Risk Awareness: Cargo Claims - Ship's Equipment

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Athos 1 – An Insider’s Perspective

The United States Supreme Court granted the application of industry groups, BIMCO, Intertanko and Intercargo to file an Amicus Curiae brief in the recently decided case Citgo Asphalt Refining Co. v. Frescati Shipping Co., Ltd., (Athos l). 

Amicus briefs are prepared by non-parties to the dispute in order to set out argument and legal authority relevant to the case under review. The lawyers representing BIMCO, Intertanko and Intercargo, Chris Nolan and Robert Denig of Holland and Knight LLC, share their advice to those negotiating charter parties subject to U.S. law when considering safe port and berth clauses.

In this time of pandemic, the authors also consider the Supreme Court’s decision in the context of a Master’s implicit right to refuse a charterer’s order to enter a port the Master considers unsafe.    

The Decision

In Citgo Asphalt Refining Co. v. Frescati Shipping Co., Ltd., (Athos l) the U.S. Supreme Court has provided a roadmap for interpreting safe berth/safe port clauses under U.S. law, ruling that the form clause commonly used in the industry must be construed as an express warranty of safety and imposes on the charterer an absolute duty to select and provide safe berth.

In a 7-2 opinion, the Supreme Court considered the key terms in the agreement consistent with the intent of the parties as is necessary in any contract dispute. Because the safe berth clause was clear and unambiguous, the majority found that the analysis began and ended with a plain meaning reading of the key terms in the clause itself.

Negotiating a charter party is a balance of leverage and sometimes a leap of faith. Certain issues are more important to companies than others, and for those issues, the language of clauses will be negotiated over email drafts for hours, days or weeks depending on its import and often insurance concerns. For the remainder of the clauses, they are often standard, with form language added, subtracted or amended over time based on industry clauses, personal preferences or the whims of previous counsel from a bygone era. The US Supreme Court, in a March 30, 2020, opinion in Citgo Asphalt Refining Co. v. Frescati Shipping Co., Ltd., provided a roadmap for interpreting one of the most prevalent and important of these charter party clauses, the safe berth/safe port clause, ruling that the form clause commonly used in the industry must be construed as an express warranty of safety and imposes on the charterer an absolute duty to select a safe berth.

Industry significance

The dispute arose from a 2004 oil spill in the Delaware River involving the M/T Athos I. After a 1,900-mile voyage from Venezuela, the Athos I struck a submerged 9-ton abandoned anchor only 900 feet from its intended berth, puncturing the hull of vessel and causing 264,000 gallons of heavy crude oil to spill into the river. The ship owning interest of the Athos I was designated the "responsible party" for the spill, pursuant to the Oil Pollution Act of 1990, and initially bore the costs of the environmental cleanup, for which the costs topped USD 100 million.

Following the environmental response, the shipowner and federal government sought to recoup money expended for cleanup costs from the vessel's voyage charterer. The safe berth clause at issue was dissected by district court judges and the US Court of Appeals for the Third Circuit over the course of a handful of trials and appeals of notable length and cost. Yet the most important legal issue concerned the interpretation of the standard industry Asbatankvoy safe berth clause slightly revised in the charter as follows:

Safe Berthing-Shifting: The vessel shall load and discharge at any safe place or wharf, or alongside vessels or lighters reachable on her arrival, which shall be designated and procured by the Charterer, provided the Vessel can proceed thereto, lie at, and depart therefrom always safely afloat, any lighterage being at the expense, risk and peril of the Charterer.

 Significantly, the Supreme Court decision turned on the plain-meaning interpretation of two words in the popular clause: "safe" and "always."

Interpreting your safe-berth clauses

In a 7-2 opinion authored by Justice Sonia Sotomayor, the Supreme Court considered the key terms in the agreement consistent with the intent of the parties as is required in any contract dispute. Because the safe berth clause was clear and unambiguous, the majority concluded that the analysis began and ended with a plain-meaning reading of key terms in the clause itself. After 15 years of court submissions and appeals, how could the language of the clause be so clear to the majority?  Below are three considerations that every Gard Member should be mindful of when reviewing their charters to determine how they are impacted:

1.Consult your dictionary: The safe berth clause required the charterer to designate a "safe place" for the vessel to traverse so long as it could continue to the selected port "always safely afloat." The use of the word "safe" must have connoted the designation of a safe berth "free from harm or risk" per the simple definition in a Webster's dictionary. Additionally, a vessel's travel "always" in a manner that is "safely afloat" must mean in every instance; all of the time. These simple concepts, when read together, must "bind the charterer to a warranty of safety."

