This is an overview of all basic causes in the MSCAT 8.2 version. The document contains explanations and examples.

Not all causes are explained. Some do not need further explanation or examples. And for others there are not enough
examples.
One should take careful note of the causes related to psychological capability and stress. As mere practical
professionals, i.e. Masters, superintendents, etc., without any specific psychological training/education we tend to
have subjective or relative notions: we compare behaviour with that of others we know.
It should further be clearly understood that intelligence level is an important factor which should be taken into
account when identifying causes which may be related, i.e. psychological categories 2. and 4.
Furthermore, often multiple causes will be identified during detailed investigations. The more a specific basic cause
appears in the fact tree, the more impact it has on the development of an event, i.e. the more important this basic
cause becomes. Corrective actions focussed on these basic causes are more likely to have a preventive character than
those based upon less prominent basic causes.
The document is intended to be provided in electronic format for later perusal.
The file is protected against changes and copying, but it can be printed.
 1. Inadequate Physical/Physiological Examples Basic Causes Examples Areas of Improvement
Capability
1.1. Inappropriate •A person opened the wrong valve, because he had a vision deficiency (colour-blind) •Setting standards for physical
height/weight/size/strength/reach, etc. •An engineer failed to take the right corrective action, because he did not hear the requirements
1.2. Restricted range of body movement alarm, having a hearing deficiency •Medical examination prior selection
1.3. Limited ability/inability to sustain body •Another tried to remove heavy equipment from a shelf, but his short stature made •Physical training
positions him doing this from a inadequate position for the task •Providing vision and hearing aids
1.4. Substance sensitivity/allergy •A superintendent cannot inspect the WBT, because of his large waist size. •Consider design and engineering
1.5. Sensitivities to sensory extreme (man machine interface)
(temperature/sound/etc.)
1.6. Vision deficiency
1.7. Hearing deficiency
1.8. Other sensory deficiency (touch/taste/
smell/balance)
1.9. Respiratory incapacity
1.10. Other permanent physical disability
1.11. Temporary disability
This category is self-explanatory and refers to a (semi-)
permanent lack of capability.
 2. Inadequate Mental/Psychological Examples Basic Causes Examples Areas of Improvement
Capability
2.1. Fears and phobias •An oiler used the wrong type of grease for a maintenance job, because he was •Specification of mental and
2.2. Emotional disturbance unable to memorize the differences between 3 of the most common types of grease psychological requirements
2.3. Mental illness •Some people have a problem in learning new things, this may partly be due to •Competence checks prior appointing
2.4. Intelligence level cultural background, i.e. “thinking ahead” and flexible response on changes, which in certain jobs
2.5. Inability to comprehend were not foreseen in “the checklist” •Psychological tests for specific
2.6. Poor coordination •For some jobs, there is a high demand on “reaction speed”, e.g. fighter pilots. jobs/tasks
2.7. Slow reaction time Insufficient ability to react in time may lead to wrong action •In some cases, where extraordinary
2.8. Low mechanical aptitude •Some people may have a problem with working in confined spaces (claustrofobia) or high demands for such capabilities are
2.9. Low learning aptitude at (open) heights (vertigo), e.g. painting the jib of a deck crane required, re-engineering tasks and
2.10. Memory failure/lapse supplying technical solutions (e.g.
electronic decision support systems)
This category is self-explanatory and refers to a (semi-)
permanent lack of capability

Note: The mentioned categories of basic causes are

addressing relative notions. Intelligence level may be
sufficient for a simple task, but inadequate for another,
more complicated task.
 3. Physical/Physiological Stress Examples Basic Causes Examples Areas of Improvement
2.1. Fears and phobias •(3.1) A simple cold affects a person’s performance, which may lead to overlooking •Ensure adequate rest periods
2.2. Emotional disturbance important details •Ensure adequate crew (quantity and
2.3. Mental illness •(3.1) Sea-sickness is another well-known reason for people to lose concentration, quality)
2.4. Intelligence level which again may lead to mistakes •A policy of paying attention to
2.5. Inability to comprehend •(3.2) The Chief Officer had been busy with Cargo Operations, Stores, various Port welfare and health on board
2.6. Poor coordination Authorities, a Vetting inspector, an audit and crew change. Although “on paper” he •Adequate supervision (which again
2.7. Slow reaction time had sufficient hours of “rest”, the accumulation of all these tasks and the impossibility requires adequate crew)
2.8. Low mechanical aptitude to relax (being in a stand-by mode during the formal rest hours) caused him to take a •A policy of timely reporting problems
2.9. Low learning aptitude wrong decision. w.r.t. stress and fatigue especially
2.10. Memory failure/lapse •(3.3) After a long west-east flight, somebody was transported to the vessel and put to when working in a harsh or unfamiliar
work immediately; suffering from a jet-lag he misjudged an important fact (fatigue due work environment
to lack of rest) •Proper planning of work and
This category refers to a temporary condition and is often •(3.4 & 3.6) When the vessel was at the shipyard in Singapore, the temperatures and additional activities (like audits and
a result of other basic causes (mostly job factors) or
external factors (also called “soil factors”) like e.g. high humidity in combination with all the unfamiliar pandemonium of banging and inspections)
weather and sea conditions. grinding – so typical for a yard – contributed to stress and loss of focus amongst •Shore support during vetting
several crew members, which made one of them forget to don his PPE. inspections
•(3.5) Due to the location and design of the auxiliary engines, there was continuous •Re-engineering of task combinations,
and excessive vibration, noise and oil leakage (causing oily fumes) in the work like Chief Officer being SSO
environment, contributing to stress amongst ER personnel.
•(3.5) During bunkering the oiler and duty engineer were exposed to the H2S escaping
form the nearby ventpipes, which caused headache and loss of concentration on the
tank level readings.
•(3.6 & 3.2) A pumpman had been working exposed to high temperatures for several
hours and when he had to line up for discharging ballast, he opened a valve in stead of
closing it (the valve being upside-down).
• (3.9) Whilst carrying out a double bottom tank inspection, the Chief officer
overlooked the serious deterioration of a ballast line.
