Question 1

What changed between the morning and afternoon working sessions that the investigation identified as a likely contributing factor?

Accepted Answer

The chief officer, who had personally supervised in the morning, was resting in the afternoon The chief officer supervised directly from the tank top in the morning, when the safer process was followed throughout. In the afternoon he was resting, and the absence of formal supervision — combined with a desire to finish the job — likely contributed to the shortcut.

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.