2.Look for limiting clause language: The interpretation of a safe berth clause friendlier to charterer interests would not have absolute warranty-type language. The majority opinion surveyed several key clauses in the charter party where the parties affirmatively included language requiring the exercising of "due diligence" and found several. This inclusion of the concept of tort-based fault in a contractual setting with other clauses reaffirmed the warranty nature of the safe berth clause because it did not include this liability-limiting qualified language.

3.Assess other industry forms: Although not dispositive, it did not aid the charterer's position that other industry forms not chosen by the parties provided a roadmap for properly limiting an absolute warranty of safely. In a footnote, the Court quoted the Intertankvoy form safe berth clause which includes "safe" port and "always" afloat language though qualified with a charterer being required to only exercise "due diligence" in selecting the berth.

The big picture when fixing your next charter party

In sum, the contract interpretation, guided by decades of Second Circuit (New York) and the United States Society of Maritime Arbitrators arbitral award holdings that the safe berth clause expressed an absolute warranty of safety, resulted in the Supreme Court ruling in favor of the shipowner. The Court's decision carries an impact broader than just the interpretation of the Asbatankvoy safe-berth clause. While the dissenting opinion noted the majority ruling "provides a clear background rule for the maritime industry to contract against," the majority ruling added important context for charterers when confirming that "[c]harterers remain free to contract around unqualified language that would other[wise] establish a warranty of safety, by expressly limiting the extent of their obligations or liability."

In every pending dispute involving an incident arising out of the interpretation of the safe berth clause, the Supreme Court has provided clear guideposts for companies and their counsel. When drafting and negotiating future agreements, traders, brokers and their lawyers should reflect on the few simple steps to provide more certainty concerning the obligations being undertaken. Carefully including the term "warranty" or "due diligence" around the use of "safe" berth and "always" afloat will be useful, initial steps to help avoid a two-decade legal saga. Further contractual nuance will be addressed with the particularities of the shipping company's business in mind.

Covid-19 implications?

The shipping industry is adapting to the Covid-19 crisis impacting the globe.  Interestingly, an advisory paragraph in the Supreme Court’s decision is informative for any owner and charterer facing concerning when entering port.  The Court reminded the parties that vessel masters have an "implicit" right to refuse entry to a port should they find it unsafe and that refusal requires charterers to pay the associated costs.  The refusal, though, has to be a "justifiable refusal.' This is a high bar, but one we may very well face in US ports with hotspot Covid-19 ratios let alone in ports worldwide.  While it is less likely an entire port will be deemed unsafe today, given the safety precautions being taken to keep people healthy and cargoes flowing, conditions continue to evolve.  If a master refused to enter port due to coronavirus conditions, he or she would have to keep a careful evidentiary record of conditions on the ground as guided by shoreside operations, Gard and their able legal experts.

Laytime and Free Pratique (The Standard P+I Club)

Laytime commences once a valid NOR is tendered. This article discusses how the requirement for free pratique can affect the validity of an NOR, looking at relevant cases to provide guidance.

Commencement of laytime

Owners will always seek to start laytime running from the moment they present their ship to charterers at the agreed port or berth so as to avoid responsibility for delays that are beyond their control.

In order for laytime to start, owners must tender a valid Notice of Readiness (NOR). The purpose of an NOR is to inform the charterer that loading or discharge operations are ready to commence and to provide a tangible starting point for laytime.

In order to be valid, the NOR must be tendered when the vessel is in all respects actually ready to load/discharge.

This will depend on a number of factors, including whether the ship has complied with all the port health and documentary requirements.

The effect of free pratique

One such factor is whether the vessel has been granted her free pratique. Free pratique is essentially the licence given to a ship to enter a port on the assurance that she is free from contagious diseases.

The granting of free pratique is seen as something of a mere formality and, at common law, will not prevent a valid NOR from being tendered, as noted by Longmore L.J. in The Eagle Valencia1. However, in reality, although this may seem like an outdated concept, the free pratique still forms an important part of the ship’s papers and can cause problems for owners if it is not obtained.

