Question 1

The Kommandor Susan report describes a chain of "latent failures" — a 2019 contractor error, no verification check, misapplied extended service intervals, and six years with no audit — none of which individually caused the fire, but which compounded into one. What if, as Master, you inherited a vessel with a long, clean maintenance history and no reported defects — what attitude does this case suggest you should take toward that "clean" record?

Accepted Answer

A clean record on paper does not rule out a latent failure quietly accumulating underneath it — the system "appears to work," the engine runs, the paperwork is clean, right up until a failure surfaces — so the Master should periodically ask what assumptions the current operating regime (e.g. extended intervals, third-party overhaul work) rest on, and when those assumptions were last actually verified The MAIB's closing question in the Kommandor Susan report is direct: "What are you assuming is safe right now — that nobody has verified since [it was last checked]?" The report's central theme is that latent failures are dangerous precisely because they are invisible — a vessel can look operationally sound, with clean paperwork and no defects, for years, while an unverified assumption quietly erodes a margin of safety underneath. For a Master, "clean" history is not the same as "verified" history, and periodically revisiting the basis for long-standing assumptions (extended intervals, past overhaul quality, equipment provenance) is part of the job — not a sign of distrust in predecessors.

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.