Pilot Training Implicated in CMA CGM Centaurus Accident
The U.K. Maritime Accident Investigation Branch has released its report into CMA CGM Centaurus' heavy contact with quay and shore cranes while arriving at the port of Jebel Ali under pilotage, citing a lack of bridge resource management training.
The accident in May 2017 resulted in the collapse of a shore crane and 10 injuries, including one serious injury, to shore personnel. It 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 maneuver and therefore no shared mental model between the bridge team and the pilot. 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 maneuver was conducted at a sufficiently slow speed to enable its safe completion.
The investigators indicate that the master/pilot exchange carried out on CMA CGM Centaurus lacked structure and detail. There was little further detail as the approach proceeded. By not actively engaging with the bridge team, the pilot effectively signaled that he did not need their assistance. The bridge team and the pilot did not have a shared mental model for the intended maneuver.
By not requiring its newly recruited pilots to undertake bridge resource management (BRM) 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. 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.
Recommendations made by the Marine Accident Investigation Branch
DP World UAE region is recommended to review and improve its management of pilotage and berthing operations in respect of large container ship 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.