In fact, the common law position is often superseded by express agreements between owners and charterers. For instance, clause 6.3 of the BPVOY4 form charterparty states that: ‘Notwithstanding tender of a valid NOR… such NOR will not be valid unless the following conditions have been met… 6.3.3 If free pratique is not granted within six (6) hours of the Master tendering NOR…the Master shall issue a protest in writing…to the port authority and the facility at the port (“Terminal”)…’

And clause 7.3.2 states: ‘Laytime or, if the Vessel is on demurrage, demurrage shall commence…upon the expiry of six (6) hours after a valid NOR has become effective as determined under Clause 6…’

Therefore, on the assumption that free pratique is a requirement of a particular port, owners must ensure that it is granted within six hours of tendering an NOR in order for it to be valid and for laytime to commence.

Situations where free pratique is not granted

If free pratique is not granted in this period, owners can protect themselves from being penalized under clause 6 by issuing the appropriate Notice of Protest.

This is without question and was confirmed in the Bow Cedar2, where it was held, obiter, that an NOR becomes effective on the master issuing a protest. However, on the assumption that the appropriate protest has been registered, the key question is: when will laytime now start to run?

Clause 6.3.3 states that if free pratique is not granted and the master does not serve a Notice of Protest, laytime will not run until free pratique is in fact granted.

Failing that, it will start when loading/discharge operations commence. However, it does not say what is to happen if free pratique is not granted but the master does serve a Notice of Protest.

Conclusion

There is no express authority on this point, but on the balance of probabilities, it is likely that laytime will start to run from the service of the Notice of Protest. This should therefore incentivise the master to serve his protest promptly after the six-hour time frame. Of course, if there is ever any doubt over the validity of an NOR, the master should be instructed to tender additional NORs at frequent intervals on a without prejudice basis in order to protect their position.

Tendering a valid Notice of Readiness (The Standard P+I Club)

It is a well-established principle of English law that laytime under a voyage charterparty will only commence once a valid Notice of Readiness (NOR) has been tendered. While the ship’s physical location at the time of tendering the NOR is an important consideration, so is the method by which the NOR is tendered.

Introduction

The commercial reality of today is that communication between the ship and its charterer is commonly done using email, rather than by earlier methods of communication such as fax and emails. However, a number of standard form charters which predate email are still widely used.

As a result, some charterparties do not mention email at all. This was the situation faced by the owner in The Port Russel1 English High Court decision.

The Port Russel Case

The Port Russel was chartered on an amended BPVOY3 form to carry a cargo of clean petroleum products.

Clause 19 of the charterparty, relating to the tendering of a valid NOR, was unamended and provided that the NOR was to be tendered either by ‘letter, facsimile, transmission, telegram, telex, radio or telephone’.

In this case, the NOR was tendered by email. The question before the English court was whether email was a contractually permissible method of serving the NOR under the charter.

The judge hearing the case concluded that email was not a permissible method to serve the NOR under this charter. In the judge’s view, the only contractual methods under which a NOR could be tendered were the methods specified in clause 19 itself. This list was exhaustive and there was little point, in the judge’s view, to specify a list of valid methods for tendering a NOR if any method was permissible.

The club’s recommendation

The decision in The Port Russel ought to be taken into account whenever fixing a ship under a voyage charterparty. An owner does not want to inadvertently tender their NOR using a method not specified/permitted in the charter, because it may have drastic consequences for their subsequent entitlement to claim demurrage.

A review of some of the more common voyage charterparties used in the liquid cargo trade reveal that some charters allow for the NOR to be tendered by email, while others do not.

If the charterparty under negotiation does not provide for the tendering of NOR using email  then, assuming email is the normal method used by the ship, it is suggested that the relevant clause relating to the tendering of NOR be amended. This can be done either in the fixture recap, or by means of an additional clause to the charterparty.

Such a clause could be a replica of clause 10 of BPVOY5 form, which provides:

‘NOR may be tendered either by email, radio or telephone, (but if NOR is tendered by radio or telephone it shall be confirmed promptly by email).’

Cargo contamination on tankers (The Standard P+I Club)

There has been an increase in the number of claims brought against ships for cargo contamination by water and other products. This article looks at ways to mitigate the loss for the owner/member when faced with a cargo contamination claim.

Introduction

When cargo is found to be contaminated, the origin of the contamination could be the shore

tank at the load port, the shore pipeline during loading or the ship itself. But if the cargo on board is found to be ‘off spec’ on arrival at the discharge port, the ship is held liable as the carrier, regardless of fault, and will be faced with a claim.

