Incident Review

135 articles

BSafe Case Study 13 — Symptoms Blamed on the Weather, Not the Cargo

Headaches, nausea and fatigue spread through the crew, and everyone assumed seasickness or bad lunch. It was phosphine gas leaking into the…

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BSafe Case Study 14 — Released Before the Second Gripe Was Even On

The bosun told the crew in the lifeboat not to release the fall preventer devices until both gripes were secured. The chief…

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BSafe Case Study 15 — The CO2 Seemed to Work. The Fertiliser Kept Reacting Anyway.

White smoke, a chemical smell, and a fixed CO2 system that appeared to fix the problem. It didn't — ammonium nitrate fertiliser…

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BSafe Case Study 16 — A Repair Party Nobody on the Bridge Knew Was There

A torn-off hatch cover let water into the forecastle store. Four crew went forward to fix it in heavy weather, with no…

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BSafe Case Study 17 — Experienced Enough Not to Need a Risk Assessment, Until He Wasn't

A contracted riding team leader decided a formal risk assessment was unnecessary — his team had done this before. Strict COVID-era separation…

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BSafe Case Study 20 — A Line That Sprang Loose From an Open Fairlead

Warping a vessel forward to accommodate a crane grab, a tensioned spring line sprang out of its open roller fairlead and struck…

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BSafe Case Study 22 — A Standby Engine Order, Given, Then Undone

A classification society condition required the engine on standby at anchor after a lost port anchor. A pilot repeated the instruction on…

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BSafe Case Study 23 — Obscured for the Final 20 Seconds

A stevedore coordinator climbed to check on his team's progress, positioning himself somewhere a suspended hatch cover would block the crane operator's…

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BSafe Case Study 25 — A Cigarette, a Sofa, and a Fire That Came Back

An AB smoked in bed after drinking ashore. A dropped cigarette caught the sofa. The crew fought it for hours, thought it…

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BSafe Case Study 27 — Behind Schedule, Departing Without a Briefing, Into 51 Knots

A cross-Channel ferry was running late. The master decided departure could proceed without tugs and without the pre-departure briefing company procedure required.…

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BSafe Case Study 28 — Twelve of Fourteen Lines Were Already Compromised

Forecast winds justified adding extra mooring lines. It wasn't enough. When 50-knot gusts hit, the lines parted one after another — and…

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BSafe Case Study 30 — The CO2 System Was Meant to Save Them. The Wire Had Parted.

An engine room fire on an 80-year-old bulk carrier met an old ship's real limitations: no bridge stop, an engine skylight that…

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BSafe Case Study — A Signal System That Only Worked If Nothing Went Wrong

The bosun, acting as banksman, deliberately moved out of the driver's sightline as routine practice — a whistle would tell the driver…

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i-Catcher — Struck From Below, Trapped Underneath

A charter fishing vessel off Kaikōura was struck by a whale and capsized in seconds. Five passengers survived in an air pocket…

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Silver Cloud II — Asleep at the Helm, Awake by the Rocks

A prawn trawler's skipper fell asleep alone on watch off Lochinver and the vessel ran itself onto the rocks. MAIB found flu,…

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Sea Eagle — Alone, Overboard, and No One Left to Notice

A lone creel fisherman went into the water working two strings of gear at once. His boat sailed on unmanned for two…

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China Champion — A Permit Written for the Job Nobody Followed

An engineer working alone on a limit switch control box went overboard in Beaufort 5 winds off Liberia. TSIB Singapore found the…

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BSafe Case Study 32 — Nobody Thought Hydraulic Oil Would Burn

A deck fitter suffered severe burns when hydraulic oil ignited during hot work on a seized flange. Britannia P&I's case study found…

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BSafe Case Study 1 — The Tank Wasn't Empty, and Nobody Checked a Second Way

A third engineer died from septic shock after hot sludge splashed him opening a settling tank manhole. A faulty level gauge and…

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BSafe Case Study 8 — Eight Days of Failed Tank Cleaning, Then Caustic Soda

A Third Officer suffered severe chemical burns from caustic soda after eight days of struggling to clean cargo tanks with no ship-specific…

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Algoma Verity: The Pilot Kept Saying "We're Going to Be Fine" — He Was Wrong Twice

NTSB's investigation into the double grounding of the bulk carrier Algoma Verity on the Delaware River found the probable cause was expectation…

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Four Tonnes From Capsize: How Three “Routine” Modifications Sank the Nancy Glen

MAIB's investigation into the loss of the prawn trawler Nancy Glen found three unassessed modifications had cut her capsize threshold by a…

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Alone on the Quay: The Cover-Up That Meant Cherry Sand's Fatal Crush Happened Twice

MAIB's investigation into the fatal mooring accident aboard the dredger Cherry Sand found the same crushing accident had happened before — and…

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The Hook That Was Never Tested This Way: CV30 and the Southern Ocean MOB

MAIB's investigation into the loss of a crew member from the Clipper 70 yacht CV30 found his safety tether hook opened under…

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