Question 1

The Kommandor Susan report notes the non-genuine bearings were installed "without the vessel owner's knowledge" during a contractor overhaul. What if, during a similar overhaul on your vessel, a junior engineer privately told you they "weren't sure" the replacement parts looked like the genuine items in the manual, but didn't want to make a fuss in front of the contractor? What does this case suggest about how a Chief Engineer should respond?

Accepted Answer

Take the concern seriously and investigate it there and then — asking to see the parts, checking them against OEM documentation/part numbers — and make clear that raising doubts about component quality is welcomed, not a nuisance, because the barrier to saying "I'm not sure about these parts" must be low The Kommandor Susan investigation identified a culture and oversight gap as a root cause: nobody challenged the assumption that the right parts were going in, and the non-genuine bearings went undetected for six years. The MAIB's lesson for Chief Engineers is to "create a culture in your engine room where engineers feel safe raising concerns about component quality" — a junior engineer's quiet doubt, taken seriously and checked in the moment, is exactly the kind of early challenge that could have prevented this entire chain of events.

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.