 4. Mental/Psychological Stress Examples Basic Causes Examples Areas of Improvement
4.1. Emotional overload •(4.1 & 4.9) It sometimes happens that external “authorities” cause a lot of unnecessary stress on •Train and prepare ship-board staff
4.2. Fatigue due to mental task load or board, because of their unprofessional behaviour. Examples: Sub-standard pilots, PSC in certain for the –sometimes- unpleasant
speed countries and other “authorities” (inspectors, auditors) with obviously insufficient professional behaviour of third parties
background, mixing absence of relevant professional knowledge and (too much) power. Such
4.3. Extreme judgment/decision demands behaviour may drive ship board senior staff over the edge, contributing to serious mistakes. •Support the Master with advise from
•(4.1 & 4.9) In present day life social media can burden a seafarer with the problems at home, shore based management in case of
4.4. Routine/monotony/boredom/overly which may influence the judgement of the sailors, e.g. the lookout had heard about harassment of dispute with authorities
routine tasks his daughter at home and did not spot the fishermen around the vessel. •Re-engineering of responsibilities
4.5. Extreme concentration/perception •(4.2) Continuous changes in the instructions from the loading master w.r.t. the cargo planning, and duties in such a way that one can
demands which required on-going adaptations of schedules of discharging, loading, berth-shifting and tank concentrate on one’s core duties
4.6. Meaningless/degrading activities cleaning, caused the chief officer to loose control over the cargo operations. •Measures to increase risk awareness
•(4.2 & 4.3) When a fire broke out on board, the Master failed to keep fire fighting operations
4.7. Confusing directions/demands under control; the fire spread rapidly. Critical decisions had to be taken quickly and under and alertness for changes
4.8. Conflicting demands/directions extremely hostile conditions. •A reticent policy towards the use of
4.9. Preoccupation with •(4.4) During tank inspections an AB seaman was put as a stand by man at the tank hatch. Several extensive operational check-lists
problems/Distraction by concern 4.10. tanks had been inspected without any problem. The seaman had a problem to stay vigilant all the •Tool-box meetings and specific ship-
Frustration time a keep a close watch on what was happening in the tank. He spotted a familiar vessel passing board risk assessment, with
4.11. Mental illness the river and whilst trying to read the ship’s name, something went wrong in the tank, without him participation of all involved in the
noting it. operations
•(4.4) The Officer on watch was used to getting a reliable position from the GPS; however a
temporary malfunction of the equipment was unnoticed, which lead to a wrong position in the •The distribution of incident-history to
chart. discuss throughout the fleet
This category a temporary condition and mostly related •(4.4) The highly qualified Chief Engineer (on a North Sea ferry) repeatedly experienced that- for •A continuous policy of avoiding
to the job-content itself or (other) emotional factors,
often of a private origin. Nevertheless, it is sometimes an unknown reason- one of the main engines tripped. He thoroughly investigated every complacency (“take five” policy)
difficult to distinguish between physiological and occurrence but could not find any malfunction or deviation. Assuming, there was a faulty sensor, •Stimulation of near miss reporting
psychological stress, because e.g. carrying out a tank he started the main engine every time without any problems. The next time this happened, he did •A good work atmosphere and
inspection (3.9 and sometimes 3.6) contributes to not investigate, but assuming it was the same faulty sensor, he started the engine immediately attention for emotional problems of
fatigue, but may also contribute to mental stress after it tripped, this time leading to major engine damage.
(working in a cramped space). •(4.4) The systematic use of extensive check-lists may also contribute to “routine” and loss of personnel on board
vigilance (reference is made to the well-known cases of “checklist-aided groundings”. •Restriction of the duration of tours of
•(4.5) The vessel crossed an area with lots of fishermen, occupied in chasing fish, rather than duty
Note: The mentioned categories of basic causes are keeping an eye on the traffic in these narrow and shallow waters. This required a lot of continuous •Monitoring of workload on board
addressing relative notions. Intelligence level may not be concentration of the OOW. When he got relieved and handed over the watch, he overlooked one
relevant at all. and ashore
detail, which contributed to his reliever misjudging the traffic situation.
•(4.6 & 4.9) The Master was kept busy for hours with all kind of long reports (e.g. 9 pages to
complete for a supplier evaluation) , which kept him from his core duties as a Master. This
contributed to his understandable irritation with “paperwork” in general. Due to this state of mind
he forgot to verify ship’s certificates, which lead to PSC detention.
•(4.8) When the Filipino seaman was half-way his tour of duty (about 5 months) he made a phone-
call to his home and got bad news about his mother’s health situation. Not being able to take any
action, he lost concentration.
•(4.9) The Bosun was in daily contact with his wife regarding the serious condition of his uncle who
had had an accident recently. During unmooring in one of the Panama Canal locks he slackened
the wrong line because he was distracted during the waiting.
•(4.10) The Second Engineer repaired the separator with an old seal, because a wrong seal had
been supplied for the third time.
•(4.11) The Superintendent approved a purchase order for the wrong seal because he had been
working for 8 weeks straight, without one day off. He was on the brink of a burn-out.
 5. Lack of Competence Examples Basic Causes Examples Areas of Improvement
5.1. Inadequate experience •(5.1) It was his first time on a chemical tanker and he had no experience with the • Proper recruitment (verification of
5.2. Inadequate orientation/induction complications of tank-cleaning when certain products had been carried. Instructions were adequate theoretical knowledge)
5.3. Inadequate initial training available, but these were too generic and not adequate for the operation. • A good system for familiarization
5.4. Inadequate update/refresher training •(5.2) He was shown around by the 3rd mate on the first day of his arrival, but did not get • Coaching and supervision of
the specific induction on the bridge equipment, which was a bit different from his former personnel with a certain lack of
5.5. Misunderstood ships. experience
instruction/information •(5.2) The new 2nd engineer had some experience on this type of vessels, but he was not • An adequate policy of identification
5.6. Lack of situational awareness/risk familiarized with some specific procedures for switching between generators, causing him to of training needs for each position;
make a serious mistake when the vessel was in confined waters.
perception/risk awareness •(5.3) It appeared that the 2nd officer did not even know the chart features and the including for shore-based personnel
5.7. Inadequate initial instruction/skill Regulations to avoid collisions at sea. His basic education at the nautical academy was • A modern system of monitoring and
training inadequate. evaluation of ship-board and shore-
5.8. Inadequate practice •(5.4) When he joined the Company, he was instructed on the applicable Company system, based personnel
5.9. Infrequent performance but during all those years (during which many changes were made) he never got any • Update training like computer based
5.10. Inadequate coaching refresher training, so he overlooked a few details. interactive refresher training
5.11. Inadequate review instruction •(5.2 & 5.4 & 9.1) The fire drills were not carried out in a realistic way, consequently –when • Good work atmosphere in which
a real fire started in the laundry- there was panic amongst the crew, which caused a delay in people will ask advise if they are in
the response. doubt
Although there is a difference between knowledge and •(5.5) Although the instructions described the procedure for analyzing accidents, he did not • A policy contributing to a high
skill, most people do not consider this important and we understand these. In his view, the procedures were misleading.