Mitigation of loss

A fundamental principle in both continental and Anglo-American legal systems is that the claimant – usually the cargo receiver – is bound to mitigate his loss. However, judges/arbitrators often rule favourably for the claimant even if they have not managed to mitigate the loss, so long as the decisions taken at the time appeared to be reasonable and sensible, which leads to the defendant being faced with a claim for the entire cargo at sale value. It is therefore in the interest of the member and the club to play an active role in mitigation discussions, either to ensure that mitigation of the loss does take place to reduce the claim amount or to build evidence that mitigation was not attempted.

Where to store the cargo?

Since keeping the vessel ‘on the move’ is always the first priority for the shipowner, the first decision to be made when facing a cargo contamination claim is usually where to store the cargo while waiting for the laboratory results and considering next steps.

There are a few options to consider for transferring the contaminated cargo.

1.Vessel’s slop tanks: This is an economical option subject to slop tanks’ availability, given that no external storage costs are incurred, and this offers the flexibility of taking the cargo to ports with appropriate reconditioning facilities. However, the cargo receiver should not be given the impression that he has thereby successfully refused to take delivery of the cargo. Also, the vessel should take utmost care to ensure that the nominated cargo tanks and associated lines are thoroughly cleaned before and after the transfer in order to prevent any increased contamination.

Due consideration should also be given to ensure that the contaminated parcel is properly isolated from the remainder of the on-specification product. In the event of a flashpoint contamination, this will include isolating the inert gas system serving the slop/nominated tanks containing the low flashpoint cargo.

2.Another vessel/barge: This option releases the vessel from keeping the contaminated cargo on board, but involves an additional potential source of contamination.

3.Shore tanks: Empty shore tanks are usually available in larger ports. However, if the cargo cannot be reconditioned in the vicinity of that port, the problem is just postponed, and not resolved.

Further, considerable storage costs may be incurred if the cargo is left in the shore tank for a long period. In cases where the vessel has several ports of call on the voyage, it might be sensible to assess whether any of the other ports provide more suitable storage/restoring facilities and make arrangements to discharge the cargo there.

4.What are the mitigation options available: The options for minimising the loss will depend on the nature of the cargo, the type and extent of contamination, the market for the product and the facilities available in the area. There are some options to consider for restoring the cargo, with the assistance of suitable cargo experts.

5.Distress/salvage sale: One solution is to sell the contaminated cargo ‘as is’. The contaminated product may, for instance, still pass as an ‘industrial grade’ product and the

difference in sound/salvage values may not necessarily be significant.

Therefore, simply selling the cargo in the contaminated state can be a quick and reasonable solution, provided there is a salvage market available.

6.Blending with sound product: Another solution could be to blend the contaminated cargo with sufficient sound product to essentially dilute the contaminants to insignificance. This option depends on the availability of sound blend stock either in another of the vessel’s tanks or in shore tanks. Due care should be taken to avoid an increase in contamination as a result of the blending operations.

Suitable experts should be consulted beforehand and throughout the process. If blending is carried out on board the ship itself then it should be done in compliance with SOLAS regulation VI/5-2 (see previous article). However, past experience has shown that

on-board blending operations are not very effective as the usual tank architecture and pipeline configuration may not allow for efficient and intimate blending of the cargo.

7.Distillation: If there are substantial quantities of contaminated cargo and blending is therefore not a realistic option, reconditioning by distillation (performed by various operators within the petroleum refining/petrochemical industry) could be an efficient way to resolve the problem.

Any mixture of two components with different boiling points can in principle be separated by distillation, thereby removing the contaminant(s) from the sound cargo. Distillation does, however, come at a price. Apart from the energy cost, 1% – 2% of the product is usually lost in the process due to evaporation. Bearing in mind that the minimum quantity of product accepted by the reprocessing plants is typically around 500mt, distillation is only economically attractive when larger quantities are involved.

8.Filtering: If the contaminant consists of solid particles (non-homogenous components), or if the contamination is minor or a matter of colour and/or odour, reprocessing/filtering may be another option available. Rather than separating the two components, as would be the case when distilling, this technique removes the contaminant(s) by running the contaminated product through a mechanical or chemical filtering unit. Due to the relatively small and mobile filtering units available, the reprocessing can even take place

on board.

The relevant reconditioning costs are also significantly lower than the distillation costs. However, there is a limited number of contaminants that can be successfully removed using this technique and also a limited quantity of contaminated cargo that can be effectively filtered within a reasonable amount of time.

