CMA CGM PUCCINI

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ATSB report into allision with beacon published

A lack of proficiency in the steering gear operation and change of control modes due to ambiguous procedures caused the 'CMA CCGM Pucchini' to allided with a navigation beacon while departing from Melbourne on May 25, 2023, an investigation by the Australian Transport Safety Bureau (ATSB) has found. An incomplete understanding of how the steering gear operated among the ship’s engineers and ambiguous language in the company’s fleetwide procedures contributed to the accident, when the ship was transiting the Yarra River. The initial investigation had showed erratic behavior by the ship leading the ATSB to investigate why the steering gear was not performing correctly. The vessel went off its intended track towards the edge of the navigable channel causing it to strike the beacon. The pilot aboard and the crew reported the rudder was responding erratically to helm orders. The investigators pieced together the cause of the erratic steering, determining that it was due to a hydraulic bypass valve being left open by the crew after an AMSA port state control inspection on May 24. This resulted in the steering system hydraulics being incorrectly configured for normal operation. With the hydraulic bypass valve being left open, the steering operated sufficiently well with minimal load on the rudder to pass pre-departure visual inspection. However, when the hydrodynamic loads on the rudder increased, with increasing ship’s speed and rudder movements, the open bypass valve allowed leakage of hydraulic oil and system pressure around the pump leading to erratic response of the rudder. The ATSB determined that several officers on board were not as proficient with steering gear operation and change of control modes as was required by regulations. The situation was complicated by the fact that the steering terminology used on board and within the CMA CGM fleet was not clearly and explicitly defined. The official fleet terminology was “steering gear failure” and did not recognize common industry terms such as “emergency” and “local steering.” The ship’s responsible officers were unaware of the dangers and further the AMSA told the investigators manipulation of the steering hydraulics was not required for the demonstration during the inspection. The 'CMA CGM Puccini' had sailed from the Swanson Dock in Melbourne after route safety checks under the conduct of a pilot and initially with two tugs in attendance. During the turn to leave the dock, the master and chief mate noticed that the rudder response appeared sluggish, as if only one steering pump was running (both pumps were operating). Neither raised their observations with each other, or the pilot, and there were no alarms to indicate a pump had stopped or other abnormal conditions. At 04.36 a.m. the ship was moving along the channel in the river, after both tugs had been dismissed. A few minutes later it passed under the Westgate bridge at a speed of 6.6 knots when the helmsman reported that the rudder was not responding to the wheel. With its speed increasing, the ship moved further off course and tracked toward the western edge of the dredged navigable Yarra River channel striking navigation beacon 32. At the time, the ship’s speed was 7.7 knots. The two tugs were nearby and returned, and helped control the ship’s erratic movement. The ship was then moved to the Webb Dock for inspection. It had sustained minor paint damage, and the beacon was significantly damaged. CMA CGM has taken measures to address the ambiguity by revising the steering guidance across its fleet. The fleetwide “steering gear failure” procedure has been amended and titled to become the “emergency steering procedure.” The Ports Victoria has also updated the harbour master’s directions for Melbourne to enhance towage requirements while transiting the Yarra River. This now includes advice for the crews of ships that experience a main engine or steering failure while transiting port waters. https://www.maritime-executive.com/article/cma-cgm-boxship-hit-beacon-due-to-lack-of-crew-understanding-and-procedures

Interim Report: Steering failure caused allision with beacon

The 'CMA CGM Puccini' went off its intended track towards the edge of the navigable channel in the Yarra River and struck a navigation beacon due to a steering failure, an ATSB interim investigation report detailed. The ship had sailed from Swanson Dock in the Port of Melbourne in the morning of May, 29, 2023 under the conduct of a pilot and initially with two tugs in attendance. Shortly after 04.18 a.m., during the turn to leave Swanson Dock, the ship's master and chief mate noticed the rudder response appeared sluggish. About 25 minutes later, when it had passed under the Westgate Bridge and both tugs had been dismissed, the ship was moving at about 6,6 knots when the helmsman reported that the rudder was not responding to the steering wheel. With its speed increasing, the ship moved further off course and tracked toward the western edge of the dredged navigable Yarra River channel. Despite efforts by the pilot and crew to slow the ship and correct its swing, the ship struck a navigation beacon, and its stern passed over the edge of the navigable channel. The two tugs were nearby and returned, and helped control the ship's erratic movement. The ship was then moved to Webb Dock for inspection. On May 26 the ship was cleared to leave port, and it departed on May 27 for Port Botany, Sydney. The following day, in preparation for arrival to Port Botany, the ship's crew again tested the steering gea. During this testing, the steering again began to behave erratically." At this time, the 2nd engineer, who had joined the ship in Melbourne, noticed the steering system's hydraulics were incorrectly configured. After the by-pass valve of the (non-running) pump was closed, there were no further erratic rudder responses. The ship subsequently sailed for Brisbane on May 30, where it berthed without incident on June 1. The ATSB commenced an investigation on the basis of initial reports that, despite multiple inspections, the erratic behaviour of the ship's steering on May 25 remained unexplained over the following days and the ship departed Melbourne with no problem identified. ATSB investigators subsequently attended the ship in Brisbane on June 2, and again in July when the ship returned to Melbourne, during which they conducted extensive testing of the steering systems, interviewed the crew, and obtained other evidence including various documents and recorded data. Investigators also obtained evidence from the incident pilot and the pilotage provider, AMSA, and port authorities. The team will also verify data and evidence to confirm the order of events, analyse the ship's steering arrangement and operation, review crew actions, and assess shipboard and CMA CGM fleetwide procedures and steering gear guidance, operation, information sharing and testing. A final report will be released at the conclusion of the investigation.