Recommendation Date
Recipient Name
Maersk Line A/S
The bridge operations on board the Leda Maersk fell short of achieving good industry practice in both planning and executing the passage under pilotage and bridge resource management.

There were indicators from previous audits that not all policies and procedures were being followed as intended by the operator. This, in combination with the non-adherence to other aspects of the policies and procedures leading up to this grounding, is an indication that the procedural failures may not have been confined to this one accident, and that the operator will need to review the standard of navigation under pilotage for all its crews to ensure that industry good practice is being followed.

On 26 June 2019, the Commission recommended to the Chief Executive of Maersk Line A/S that they review the implementation of the company’s safety management system across its fleet with respect to navigation and pilotage, and take the necessary steps to ensure a high standard is achieved by all crews on all its ships.
Reply Text
1. Maersk Line has identified that training of ship staff is of utmost importance to ensure effective implementation of company procedures and for ensuring safety of navigation, including navigation in pilotage waters. In this regard following measures have been taken:
- All navigators must undergo mandatory ECDIS training by Seagull A/S
- Already commenced in 2019.
- Aim is to enhance knowledge of navigators and to ensure optimum use of ECDIS as a tool.
- This will be followed up by refresher training at two year intervals so that navigators remain up to date.
- Further, all navigators are required to undergo Bridge Team Enhancement Programme Training.
- The programme focusses on improved bridge team work and optimum use of bridge resources.
- In bridge simulator phase of this course navigating officers are put through scenarios which replicate navigation incidents that occur during coastal and pilotage waters.
- As we employ over three thousand navigating officers, this process is being undertaken in a phased manner and will be completed in the year 2025.

2. Company procedures pertaining to navigation and use of ECDIS have been revised recently. This has been done so that navigators find them easier to understand, which in turn will increase adherence to these procedures. Overview of revised SMS procedures is attached herewith.

In accordance with the ISM code internal audit is carried out annually to verify compliance with the requirements of the Safety Management System. [These include navigation audits by a superintendent.] [The] last internal audit for Leda Maersk was conducted in Feb 2019.
Related Investigation(s)