Question 1

What warning sign had masters within the fleet already raised with the company before this sailing?

Accepted Answer

A request for bridge indicator lights showing bow and stern door position directly, rather than relying on verbal reports Masters had previously suggested fitting door-position indicator lights to the bridge — a change that would have removed the need for anyone to assume the doors were shut. The suggestion went nowhere before the disaster.

Question 2

Gard's loss prevention guidance repeatedly highlights that many serious incidents follow a 'normalisation of deviance' — small departures from procedure that become accepted because nothing went wrong before. As Master, what's the most effective way to counter this on board?

Accepted Answer

Actively encourage crew to raise near-misses and procedural drift without fear of blame, and personally follow the same standards you expect of others Gard's guidance on human factors and safety culture identifies normalisation of deviance — where shortcuts that 'worked fine last time' quietly become the new normal — as a precursor to many serious casualties. The most effective defence is an open reporting culture for near-misses and minor deviations, combined with visible leadership from the Master, who sets the tone for what is and isn't acceptable on board.

Question 3

Gard's guidance on near-miss reporting notes that crew sometimes hesitate to report their own minor errors or close calls. As an OOW, why does Gard say this matters for the wider fleet, not just your own ship?

Accepted Answer

Near-miss data, shared and analysed across a fleet (and via schemes like CHIRP Maritime), helps identify recurring risks before they cause a serious incident elsewhere Gard's loss prevention work draws heavily on aggregated near-miss and incident data — including confidential schemes such as CHIRP Maritime — precisely because a near-miss on one vessel is often a warning sign for a hazard that exists across many similar ships. A culture where OOWs report close calls without fear of blame is one of the cheapest and most effective loss-prevention tools available.