tend to agree with them. Nevertheless we will go into retention rate of experienced and
detail for both important categories. •(5.6) The engineer was working beneath the floor plating and bumped his head on a pipe competent personnel
line he did not remember. • A policy to avoid using training as a
Skill is about “practising”. Somebody may have an •(5.7) He knew a lot about the fire-triangle and the working of powder extinguishers, but “cure-all” for other basic factors.
adequate level of knowledge of the English language (can never received any training. When a fire broke out, he did not manage to use the equipment
read and understand written instructions), but may not correctly. • Clear and simple instructions,
be able to communicate effectively in English (skill). avoiding overkill and academic and
•(5.8) He received instruction from a colleague, who did not have any practical experience juridical terminology
either. As a consequence, he did not manage to do the job safely.
•(5.8) Fire drills were carried out in a “routine” and rather unrealistic way. Everything was
• Very much the same as the previous
prepared and than the standard drills were carried out, without allowing for “surprises”. category, although there is more need
When a real fire broke out, the crew was not sufficiently prepared and especially the Master to provide supervision and coaching
failed to act in a flexible and professional way. • Sufficient training of skills in
•(5.8) The officers never practised basic navigation skills, like visual position fixing and dead- specialized environment, including
reckoning, as a consequence, they did not notice that the ECDIS , due to GPS failure was in refresher training
dead reckoning mode and that wind and current pushed the vessel too close to the shore, • Drills to be carried out in a realistic
where it ended up on the rocks way in order to challenge the crew to
•(5.9) He attended a 3 days AMOS-W training 2 years ago, but since then never worked with response adequately, even as
this software. Suddenly he was placed on board of a ship where AMOS-W was installed. unforeseen scenario’s occur
•(5.10) Due to lack of manning, the boatswain did not find enough time to keep an eye on • Ensure training is planned properly
the young and inexperienced O.S. During mooring operations the Chief Officer found him and followed quickly by practising.
standing at the unsafe side of a mooring line, whilst heaving on it. • Often, lack of coaching is a result of
•(5.11) Ten years ago, he attended a practical fire-fighting training ashore, since then insufficient man-power on board
however he never got any refresher training (another basic cause)
• A combination of lack of skill with
lack of supervision is a frequent cause
for unsafe acts and practices.
 6. Improper Motivation Examples Basic Causes Examples Areas of Improvement
6.1. Improper performance/behaviour is •(6.1) The official company policy was to report incidents and near-miss cases. In practice •A policy to create and promote a
tolerated/rewarded however, masters who never reported a near miss (and managed to keep the secret) received healthy and positive work atmosphere
6.2. Proper performance/behaviour is praise from the Company. in the organization
•(6.1) The incinerator was out of order and the crew dumped a lot of plastic overboard. The
discouraged/punished Master was aware of this, but did not take action to stop it. •Ensure mutual understanding
6.3. Lack of incentive •(6.2) The master refused to bribe the Port State Control officer and got reprimanded for this by between ship and shore (e.g. by
6.4. Improper production incentive his superiors ashore. traineeship)
6.5. Improper Cost Reduction Incentive •(6.3) The crew managed to dramatically improve the cosmetic appearance of the ship in a very •Display commitment as Top
6.6. Excessive frustration short period of time. They expected some token of appreciation from shore based management, Management
6.7. Inappropriate aggression but never received this. •Avoid conflicting policies and
6.8. Improper attempt to save •(6.6) When the P crew heard that, after all these years of loyalty to the Company, they were to be practices; sometimes commercial
replaced by another nationality, they lost motivation and started to neglect maintenance.
time/effort •(6.4) The Company gave a reward to the Master who –measured over a period of a year- performance conflicts with safety and
6.9. Improper attempt to avoid managed to perform the cargo operations in the shortest possible time. Consequently on board of health objectives
discomfort one of the vessels, the crew started to prepare for loading and remove the slab-type hatch covers •Careful evaluation of the choice of
6.10. Improper attempt to gain attention with the ship’s crane, whilst the vessel was still at anchor and rolling heavily in a 3 meter swell. The performance indicators and objectives
6.11. Inadequate discipline swinging hatch cover hit the chief officer, who was seriously injured. •Many problems (partly) caused by
6.12. Inappropriate peer pressure •(6.7) The superintendent visited the ship and spread a lot of terror and fear among the crew; his improper motivation are originated by
6.13. Improper leadership example attitude contributed to loss of motivation on board. lack of leadership and clear and
•(6.8) Although the visibility dropped to about 1 mile, the Master decided to continue full sea-
6.14. Inadequate performance feedback speed, because he wanted to be in time in the port of loading (assuming the Company would realistic standards
6.15. Inadequate reinforcement of appreciate this) •Improper motivation does not
proper behaviour •(6.9) A maintenance job in a hot location with restricted access had to be carried out. In order to appear out of the blue; it is a basic
6.16. Abuse (intentionally) create more physical freedom, the fitter took of his (spark resistant) boiler suit and did the welding personal factor which is mostly the
6.17. Misuse (unintentionally) job in a T-shirt. result of other (job) factors.
•(6.10) Due to lack of support from the shore based organization, ship-board staff encountered
difficulties in maintaining the ship. The Chief Engineer decided to provoke a PSC detention, by
Motivation is the notion about what is driving people to allowing the engine room to get very dirty in the expectation that the problems arising from such a
certain behaviour (wanted or not wanted). It is often the detention would wake up responsible staff ashore.
result of behaviour of others (colleagues and superiors), •(6.11) When the new 2nd officer joined the ship, he heard from his predecessor, that several
but may also be based on individual personality and ratings disobeyed orders and got away with it, because the Master was reluctant in maintaining
attitude. discipline on board
•(6.11) The Master requested a violent and aggressive AB to be replaced in next port, but the
Company did not see the need for this (travelling cost)
•(6.12) He came on board with the a high level of safety motivation, but when he wanted to work
according to safe work practices, his colleagues told him he was over-zealous and should adapt to
“more practical” work methods
•(6.13) The safety regulations required wearing safety shoes, boiler suit and a helmet on deck, but
the Superintendent, visiting the ship, went on deck wearing sandals, a shirt and a cap.
