Case Studies
Worked scenarios built from recurring situations, and the lessons they carry. They are teaching cases, not the record of identified incidents: no ship, IMO number, port, year or investigation report is named, because none is being reported, linked to MARPOL Operations topics.
Illustrative composite caseCase 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 →
Illustrative composite caseCase 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.
Illustrative composite caseCase 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. (“minor NC” is a category of practice: the ISM Code defines only the major non-conformity — see the dedicated page.) 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, 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 →
Illustrative composite caseCase 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.
Illustrative composite caseCase 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 →
Illustrative composite caseCase 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.
Illustrative composite caseCase 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.
Illustrative composite caseCase 8 -- The "extended" certificate that was no longer valid
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.
Illustrative composite caseCase 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, 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.
In upcoming updates: new case studies as the platform grows with further modules and sections.