Case Studies

What happened: In this scenario an unauthorised pipe bypasses the bilge separator and enables untreated oily-water discharges.

How it was discovered: Discrepancies between records, tank quantities and declared operations prompt physical checks of piping and equipment. Sludge and bilge balances remain distinct; an estimated production figure alone does not prove an illegal discharge.

Consequences: PSC measures and investigations may follow in the scenario. Penalties and personal liability depend on evidence and jurisdiction, not merely on the label “magic pipe”.

Lessons learned: Periodically reconcile data, preserve evidence and report unauthorised modifications. Set the internal checking interval in the SMS; this example creates no universal monthly-balance requirement.

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

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

Consequences: The discrepancy calls for further investigation and evidence checks. Any detention requires assessment of seriousness and PSC criteria; it does not automatically follow every record-book error.

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 →

What happened: Three audits on ships in the same fleet find incomplete maintenance records, closed only through local reminders. ISM 1.1.9 defines non-conformity and 1.1.10 major non-conformity; “minor” is a practice label, not a third Code definition.

How it was discovered: At the periodic SMS management review, aggregated analysis identifies unclear responsibilities and ineffective due-date controls. Automatic reminders may help, but are neither the only solution nor a universal ISM requirement.

Consequences: no detention, but a major NC is opened by the certification body at the next external audit, as a major non-conformity in this illustrative context because the auditor considers a serious or systemic SMS failure demonstrated; actual classification depends on evidence and applicable criteria.

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 →

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 →

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: A third detention falls within 24 months and, by assumption, the flag is on the relevant grey list. The authority checks all Paris MoU refusal-of-access conditions. High Risk status requires its own calculation and cannot be inferred from the detention count alone.

Consequences: In this case a refusal-of-access order is issued under the applicable regime. Lifting requires both the minimum period and the prescribed conditions; elapsed time alone does not restore access.

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 →

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 raises the alarm without entering. The trained team activates the rescue plan under a leader, assesses risks and prepares respiratory protection, equipment, communications and external assistance as needed. Recovery follows the plan: breathing apparatus alone does not authorise entry.

Consequences: In the scenario both casualties are recovered and receive first aid and medical assessment. Loss of consciousness is actual harm: the event is not merely a near miss, and absence of lasting effects must not be assumed.

Lessons learned: Do not improvise a rescue entry. Team preparation, a plan, equipment and risk control are essential. Personnel with entry or rescue responsibilities participate in drills at least every two months under SOLAS III/19.3.3.

Go to the Enclosed Space Entry page →

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 failure reveals the missing spare. The Master and Chief Engineer assess redundancy and limits, apply the SMS and involve the Company and competent authorities as needed; proceeding at reduced speed is not automatically safe.

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 →

What happened: to avoid a renewal survey in a port with no surveyor available, the ship obtains an illustrative Administration-authorized extension of a statutory certificate under the specific applicable SOLAS provision to reach the survey port. The ship then operates beyond the expressly authorized conditions or date; this is neither automatic nor a class certificate extension governed by HSSC.

How it was discovered: during a subsequent PSC inspection, the Port State Control Officer (PSCO) compares the certificate, authorization and applicable conditions and finds that the authorized validity has ended.

Consequences: in this illustrative case the authority orders detention until certification is restored; actual action depends on the certificate, circumstances and applicable PSC criteria.

Lessons learned: every extension requires a specific statutory basis, compliance with its conditions and competent authorization; class and statutory certification remain distinct.

Go to the HSSC page →

What happened: During the SIRE 2.0 inspection the crew uses memorised phrases instead of explaining actual work. The inspection-specific CVIQ is not supplied to the operator in advance: prepare evidence and procedural understanding, not answers to a known inspection questionnaire.

How it was discovered: Follow-up questions and demonstrations reveal gaps in understanding procedures. The inspector records observations and evidence and considers relevant PIFs under OCIMF guidance; this is not a universal negative score for shipboard culture.

Consequences: a "Not as Expected" observation on the Human Factors dimension, and the prospective charterer, applying its own commercial and assurance criteria, decides not to proceed with the fixture; SIRE 2.0 does not award a universal approval score.

Lessons learned: SIRE 2.0 observations distinguish Hardware, Procedure and Human Factors aspects (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 →