•(6.14) Unsafe work practices were followed for a long time, but the superiors did not make any
remark.
•(6.15) After a seaman had got a rust particle in his eye , by not wearing his safety goggles (causing
a LTI case), the safety officer assembled the crew in order to tell them that such carelessness was
intolerable. At the same time he reminded the audience always to report near misses.
 7. Unclear Organizational Structure Examples Basic Causes Examples Areas of Improvement
7.1. Unclear/conflicting reporting •(7.1) The system for ordering spare parts was changed and it was not clear to the •Regular review of the procedures
relationship Chief Engineer that critical spares had to be ordered directly through the •Include adequate information
7.2. Unclear/conflicting assignment of Superintendent procedures in any Management of
function/role •(7.1) As it was unclear whom to inform, the superintendent, having received signals Change process
7.3. Unclear/conflicting from the master about shortage of crew, conveyed the message to crewing
accountability/responsibility/task department, without informing DPA or other higher level of authority. Consequently,
no decisions were taken to review the manning level.
•(7.2) Due to the merger of two shipping companies it was not clear who was
This category is about the structure of the organization. responsible for the new fleets
On board the roles and relations are traditionally clear.
Ashore there may be challenges. •(7.2) The ship’s superintendent, with budget responsibility for the vessel was
appointed to perform the internal audit on board.
•(7.3) An Electro Technical Officer (ETO) was injured when working at a high voltage
panel. He was not aware of the fact that –due to redundancy- the system was not yet
fully isolated. The job description for the ETO indicated that he "reports" to the Chief
Engineer. This was interpreted to mean that it was necessary to report on tasks
completed. The job description should be made clearer to indicate that work must be
pre-planned with the Chief Engineer, who must know what electrical work is being
done on board ship.
•(7.3) Many changes had been made to the management system over the past 10
years. It appeared that the responsibility for monitoring the corrective actions was
described in two chapters. It appeared that both DPA and Superintendent were
ultimately responsible.
•(7.3 and 8.7) Both the Chief Engineer and the Chief Officer assumed the other was
responsible for issuing hot work permits for hot work outside the engine room.
Consequently, the sub-contracted technician started to work with a disc grinder on
the monkey island, without any special safety measures.
 8. Inadequate Leadership Examples Basic Causes Examples Areas of Improvement
8.1. Inadequate HSEQ/asset strategy •(8.1) The maintenance policy of the company was based on break down maintenance only, •Clear and logical description of the
8.2. Inadequate leadership development leading to poor maintenance and port state control detentions•(8.2 & 8.3) Because the tide Organization, Responsibilities and
8.3. Inadequate delegation was rising fast, the OOW told one of the OS on watch to slacken the mooring lines. The OS Authorities
8.4. Inadequate standards had never done this before on his own. •Internal Communication in all
8.5. Inadequate •(8.2 & 8.3) The Company SHE-Q auditor delegated the internal audit to a superintendent, respects
communication/implementation of policy/ who never had done this before, without giving him the required back-ground information •Risk Assessment as a natural element
procedure/practice (improper and insufficient delegation) of work preparation and planning
8.6. Conflicting •(8.3) The Chief Officer told the relatively inexperienced Deck Cadet to take care of tank •Adequate resources, especially in
cleaning operations (improper delegation)
policy/procedure/practice •(8.4) The work procedures issued by the Company were all written in complicated wording, staffing needs
8.7. Inadequate work/process hence not understood and not complied with eitherI •Training of managers and senior staff
planning/programming •(8.5 & 8.3) The boatswain told the relatively inexperienced OS to watch the mooring lines, in management techniques
8.8. Condone deviation from but never told him what to look for; when the breast line became too tight he only noticed •Competency management in a full
policy/procedure/practice this when it was too late. Management circle (including
8.9. Condone misuse of equipment/tool •(8.5 & 17.2) All the maintenance documentation was in German language and although the appraisal)
8.10. Condone improper/inappropriate drawings were clear enough, some written details escaped the attention of the engine room •Management of Change as far as non
behavior staff. technical issues are concerned
8.11. Inadequate management •(8.5) The shore-based organization directly sent the new regulations to the ships in order •A policy aiming at a high retention
information to implement the changes. This, however lead to differences in interpretations varying from rate
8.12. Inadequate monitoring/closure of ship to ship.•(8.6) People were told to work safely, not to take any risk and rather stop the
audit actions work than proceed, if not deemed safe. At the same time, there was a publication about
shortage of budget and the need to produce as much as possible.
•(8.5) Partly due to lack of experience with other nationalities, ship’s staff was not able to
This category is about the general organization of the communicate in an effective way with the new crew.
work. In this category the leading factors, i.e. planning, •(8.5/ 8.7) In the (bulk)terminal regulations it was stated that a vessel loading more than
preparation, instructions, procedures, policies and 14.000mt of cargo will be loaded at 10.000 mt/hr. The master was not informed about this
standards are relevant. In this important category,
communication between departments, i.e. between and, when the loading went much faster than planned, forced the terminal to stop loading
vessels, office, office departments, is playing an at this rate by closing hatches.
overwhelming role. •(8.6) Some oil-majors encourage companies to adopt a no-blame culture, but it happens
that, as soon as a serious near miss is reported, the company in question is black-listed.
•(8.7) Quite a lot of serious near-misses or even collisions happen every year due to the
undesired priority given to sticking to the passage plan and predefined way points in
situations where a flexible approach (observation, evaluation and action) concerning safe
navigation is required. In such situations the passage planning may become contra-
productive.
•(8.7 & 10.5) The commercial department had made an agreement with a charterer, which
was far too optimistic (in time and budget) and caused unacceptable time pressure for ship’s
crew
•(8.7) When the ship arrived in Antwerpen, the following extra activities were planned: crew
change, fuel and lub-oil bunkers, stores, a survey, several repairs, 2 vetting inspections and
an audit. To make things worse, there was also an unexpected port state control inspection.
•(8.7) As it appeared that the previous 2nd mate had made many mistakes in correcting the
charts, the present 2nd mate was told to verify this and correct the charts where needed.
This caused a lot of stress and made him correct charts during his watch on the bridge,
whilst the vessel was in confined waters.