Also, about 0.5% of the product is expected to be lost in the process (not including the contaminant(s).

Conclusion

Salving contaminated cargo is not achieved without effort and cost, but the above are options worth considering and the most appropriate for the particular case should be adopted. Both the member and the club will benefit from actively ensuring that the cargo interests take steps to mitigate their loss, as well as putting forward to the cargo interests

some proper mitigation options to reduce the level of the claim.

Blending versus commingling (The Standard P+I Club)

On 1 January 2014, an amendment to SOLAS Chapter VI on the Carriage of Cargoes and Oil Fuels came into force, prohibiting the blending of bulk liquid cargoes and production processes on board ships during the sea voyage. As SOLAS does not define the meaning of ‘sea voyage’, this ambiguity has led to a number of questions from members about these amendments to Chapter VI and regarding blending/commingling generally.

Definitions

Blending is defined by SOLAS as follows:

‘Physical blending refers to the process whereby the ship’s cargo pumps and pipelines are used to internally circulate two or more different cargoes with the intent to achieve a cargo with a new product designation.’

Commingling on the other hand means the operation of loading in the same cargo space on board a ship parcels of the same product/bulk cargo (usually liquid) with the same specification from different sources such as different shippers or ports, but without taking any other steps in relation to the product/bulk cargo other than to carry and discharge and deliver it.

Loading of the same product with the same specification from different shore tanks, barges or trucks, etc. from the same port or the same single terminal does not constitute commingling (or blending).

The ‘same product’ does not mean identical products as it is appreciated that chemical composition, including water, cat fines, etc. might vary slightly. However, the product variation must fall within acceptable limits for the cargo to retain the same cargo categorization.

Cargo operations in practice

Blending and commingling constitute intentional contamination of one cargo with another; so charterers/shippers/receivers should bear the risk of the cargo not being mixed to form a homogenous product.

The master should be given specific instructions prior to loading to assess whether the multiple grades can be safely loaded in the specific cargo tanks without any risk of tank overflow or pollution. It is also recommended, if possible, to get the chemical analysis of the final product done prior to loading

to check on the physical and chemical characteristics of the cargo, especially the pour point, cloud point and if there is going to be any wax formation which might lead to excessive cargo remaining on board on discharge.

When agreeing to blending or commingling cargoes, the master should also consider the overall effect on the ship’s stability. The blended density will be different to that of the originally loaded cargo and this may have a direct effect on the ship physically, including trim and draught.

Also, when blending or commingling crude oil cargoes, significant wax drop-out can occur, which will result in difficulties in discharging and significant cleaning costs.

Bills of lading and LOIs

It is important that the exact cargo description and the exact operation are clearly defined in the bill of lading to avoid falling foul of the provisions to the cargo rules regarding description. The bill should show:

·       quantity;

·       cargo type;

·       loading port; and

·       date

for all the blended or commingled cargoes.

Where bills of lading have already been issued for part of the cargo on board, the master should ensure that these are surrendered and cancelled before any new bills, which cover the final product, are issued.

Where commingling (or blending) is requested by cargo interests, it is recommended that a letter of indemnity is sought.

Of course, an indemnity is only as good as the creditworthiness of the party granting it, so before going ahead, members should ensure that they are fully satisfied with the financial standing of the indemnifiers.

An LOI is not enforceable if the underlying transaction is intended to defraud a third party, for example, where it is received in return for misdescribed cargo.

Club cover - Commingling

Claims arising out of commingling are generally accepted as poolable. In so far as a cargo claim does arise, it is essential for poolable cover that the bill of lading properly reflects the cargo on board as set out above.

Failing which, members will fall foul of provisos (7) and (8) to the cargo rules regarding description.

Provided the bills of lading properly reflect the cargo on board, P&I cover will be operative in the usual way.

Club cover - Blending

In relation to blending operations, there is currently no express exclusion in the

Pooling Agreement. However, given the specialist nature of the blending operation, which is comparable to using the ship as a floating chemical laboratory, to the extent that liability arising from a blending operation could

be considered imprudent, unsafe, unduly hazardous or improper, this may trigger the hazardous trade exclusion, which would render any claim discretionary under rule 4.8.

In reviewing such a claim, the board will take into consideration whether the recent changes to SOLAS Chapter VI have been complied with. The same provisos with respect to issuing bills of lading would also apply.

