The grounding of the 4,045 TEU container ship Leda Maersk in June 2018 at New Zealand’s Port Otago was a result of the harbour pilot and crew ignoring navigation equipment, an accident investigator has concluded.
New Zealand’s Transport Accident Investigation Commission’s (TAIC) accident report noted that the harbour pilot of the Port of Otago, along with the crew on the bridge, were primarily navigating using visual cues outside the ship, i.e. they were looking out of the window rather than using the ship’s navigation equipment. Those navigation aids “clearly showed the ship deviating from the centre of the channel”.
Interestingly, TAIC revealed that this incident repeated lessons from a similar occurrence at the harbour two years earlier.
On the day of the incident, the accident report reveals, shortly after taking control of Leda Maersk, the pilot’s electronic equipment indicated that the ship was off-centre. The accident report reveals that a check by the pilot revealed that an offset that “allow[s] for the position of the [equipment] aerial in relation to the ship’s centreline” was causing the equipment to show that the ship was 18 metres further to the ship’s left (port side) than it actually was. The pilot then took the decision to discontinue using that piece of equipment for monitoring the ship’s progress because he couldn’t remove the offset.
However, he failed to inform the crew that he was not using the equipment and was instead only using visual cues and the ship’s radar. The use of visual cues was useless because the ship was sailing when it was dark outside, meaning that the pilot and crew quickly lost sight of both the high cliffs on both sides of the channel and the channel’s navigation lights. Also, the containers on the ship were stacked six high and blocked out the sight of the navigation lights from the viewpoint of the ship’s bridge.
As the ship continued to sail off-course, the installed ECDIS navigation equipment sounded an alarm. Although a member of the crew acknowledged the alarm, it was then ignored. The crew member in question did not inform anyone else that the alarm had sounded. Shortly after, the ship heeled and ran aground.
Following their extensive investigation, TAIC concluded that the standard of bridge resource management onboard the Leda Maersk fell short of industry good practice and that the bridge crew were not fully following the policies and procedures of the company. They also found that Port Otago’s policies, procedures, and compliance monitoring during pilot operations fell short of meeting good industry standards.
TAIC identified five key human factors that led to the grounding of the container ship: lack of teamwork, complacency (the bridge team “put too much faith in the pilot getting it right”), a lack of situational awareness, a failure to communicate or act on alerts, and underlying issues with safety culture.
TAIC has since recommended Maersk Line conduct a fleet-wide review of its safety systems in respect of navigation and pilotage. Maersk subsequently confirmed that their navigators must undergo mandatory ECDIS (now under way) and Bridge Team Enhancement Programme training (to be completed by 2025).
Port Otago received the TAIC recommendation that it should take necessary actions to ensure pilotage operations fully meet good industry practice. The port later confirmed that all pilots have been given refresher training on the use of their pilotage equipment.