 9. Inadequate Supervision/Coaching Examples Basic Causes Examples Areas of Improvement
9.1. Inadequate •(9.1) When a drill had been carried out, people went back to work without having a •Recruitment procedure to include
instruction/orientation/training de-briefing. Consequently, they did not learn from their mistakes. leadership and coaching capabilities
9.2. Inadequate information documents •(9.1 & 5.2 & 5.4) The fire drills were not carried out in a realistic way, consequently – •Assessments for promotion to
in supervision/coaching when a real fire started in the laundry- there was panic amongst the crew, which include coaching capabilities
9.3. Lack of supervisory/management job caused a delay in the response. •Development of personnel
knowledge •(9.3) A MSc graduate with a degree in Business Administration was appointed as assessment tools
9.4. Inadequate match between Fleet manager. Due to his lack of understanding of the business he was in, he did not •Development of an on-going
qualifications and job/task requirements manage to run the fleet effectively. evaluation system
9.5. Inadequate performance •(9.3) The new Chief Officer was a fine 2nd Officer, but his lack of leadership skills and
measurement and evaluation experience made him the wrong choice.
9.6. Inadequate performance feedback •(9.4) As there was nobody to supervise the inexperienced 3rd officer, when he was in
charge of cargo operations, he made several serious mistakes.
•(9.5) The Master complained about his incompetent officers, but it appeared that he
This category is also about the general organization of never monitored them, when they were on duty and consequently the appraisal was
the work, but here the lagging factors, i.e. feed back,
guidance, monitoring and evaluation are important. not based on facts, but on feelings.
Here also communication is paramount, but is more •(9.6) The Master was on the bridge when the 2nd officer made a course correction
focused on communication between people. without verifying that this could be done safely, but he did not tell him what was
wrong.
 10. Inadequate Management of Change Examples Basic Causes Examples Areas of Improvement
10.1. Inadequate hazard •(10.5 & 8.7) The commercial department had made an agreement with a charterer, •Training programme on management
identification/risk evaluation in design which was far too optimistic (in time and budget) and caused unacceptable time of change
10.2. Inadequate identification of failure pressure for ship’s crew •Company campaign on change
mode •(10.1) When the vessel became engaged in a new charter in Nigeria (where she never management
10.3. Inadequate evaluation of had been before), ship-board personnel encountered various security related •Focus in internal audits on
customer/stakeholder requirement problems, which were not foreseen by the Company. procedures which are related to the
10.4. Inadequate identification of legal •(10.2 & 8.7) Risk assessment was formally performed ashore and on board, but it was management of change process
requirement done in a very superficial way, in order to “get it over with”. Consequently, a few •Review of the policies, procedures
10.5. Inadequate consideration of important risk scenario’s had been overlooked. and instructions of the management
human/ergonomic factor in design •(10.2 & 8.7) The first time the vessel approached this port with its complicated of change process
10.6. Inadequate design process / approach (shallow water, strong tidal currents and narrow passage), she touched
standard / specification / criterion bottom, because of inadequate passage planning.
10.7. Inadequate process control •(10.1 & 8.7) Whilst replacing the turbo charger, a sling parted, because there had
automation been insufficient calculation of the immense forces exercised on the sling during the
10.8. Inadequate (technical) movement of the heavy load.
standard/specification or absence thereof
10.9. Inadequate review of project risks
10.10. Inadequate monitoring of
construction / fabrication / assembly
10.11. Inadequate assessment of
operational readiness
10.12. Inadequate
commissioning/handover process
10.13. Inadequate monitoring of initial
operation
10.14. Inadequate management of
change process

This category applies to all changes in the organization. It

can be applied to shipboard operations, ship
management activities, chartering activities, etc.
There is a distinct connection with leadership.
 11. Inadequate Supply Chain Examples Basic Causes Examples Areas of Improvement
Management
11.1. Inadequate specification on •(11.1) The Chief Engineer ordered “Fuel Injectors for Auxiliary Engines” , without •A policy of adequate technical
requisition/purchase order specifying for which of the auxiliary engines (from 2 different makers). As a result, the resources
11.2. Inadequate research on material / wrong spares arrived on board, causing delay. •Especially for critical equipment
equipment / tool / supply / etc •(11.2) Although “2 inch stainless steel pipes” were ordered, nobody verified the type •Critical Equipment is properly
11.3. Inadequate specification to vendor of stainless steel, which was required for the hazardous material. identified
11.4. Inadequate mode/route of •( 11.2 / 14.2 / 14.3 /15.2) Accidents, like crushing fingers, occurred frequently as •Adequate spares are kept
shipment result of the size and weight of studs to be placed in the holds in special steel pots, •Adequate and user-friendly PMS
11.5. Inadequate receiving especially when slight deformation of the steel pots (caused by the impact of swinging •Professionalizing of Purchasers
inspection/acceptance studs) made it even more difficult to insert and lock the studs in place. (knowledge of IMDG Code etc)
11.6. Inadequate communication of •(11.2) Safety Harnesses were delivered on board with a standard halyard. Simple •Subscription to special technical
information about hazards research would have lead to ordering a modern shock-absorbent type of safety literature
11.7. Improper handling of material harness. •Hiring reliable and professional
11.8. Improper storage of material •(11.3) The supplier did not receive clear specifications and assumed the standard Agency
11.9. Improper transporting of material boiler suits were ordered, but these were not suitable for welding and grinding jobs. •Supplier evaluation system
11.10. Inadequate shelf life/validation for •(11.4) Expensive equipment was requested and could have been send to Antwerp, •Working with only “approved
re-use of materials/equipment but the parcel was forwarded to Lagos, where customs formalities caused so much suppliers”
11.11. Inadequate identification of trouble, that the ship had to stay at the anchorage for one extra day. •Sufficient budget (overall Company
material •(11.5 / 11.8) About 40% of the stationary delivered on board appeared to be soaked Policy)
11.12. Improper salvage/waste disposal with oil, because it had been in the wrong storage area for some time and nobody
11.13. Inadequate selection of opened the boxes when delivered on board.
contractor/supplier •(11.6) New rust remover was send to the ship, but the safety material data sheets
were not delivered.