SOLAS

1 January 2014 saw the entry into force of a number of amendments to SOLAS. Amongst these, the changes to SOLAS Chapter VI – Carriage of Cargoes, Regulation 5.2, have a particular significance for the conduct of cargo operations on board tankers.

Regulation 5.2 now prohibits the practice of physical blending of bulk liquid cargoes during sea voyages.

For the purpose of the SOLAS amendments, physical blending operations have been defined as:

‘the process whereby the ship’s cargo pumps and pipelines are used to internally circulate two or more different cargoes with the intent to achieve a

cargo with a new product designation’.

The regulation goes on to state that: ‘any production process on board a ship during sea voyages is prohibited’.

It should be noted, however, that this regulation:

‘does not preclude the master from undertaking cargo transfers for the safety of the ship or protection of the marine environment’.

The regulations do not apply where cargo is recirculated within its cargo tank or through an external heat exchanger during the voyage for the purpose of maintaining cargo homogeneity or temperature control, including when two or

more different products have previously been loaded into the same cargo tank within port limits.

Likewise, where a cargo becomes homogeneously mixed simply by discharging it ashore alongside a terminal using the ship’s pumps, this will not fall foul of the new SOLAS regulations. The same would be true where the operation takes place by STS operations either within port limits or STS operations at sea.

If the ship alone was blending cargo on board by recirculation between tanks during a sea voyage, this would clearly be in breach of the new regulations.

The same would arguably be true if the ship was blending at a designated site offshore. We say ‘arguably’ because SOLAS does not define the meaning of ‘sea voyage’ and this ambiguity has led to a number of questions from members. That said, although SOLAS does not define the meaning of ‘sea voyage’, the intention of the regulation would appear to prohibit the physical blending of bulk liquid cargoes using the ship’s cargo pumps and pipelines outside port limits, whether at anchor or not.

If a member intends to undertake physical blending operations within port limits, whether at anchor or moored, authorization should first be sought from the local port state administration in order to ensure that the local interpretations of Regulation 5.2 are understood and complied with.

Whether blending is permitted if a ship is at anchor outside port limits is still open for discussion and will depend upon the flag state and local authority’s interpretation of ‘sea voyage’.

Conclusion

Each instance of commingling and blending will need to be considered on its own facts so that the club can determine whether there are any cover issues which might arise from the cargo operation in question. The above is therefore only for general guidance, and members and brokers should speak to their usual club contact should they have any questions.

Related articles at,

https://safety4sea.com/commingling-and-solas-compliance/

Incident investigation: Search for the Cause, not the Villain

In cooperation Gard P+I Club/MAIB U.K.

When investigating incidents, it is not just about the individuals involved in the incident, but the interacting causes which make up the conditions surrounding the incident.

Incident investigations often conclude with placing the blame for an incident on the crew. Causes of the incidents are usually identified as procedural violations, incompetence, lack of situational awareness or the catch all, human error. Take for example a grounding incident which occured because the officer on watch fell asleep. Investigations of such incidents would usually blame the fatigued officer or the Master when the investigation is limited to individuals. 

An investigation should ask questions such as why he fell asleep? 

Were last port operations too strenuous on the officer? 

Was the manning adequate for the vessel’s operations? 

What commercial pressures were at play? 

How would the company have reacted if the master was to request a delayed departure citing fatigue as a reason? 

And finally, what is the company culture like? 

The above questions can provide an overview of the conditions that led to the incident and to help understand the underlying issues.

An investigator’s ability to conduct a fact based investigation and understand the conditions that prevailed during the incident is sometimes derailed by their focus on finding a guilty individual. This is known as the ‘blame instinct’ and greatly undermines the ultimate aim of incident investigation, which is to find the root cause and prevent a similar occurrence happening in the future. 

Such practices are usually reflective of an organisational culture that does not support open and honest reporting of failures due to the fear of consequences.

To bring about a change in the way we investigate incidents, we should bear in mind that it is not just about the individual or group of individuals involved in the incident, but multiple interacting causes which make up the conditions surrounding the incident.

Next time there is an incident, no matter how small, treat it as a symptom that there is something in the system that needs improving. It is about learning, not blaming.

The MAIB U.K. has published the Safety Digest 01/2020 with Lessons Learnt from Marine Accidents Report. The document may be read at,

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/876845/2020-SD1-MAIBSafetyDigest.pdf