The crash which saw a CMA CGM vessel run into the DP World-run Port of Jebel Ali was caused by the ship’s pilot not knowing how fast it was going, according to a report by the UK government agency, the Marine Accident Investigation Branch (MAIB).
At 11:37am on May 4 2017, the UK registered containership CMA CGM Centaurus made heavy contact with the quay and two shore cranes while approaching the Jebel Ali Port in Dubai, resulting in 10 injuries and one serious injury.
Port Technology International reported on it at the time and later obtained, via a source at the port, exclusive images of the devastation caused by the crash.
In its report, MAIB pointed to a breakdown of communications on the vessel, with the pilot failing to engage with the bridge team due to a lack of a shared mental modal.
Subsequently, the pilot operated in isolation and the ship was unable to attain a sufficiently rate of turn as it prepared for berthing.
MAIB made a number of recommendations in its report, including DP World reviewing and improving its management of pilotage and berthing operations in respect of large container ship movements.
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It also called on the International Chamber of Shipping (ICS) and the International Harbour Maritime Pilots’ Association and the International Harbour Masters’ Association to promote the benefits of improve bridge and pilotage procedures.
Credit: MAIB
In its report, the MAIB said: “The accident 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. 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.
Credit: MAIB
"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.
"This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame".
Heavy contact made by container vessel CMA CGM Centaurus with quay and shore cranes
Location: Port of Jebel Ali, United Arab Emirates.
Accident Investigation Report 17/2018
Investigation report into marine accident including what happened, safety lessons and recommendations made:
Summary
At 1137 on 4 May 2017, the UK registered container ship CMA CGM Centaurus made heavy contact with the quay and two shore cranes while under pilotage during its arrival at Jebel Ali, United Arab Emirates. The accident resulted in the collapse of a shore crane and 10 injuries, including one serious injury, to shore personnel.
The accident 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. 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.
Safety lessons
- 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 signalled that he did not need their assistance. The bridge team and the pilot did not have a shared mental model for the intended manoeuvre.
- By not requiring its newly recruited pilots to undertake BRM-P training, Jebel Ali port authority missed the opportunity to both emphasise 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 recognise that time-pressure, in the quest for terminal efficiency or financial reward, can have a negative effect.
Recommendations
- DP World UAE region (2018/127) are 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 (2018/128) 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.
Related publications
Guidance on BRM-P developed by the International Maritime Pilots’ Association as a result of this investigation, are included in the annexes to the investigation report.
Published 18 October 2018
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