•(11.7) The electronic equipment was packed in a crate without any shock absorbing
This category again, is a process, which starts with the protective material, as a result it was partly damaged
specification of requisitions and ends with delivery of
materials on board. In addition, a few topics, like •(11.9) The critical equipment was send to the ship via ordinary mail in stead of air-
contractor selection are included. Failure in purchasing freight, as a result it arrived too late.
may be caused by other basic causes, like “Lack of •(11.9 / 11.11) A major chemical manufacturer who loaded drums of acids and alkalis
Knowledge” (does not know how specify requisitions) or
Inadequate Policies (policy to try and purchase the into the same container, a practice specifically prohibited by all the dangerous goods
cheapest spares, even in case of critical equipment). regulations. This was discovered when the container was inspected. When questioned,
the manufacturer shrugged his shoulders and commented: "Why not? It was all Class
3, wasn't it?" The container had been stopped because liquid was leaking from it. This
was found to come from a jar of sulphuric acid which had been stowed upside down.
•(11.9 / 11.4) The purchasing department purchased new hand flares for the vessel
and tried to send this by air-freight.
•(11.12) One of the factors contributing to the improper waste disposal (dumping
overboard) incident appeared to be that there was no facility for waste reception in
any port in this area.
•(11.13) When PSC inspected the vessel and found that most of the fire extinguishers
were useless, the Master told him that in the previous port all the extinguishers had
been “serviced’ by an unknown service station, selected by the Company.
 12. Inadequate Maintenance/Inspection Examples Basic Causes Examples Areas of Improvement
12.1. Inadequate assessment of Inadequate Preventive Maintenance: •A planned maintenance system
preventive maintenance needs •(12.1) In the PMS it was not foreseen that the pump seals had to be renewed every 3 according to ISM 10 principles (risk
12.2. Inadequate preventive lubrication months, consequently insufficient spares were kept. based)
and servicing •(12.2) Due to insufficient lubrication, the fairlead rollers were seized, creating a lot of •Adequate (basic and update-)
12.3. Inadequate adjustment/assembly chafing damage to the mooring lines training and education of personnel,
12.4. Inadequate preventive •(12.2) The ship was a rust-bucket, she had not been chipped and painted for several including specialized technical skills
cleaning/resurfacing years. •A HRM policy aiming at a high
12.5. Inadequate communication of •(12.3) Due to improper adjustment after pulling of pistons there was insufficient retention rate and thus contributing to
corrective maintenance needs piston ring clearance “ownership” of ship’s personnel
12.6. Inadequate scheduling of •(12.4) The deck paint came off shortly after re-painting. Deck maintenance had been •Adequate resources in terms of
maintenance work done during a recent North-Atlantic transit. budget, man power, material and
12.7. Inadequate assessment of repair professional shore-based support
needs Inadequate Break-down Maintenance: •Regular inspections by shore-based
12.8. Inadequate parts •(12.5) The crane broke down and spares were ordered by Chief Engineer, but he line managers
substitution/replacement forgot to inform the Company about the required repair time, considering the weather •Transparent work instructions for
12.9. Inadequate inspection conditions (sheltered waters, not existing in the area). Consequently the expectations maintenance
method/interval about the time needed were too optimistic, causing unnecessary business pressure on •A genuine spares policy
12.10. Unable to inspect the ship’s staff. •Standardization of equipment and
•(12.6) The Superintendent arranged a dry dock for a large number of repairs and machinery in the fleet
modifications, but the scheduling was far too optimistic, leading to insufficient •Identification (and standardization)
Split into preventive maintenance, which can be planned verification of the work done. In a later stage this contributed to serious machinery of man-hours required for
and break-down maintenance which cannot be planned
in advance, this category deals with maintenance from an failure. maintenance jobs in accordance with
organization point of view and not as a result of •(12.7) After a serious near miss, due to a black out, which occurred when the ship maker’s instructions and/or own
insufficient maintenance (like: “the ship was poorly had been close to a lee shore during a strong gale, the technician did only reset a few analysis
maintained”, which may be caused by almost all other
categories of basic causes). Although there is a strong instruments, without investigating what caused the malfunction of the sensors. •Staffing based on this analysis
connection between this category and the Company’s l •(12.8) It was a habit on the vessel to retain the rejected spare parts in stock, inspired •An open and constructive two way
Planned Maintenance System, also other basic causes are by a false sense of economy. When a pump broke down, these “spares” were used, communication between ship and
usually playing a contributing role (like: “lack of
resources” may lead to “inadequate substitution of causing serious damage after a few weeks. shore
parts” 11.2.4). In our view, there is no need for too much •(12.9) The exhaust valves of one aux. engine started leaking after overhaul was
detail as far as “inadequate preventive maintenance” is replaced by endoscopic inspection
concerned; this sub-category consists of 2 steps:
assessment of needs and performance of the work itself, •(12.10) The exhaust valves of one aux. engine started leaking because it could not be
the latter always being the result of other basic factors. stopped for inspection or overhaul due to the second aux. engine being out of order
for several months.
 13. Excessive Wear/Tear Examples Basic Causes Examples Areas of Improvement
13.1. Inadequate planning of use •(13.1) It was decided to test the free-fall lifeboat with a number of crew on board, •Development of a condition based
13.2. Improper decision on extension of strapped in their seats, when the ship was at anchor and the weather conditions were monitoring system
service life unfavourable (strong wind, high waves and a strong tidal current). As a result the boat •Recruitment and selection
13.3. Inadequate inspection/monitoring was damaged and also the crane, whilst recovering the lifeboat. procedures to be reviewed
13.4. Improper loading/rate of use •(13.2) Although the PMS indicated that the engine had to be overhauled after x •Update maintenance documentation
13.5. Used for wrong running hours, the overhaul was done with 5000 hours over the limit and instructions
purpose/task/activity •(13.2) The mooring lines were in a poor state but –in order to save money- the •Enhance inspections and
Master ordered to cut the worst parts out and to add several new splices to the maintenance
already existing ones. •Increase/decrease inspection
This important category is about “use”, not about design •(13.3) In dry-dock it appeared that the condition of the ballast tanks was poor; the intervals
or original product quality (which can be categorized
under 9-engineering, 10-purchasing or 12-tools and coating had practically disappeared and serious pitting corrosion was found; the
equipment). Equipment for instance, may break apart in inspections had never been carried out by staff
an early stage, because of poor quality of material or •(13.3) The lifeboat was stowed on davits without resting on chocks. As a result, the
design. It may also fail due to improper use or lack of
inspection or maintenance, which should be categorized lifeboat hook assemblies and the fixing plates were always subject to heavy and
here fluctuated stress, particularly in rough seaways. The combination of the direct and
fatigue stresses would have additional loading on the aft hook assembly and the fixing
plates. During a drill the hook assembly broke free from the GRP keel, causing loss of
life of several crew members
•(13.4) The engine room gantry crane was approved for 10 tons, but regularly
overloaded. As a result, the bearings were found worn out.
