wood fell overboard during a spinnaker launch at Cowes. Her lifejacket inflated but rode up over her…

5 min read
The Chain Nobody Checked: What the Death of the Deckhand on Cornishman Tells Every Fishing Vessel Skipper About Lifting Equipment

MAIB Report 8/2025 — a deckhand was fatally struck when a beam trawler's quick-release chain fractured. The chain was the wrong grade…

5 min read
18 Hours in Debt: What the Loss of Sustain Tells Every Fishing Skipper About Fatigue, Watch Alarms, and the Decision to Sail

MAIB Report 9/2025 — the prawn trawler Sustain grounded at 7.7 knots after the skipper fell asleep at the helm carrying 18…

5 min read
The Fifth Time: What the Death of the Skipper on Nista Tells the Creel Fishing Industry About Lone-Operated Fishing and Back Rope Entanglement

MAIB Report 10/2025 — the skipper became entangled in the back rope of his own creel fleet and drowned. He was the…

5 min read
The Seat That Paralysed Her: What the Lundy Explorer Accident Tells Every Commercial RIB Skipper About Passenger Safety and the Front Third Rule

MAIB Report 11/2025 — a 28-year-old sea safari passenger was permanently paralysed when the RIB Lundy Explorer slammed into a wave. She…

5 min read
The Toggle and the Becket: How a Loose Lifejacket Fitting Killed a Deckhand on Kingfisher

MAIB Report 12/2025 — a deckhand was dragged overboard when a creel toggle threaded through his PFD's loose rescue becket. His 275N…

5 min read
The Fire the CO2 System Couldn't Reach: What Finnmaster's Engine Room Fire Teaches Every Chief Engineer About Modifications, Servicing, and Blind Trust

MAIB Report 13/2025 — a fire broke out in Finnmaster's auxiliary engine room after an unapproved fuel hose modification failed. The fixed…

5 min read
27 Knots in a 10-Knot Harbour: What the Göcek Tender Collision Teaches Every Master About Authority You Don't Use

MAIB Report 14/2025 — a superyacht tender, helmed by the owner's representative at 27 knots in a 10-knot harbour, struck a drifting…

5 min read
342 Containers, One Night: What MSC Zoe Taught the Industry About Stability, Shallow Water, and Not Knowing How Bad It Is

On the night of 1-2 January 2019, the 19,244 TEU MSC Zoe lost 342 containers into the North Sea north of the…

5 min read
BSafe Case Study 5 — A Rescue Attempt That Became a Second, Then a Third, Emergency

A chief officer descended into a log cargo hold and collapsed within steps. The bosun's warning went unheeded. Every rescue attempt that…

5 min read
BSafe Case Study 18 — The Chart Showed the Shoal. The Alarms Never Fired.

A bulk carrier ran aground with its ECDIS never sounding a single audible or visual warning. The OOW spotted the charted shoal…

5 min read
BSafe Case Study 21 — Thirteen Days Between a Headache and a Death

A cadet inhaled fumes from a bunker tank vent, reported a headache the next day, and was managed with rest and a…

5 min read
BSafe Case Study 24 — Six Days Sealed, and No Gas Detector Would Have Caught It

Two fumigation contractors collapsed inside a cargo hold that had been sealed for six days. Toxicology found no poison in either man…

5 min read
BSafe Case Study — A Strong Smell Was Read as Proof, Not a Warning

An ordinary seaman entered a cargo tank before its enclosed-space permit was issued, wearing a filter mask that offered no real protection.…

5 min read
BSafe Case Study 2 — A Job That Grew Past Its Own Permit

An AB was told to clean rust off a turnbuckle at deck height. He climbed an unstable, unsecured ladder to lubricate a…

5 min read
BSafe Case Study 4 — Nobody Knew He Was in There Alone

An electrician mentioned he 'might' work on a live 440V panel. No permit, no lockout, no lone-working check. He was found unresponsive…

5 min read
BSafe Case Study 6 — The Morning Did It Right. The Afternoon Didn't.

Same ship, same scaffold tower, same day. In the morning, crew climbed down before every reposition and wore safety lines. In the…

5 min read
BSafe Case Study 7 — Neither of Them Knew Where the Other One Was

A second officer was crushed between a gantry crane and stacked hatch covers while the chief officer, driving the crane, had no…

5 min read
BSafe Case Study 9 — A Sling That Would Have Failed a Visual Check

Two ABs stood in the fall zone to free a lifting gear snag that had happened before, many times, with no near-miss…

5 min read
BSafe Case Study 10 — Fernanda: Two Open Dampers and a Total Loss

A switchboard fire on the Fernanda spread through open accesses before the crew even had it fully closed down. Two fire dampers…

5 min read
BSafe Case Study 11 — A Two-Person Job, Done By One

A lashing bar, designed to slip easily into a container's corner fitting, slipped back out just as easily. Left hanging vertically by…

5 min read
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