Learning

# Case Studies Live

Analysis of real (anonymised/illustrative) cases and lessons learned, linked to MARPOL Operations topics.

### Case 1 -- The "magic pipe": illegal bypass of the bilge separator

What happened: on board several ships involved in international proceedings, a bypass pipe was installed that circumvented the Oily Water Separator, discharging untreated oily water directly into the sea.

How it was discovered: a discrepancy between the declared sludge balance and the output estimated from the purifiers, together with crew testimony.

Consequences: very heavy financial penalties for the owner, criminal proceedings against the Master and Chief Engineer, detention.

Lessons learned: keep a consistent monthly sludge balance; any piping not shown on the approved diagram must be reported immediately.

Go to the Sludge Management page → · Go to the Bilge Water Management page →

### Case 2 -- Detention over an Oil Record Book with inconsistent entries

What happened: during a PSC inspection, comparing bilge tank soundings against the volumes logged in the ORB revealed a significant, unexplained inconsistency.

Consequences: detention of the ship pending clarification, followed by a closer inspection of the piping.

Lessons learned: consistency between logged records and physical data (soundings, OWS running hours) must be checked periodically by the crew itself, not only during an inspection.

Go to the Oil Record Book page →

### Case 3 -- The ignored "minor" Non Conformity that becomes systemic

What happened: for three consecutive internal audits, on different ships in the same fleet, the same minor NC is found: maintenance checklists not filled in regularly. Each time it is closed with a local action (a reminder to the crew), without ever tracing back to the common cause.

How it was discovered: only at the annual Management Review, when aggregating data across all ships, does it emerge that the problem is the same across three units: the PMS does not generate automatic reminders.

Consequences: no detention, but a major NC is opened by the certification body at the next external audit, for "ineffective management of the NC/CAPA process at fleet level".

Lessons learned: minor NCs must always be reviewed in aggregate, not just ship by ship: a repeated pattern is a systemic signal, not a set of isolated episodes.

Go to the Non Conformity page → · Go to the Management Review page →

### Case 4 -- Grounding with an up-to-date ECDIS but disabled alarms

What happened: a ship with regularly updated ENCs grounds during a last-minute deviation from the planned route, not checked in real time by the bridge team.

How it was discovered: the post-incident investigation finds that the cross-track error alarm had been disabled to reduce false alarms along a stretch of coastal route, and that the passage plan's monitoring phase had not actually been carried out after the deviation.

Consequences: hull damage, ship out of service for repairs, investigation by the Flag Administration.

Lessons learned: having up-to-date ENCs does not compensate for absent monitoring; safety alarms must be configured correctly for the route, not disabled.

Go to the ECDIS page → · Go to the Passage Planning page →

### Case 5 -- From detention to banning: underestimated escalation

What happened: a ship flying a Grey List flag suffers a second detention within 18 months for unrelated deficiencies (once firefighting equipment, once MARPOL documentation). Neither is analysed as part of a fleet-level pattern.

How it was discovered: at a third inspection, the ship's Ship Risk Profile is already High Risk; a new serious deficiency leads to a third detention, which triggers the banning threshold set for Grey List flags (more than 2 detentions in 24 months).

Consequences: a ban from Paris MOU area ports for the minimum period prescribed, with a significant reputational and commercial impact on the owner.

Lessons learned: every detention must be monitored against the flag's specific banning thresholds, not treated as an isolated episode; Company Performance at fleet level must be actively managed, not just the single ship involved.

Go to the Detention and Banning page → · Go to the Ship Risk Profile page →

### Case 6 -- The rescue attempt that worsens an enclosed space incident

What happened: a crew member enters a double-bottom tank without having the atmosphere tested, believing it safe because it had been ventilated the day before, and loses consciousness. A colleague, alarmed, immediately enters to rescue him without breathing apparatus.

How it was discovered: a third crew member, alerted by the shouting, correctly applies the procedure learned in the last bimonthly drill: he does not enter, alerts the rest of the team, puts on breathing apparatus and recovers both casualties with rescue equipment.

Consequences: the two rescued crew members recover with no lasting effects thanks to the third member's prompt and protected intervention; the episode nonetheless highlights two serious breaches of the entry procedure.

Lessons learned: the rule "never rescue without breathing apparatus" made the difference between a close call and a multi-fatality tragedy; the bimonthly drill, taken seriously, saves lives even when the initial entry procedure fails.

Go to the Enclosed Space Entry page →

### Case 7 -- The critical spare that wasn't there

What happened: an auxiliary cooling pump, correctly identified as critical equipment in the PMS, fails while under way. The required spare is listed as available, but is not physically on board: it had been used months earlier on another unit and never reordered.

How it was discovered: the Chief Engineer discovers the absence only at the moment of the failure, with the ship forced to proceed at reduced speed to the next port to await the spare via express courier.

Consequences: significant operational delay and extra express-shipping costs, plus a prolonged period of the cooling system operating under sub-optimal conditions.

Lessons learned: keeping the critical equipment list in sync with actual spares availability requires active, continuous checking, not just a formally correct list.

Go to the Critical Spares Management page →

### Case 8 -- The "extended" certificate that was no longer valid

What happened: to avoid a renewal survey in a port with no surveyor available, a ship obtains an extension of its class certificate. The extension is mistakenly calculated from the date of the request rather than the original expiry date, in fact exceeding the maximum 3-month limit allowed under the HSSC.

How it was discovered: during a subsequent PSC inspection, the PSCO recalculates the extension window from the original expiry date and finds that the certificate has in fact been expired for several weeks.

Consequences: detention until the renewal survey is completed, with the ship treated as lacking a valid certificate for the excess period.

Lessons learned: the maximum 3-month extension must always be calculated from the certificate's original expiry date, never from the date of the request or of an intermediate event.

Go to the HSSC page →

### Case 9 -- The SIRE 2.0 vetting that failed despite perfect hardware

What happened: during a SIRE 2.0 inspection for a charter with an oil major, the crew answers every CVIQ question with the same standardised formula, trying to "recite" the expected answers instead of explaining the actual procedure applied on board.

How it was discovered: the inspector, suspicious of the uniformity of the answers among different crew members, probes further with follow-up questions and finds that several officers cannot explain the exceptions to the standard procedure. Despite the Hardware being in excellent condition, negative Performance Influencing Factors are assigned on communication and safety culture.

Consequences: a "Not as Expected" observation on the Human Factors dimension, with an overall score insufficient for the charter despite zero Hardware deficiencies.

Lessons learned: SIRE 2.0 explicitly assesses three independent dimensions (Hardware, Procedures, Human Factors): perfect equipment does not compensate for a crew that does not genuinely understand the procedures it applies.

Go to the Vetting Knowledge section →

In upcoming updates: new case studies as the platform grows with further modules and sections.

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