•(13.4) Due to maintaining maximum revs when the vessel crossed the Bay of Biscay
during a gale with a high swell, the hatch covers got cracked.
•(13.5) A heavy piece of machinery had to be moved on deck but there was no crane
available. One of the engineers than took 2 empty Acetylene cylinders and used these
as rollers under the load. He managed to relocate the machinery part, but did not
notice, that the acetylene cylinders had been (almost invisibly) cracked, which caused
one of these to rupture, when being refilled ashore.
 14. Inadequate Examples Basic Causes Examples Areas of Improvement
Tool/Equipment/Machinery/Device
14.1. Inadequate assessment of needs •(14.1) In order to enable the OOW to read the draught aft upon arrival at the •Critical equipment and parts
and risks anchorage, a rope ladder was in use in stead of a more-stable type of ladder, which identified and standards set
14.2. Inadequate consideration of human caused him to loose grip on the ladder •Strict specifications for equipment
factors/ergonomics •(14.1) A service engineer, whilst disembarking the vessel lost grip on the pilot ladder and tools
14.3. Inadequate (supplier) and fell in the water; he did not wear a coat with reflecting tape and any buoyancy aid. •Adequate budget for equipment and
standard/specification The organization had not considered this outfit to be necessary. tools
14.4. Incorrect •(14.1 / 14.2) Although the ship was slightly undermanned and in need of de-scaling •Training and instruction for users
measurement/detection/(process) control and painting the Superintendent did not provide the Master with a small sandblasting •Work instructions for more
14.5. Inadequate availability of tool / compressor, as requested by him. complicated or critical equipment
equipment / machinery / device •(14.2 / 14.3 / 11.2 / 15.2) Accidents, like crushing fingers, occurred frequently as •Involvement of ship-board personnel
14.6. Inadequate result of the size and weight of studs to be placed in the holds in special steel pots, when choices are made
inspection/repair/maintenance especially when slight deformation of the steel pots (caused by the impact of swinging •Feed-back from ship about adequacy
14.7. Inadequate adjustment/calibration studs) made it even more difficult to insert and lock the studs in place. of new equipment and tools
14.8. Inadequate salvage and •(14.2) Due to the absence of lifting appliances, the crew had to move equipment up •A system for “automatic”
reclamation to 100 kgs in and out the workshop manually. replenishing of stocks (stickers, labels,
14.9. Inadequate removal and •(14.3 / 16.3) Chemicals for cleaning and removing rust was provided without the barcode etc)
replacement of unsuitable items required MSDS •Hiring approved service suppliers
•(14.3 / 16.1) Due to absence of an instruction manual, the equipment was operated only
in an erroneous way, leading to some damage
This category is specific for tools and equipment and has •(14.4) The personal gas-meter of the bosun went off because the hold access had
some overlap with other categories i.e. 11: Supply Chain
Management, 12: Maintenance/Inspection and 15: only been measured at the entrance and not all various levels.
Product Design. •(14.5) Due to non availability of professional spanners, a set of domestic spanners
were purchased on the local market. As a result one of the spanners did not fit
correctly causing it to slip when some force was applied on it.
•(14.6) The powder extinguishers were refilled after a drill, but as this was done
improperly, the extinguisher failed when it was needed to attack a fire.
•(14.7) The personal gas-meters of the deck officer and pumpman went of in the tank,
because the gas-meters had been calibrated with the wrong span-gas.
•(14.8) After discharging it appeared that all the dunnage material, which was needed
for the next loading port had disappeared
•(14.8) Tools which had been used for the repairs in dry-dock were not timely
collected by ship’s staff and disappeared.
•(14.9) Since there had been no time to stop the main engine the leaking flange on the
booster pump had been repaired with a makeshift “bandage”.
 15. Inadequate Product/Service Design Examples Basic Causes Examples Areas of Improvement
15.1. Inadequate assessment of needs •(15.1) In the galley the fire alarm button was located in the corridor. The shutdown •Inspections/ verification by
and risks switches for the galley fans were at the far end of the galley and the CO2 release Superintendent
15.2. Inadequate product/service mechanism at another end. This resulted in having to pass the stove (the likely source
standard/specification/concession system of a fire) three times in order to make alarm and combat a fire.
15.3. Inadequate product/service design/ •(15.2 / 14.2 / 14.3 / 11.2) Accidents, like crushing fingers, occurred frequently as
development result of the size and weight of studs to be placed in the holds in special steel pots,
15.4. Inadequate product/service especially when slight deformation of the steel pots (caused by the impact of swinging
standard studs) made it even more difficult to insert and lock the studs in place.
15.5. Inadequate product/service design •(15.3 / 15.4) When introducing their dry cargo vessel in their fleet, the tanker
validation company had not amended the ship board procedures for this different type of vessel
15.6. Inadequate product/service design which has different compliance and inspection requirements.
verification •(15.5) The voyage plans were set up by the 2/Officer, but the Master did not check
15.7. Inadequate product/service them for any errors and omissions.
planning •(15.6) The SOPEP was developed by the shore captain, but it had not been send for
15.8. Inadequate product/service quality approval to the Administration.
verification •(15.7) The Charter party required the vessel to be delivered very shortly after the
previous re-delivery, which caused significant additional workload on the deck officers
and crew because the cargo holds needed to be cleaned in a very short time.
There is an obvious overlap with 14 Inadequate Tools, •(15.8) Delay in maintenance was caused by incorrect parts which had not been
Equipment etc. This category is related to the design
phase, whereas 14. is related to the execution part of it. checked when they were supplied to the vessel.
•(15.8) A formal complaint from the Charterer was received. Evaluation talks with the
Charterer had not been held and remarks and their (informal) comments regarding
the vessels had not been identified as serious.
