Legionella bacteria detected. A new commanding officer, working through a routine handover, found the vessel's potable water system had gone roughly two years without documented testing (CHIRP report M2849). Lab results came back positive for Legionella at unsafe levels.
Several crew later said the water issue was not new; they had noticed it before. What changed was that this officer treated it as something to test, not something to live with.
CHIRP's comment names the mechanism directly: repeated exposure to a problem can lead to it becoming accepted as normal, rather than flagged for investigation. The response once it was tested (restricting water use, providing alternatives, cleaning the system) was straightforward. The failure was upstream of that, in the two years nobody tested.
What's the one thing on your vessel that everyone's noticed, and nobody's tested?
#MaritimeSafety #SafetyManagement #Maintenance #SafetyCulture #LessonsLearned
