CMA CGM Crash due to miscommunication -MAIB

Miscommunication between the bridge team and the pilot led to the collision between the UK-registered containership CMA CGM Centaurus and the quay and the shore cranes in Jebel Ali, United Arab Emirates on May 4, 2017.

The accident resulted in the collapse of a shore crane and 10 injuries, including one serious injury, to shore personnel.

According to a report from the UK’s Marine Accident Investigation Branch (MAIB), the collision occurred because the ship was unable to attain a sufficiently high rate of turn into a basin in preparation for berthing.

“The pilot was unaware of the ship’s speed, and the ship’s bridge team were uncertain of the maximum speed required to complete the turn safely. There was no agreed plan for the intended manoeuvre, and therefore no shared mental model between the bridge team and the pilot,” MAIB said.

“Consequently, the pilot was operating in isolation without the support of the bridge team, allowing the pilot’s decision-making to become a single system point of failure. The pilot’s performance was focused on efficiency, which influenced his decision to turn the ship into the basin without ensuring that the manoeuvre was conducted at a sufficiently slow speed to enable its safe completion.”

One of the main takeaways is that the exchange between the master and pilot lacked structure and detail.

By not actively engaging with the bridge team, the pilot effectively signalled that he did not need their assistance, the report indicates.

“By not requiring its newly recruited pilots to undertake BRM-P training, Jebel Ali port authority missed the opportunity to both emphasize its commitment to the effective integration of its pilots with bridge teams, and ensure its pilots were trained/refreshed in the principles of BRM,” MAIB added.

As indicated, despite extensive industry guidance, there continues to be a reluctance by masters and pilots to work together in accordance with the principles of BRM.

“Many of the factors in this accident can be attributed to a focus on completing acts of pilotage as quickly as possible. The priorities set at senior management level have a significant impact on the safety culture of a port, and there is a need to recognize that time-pressure, in the quest for terminal efficiency or financial reward, can have a negative effect,” the report further adds.

In conclusion, MAIB recommends DP World UAE region to review and improve its management of pilotage and berthing operations in respect of large containership movements within the port of Jebel Ali.

The International Chamber of Shipping, the International Maritime Pilots’ Association and the International Harbour Masters’ Association are recommended to promote the benefits of adhering to effective bridge resource management procedures during acts of pilotage and to endorse the Bridge Resource Management training for pilots course as an effective means of achieving this.