 16. Inadequate Work/Production Examples Basic Causes Examples Areas of Improvement
Standards
16.1. Inadequate identification of •(16.1) On board the tanker vessel the Master and Chief Engineer were recently •Active involvement of ship-board
requirements (regulatory/industry promoted, subsequently the vessel was rejected by several oil majors for not staff when developing/ reviewing
code/permit-to-operate) complying with their Experience Matrix. work standards
16.2. Inadequate risk •(16.1) Changes in Rules and Regulations did not lead to updating the relevant •Applying the sound Keep it Simple
identification/evaluation in development procedures and instructions Policy
of standard •(16.1) No clear instructions could be found concerning the Master’s Review, it was •Obtain constructive feed-back from
16.3. Inadequate standard from supplier/ only stated that the master should carry out a review the Master in his Master’s Review
contractor •(16.1) The vessel was detained because specific flag requirements regarding •Respond upon feed-back from the
16.4. Inadequate coordination with reporting had not been complied with. The company operated all vessels with the vessel
process design when developing standard same flag, except this only vessel. •Ship visits (and even sailing with the
16.5. Inadequate employee involvement •(16.2) No procedures were available for identification and evaluation of operational ship during a short voyage) for those
in developing standard risk shore-based staff involved in
16.6. Conflicting standards/improper •(16.3) The service engineer burned himself, because he did not wear fire proof development of standards
prioritization of standards overalls •Briefing and de-briefing of senior-
16.7. Inadequate publication of standard •(16.4) The Shore based Organization developed so many new instructions, that for staff in the office
16.8. Inadequate distribution of standard ship-board staff it was impossible to keep track of it •Periodical meetings with Captain’s
16.9. Inadequate translation of •(16.5) Despite the remarks and comments of the impractical checklists, the company and other senior officers
appropriate language had continued to produce checklists for nearly all shipboard activities which were not •Translation (English language + work
16.10. Improper use of language specific for the vessel. language o/b) of relevant instructions
16.11. Inadequate training of standard •(16.6) The procedure for entering a tank mentioned that the Oxygen level must be if needed
16.12. Inadequate reinforcing of 20.9%. However, the permit to work for entering into enclosed space required the •Courses to improve English language
standard with signs, colour codes and job oxygen level to be higher than 19.7% (the alarm setting for low oxygen) skills if needed
aids •(16.7) It was found that the documented system on board comprised 12 big volumes, •Adequate system for tracking
16.13. Inadequate monitoring of practically discouraging ship’s staff to make themselves familiar with the contents changes in Legislation, updating
standard compliance •(16.8) New procedures had been issued, but were not discussed during the Captain’s relevant documentation and
meetings communicating the changes in
•(16.9) The german maintenance manual for the main engine had been translated in practical terms to responsible
Managing Risk, basically requires 3 steps: Identify a Google for the Russian engineers. personnel
Program to manage risk, establish Standards and ensure
Compliance of the standards (includes: implementation, •(16.10) The Shipboard Safety Management manual was written in inaccessible •Internal audits carried out by well
monitoring, verification and review). “Standards” include “juridical” English and the ship’s crew was all from the Ukraine. trained personnel, independent from
concrete Policies, Procedures and Instructions, which are •(16.11) During an Internal Audit it was found that many procedures were unknown. areas being audited
usually laid down in a written form (manuals, on-line etc).
Most of the Control Action Needs (System) may be found The all new crew had been assigned to the vessel only weeks prior to the audit and •Root cause analysis also performed
as standards. This category therefore is not dealing with not had any formal familiarization or training in the management system by internal auditor in case of findings
the contents/quality/ effectiveness/efficiency of the •(16.12 / 16.13) Although for practically everything a checklist had been developed •Inspections and verification tools
Standards as such, because in such a case we are dealing
with the System itself (Root causes), but about evidence and all checklists were ticked off religiously, the vast majority of ship-board personnel (e.g. on tankers: use SIRE checklist for
of absence of developed standards and inadequate did not even look in them periodical self-assessment on board)
communication, maintenance and monitoring of the •(16.13) Due to the fact that Internal audits never lead to any identification of the real •Development of verification methods
existing standards. For example: if there is a standard for
training personnel (system) and there is evidence that (basic) causes of non-compliance and only measures were taken at symptom level, the for technical maintenance
the Root Cause is this Standard itself being inadequate (if ship was rejected by the oil majors after each vetting
-for instance- we frequently identify “lack of skills” being •(16.13) The Chief Engineer never verified why maintenance jobs, which according to
a Basic cause), it may lead to modifications in the
Standard itself (Control Action Need: improve the maker’s manual required 8 man-hours, were carried out in 30 minutes.
Training Standard). It may however also be the result of
another Basic Cause, like Inadequate communication of
the Standard (people are not adequately informed about
the existence of the training policy of the company).
 17. Inadequate Examples Basic Causes Examples Areas of Improvement
Communication/Information
17.1. Inadequate information handling •(17.1) The new requirements from IMO were not forwarded to the vessels in time, Communication is an intrinsic personal
17.2. Unclear information resulting in deficiencies and detentions characteristic which is difficult to
17.3. Inadequate transfer of information •(17.2) As a rule the IMO Resolutions were forwarded to the vessels without any change. Intensive training in any form
between internal parties comment is necessary, together with giving the
17.4. Inadequate transfer of information •(17.2) On deck the Bosun indicated that the special tools could be found in the good example.
with client/stakeholder forecastle Furthermore, effective communication
17.5. Inadequate transfer of information •(17.3) The minutes of meeting of the weekly meeting of department heads were tools are paramount. Complicated
with authorities incomplete and not sent to all departments reporting procedures do not help with
17.6. Inadequate transfer of information •(17.4) The ship/shore checklist was not fully completed and not signed by the loading effective communication.
with other external parties master
17.7. Inadequate communication •(17.4) The bunker checklist was not filled in with a representative of the bunker
structure barge
17.8. Inadequate databases/information •(17.5) For arrival in the new port the prescribed format was not used, resulting in the
system omission of specific data requested by that port
17.9. Inadequate communication •(17.5) The recent damage to the ship’s hull was not reported to Class
method/technique used •(17.6) The agent could not tell the Master when the truck with provisions would
arrive. As a result the crew had to violate the rest hour requirements when the truck
arrived during the evening
In many incidents some form of communication failure •(17.7) On board internet connection was restricted to the GSM signal from ashore.
plays a role. For most of these categories there is some
overlap with other causes. It is important to realize that During northern North Sea passages voyage instructions could not be received
this category should be used only for the specific through e-mail and office staff was not always aware of the limited internet
communication issue. connection
•(17.8) The computers on board were running on outdated OS versions, which
resulted in slow working of the PMS and subsequently maintenance was not not
always up to date
•(17.9) With the bunker barge it was agreed that shouting and signalling would be the
way to communicate between the crew and skipper. This resulted in a very slow
response when a flange started leaking.