Safety issue

Safety issue description

The ship's managers' (CMA CGM) safety management system procedures and guidance for steering gear operation across its fleet were ambiguous and did not clarify the different terminology to those commonly used by the industry. This increased the risk of incorrect configuration of the steering gear, which occurred on board CMA CGM Puccini. 
Issue number MO-2023-002-SI-01
Issue owner CMA CGM
Transport function Shore operations
Issue status Closed – Adequately addressed
Date issue released 12/02/2025
Issue status justification

CMA CGM has retitled the ‘steering gear failure’ procedure to ‘emergency steering procedure’. The procedure has been updated to include a definition of ‘emergency steering’ and directs that immediate actions to be taken on the bridge include testing of the steering gear and preparation for changing to steering from the steering gear room. The amended procedure was implemented fleetwide on 26 June 2025. 

These actions significantly reduce the likelihood of recurrence of this incident (residual risk of a recurrence of this incident assessed as being acceptable) and adequately address the safety issue.
Issue finalisation date 15/09/2025

Safety action

Action type Proactive action
Action number MO-2023-002-PSA-01
Organisation CMA CGM
Action description

Following the incident, CMA CGM shared details of the incident with all ships in its fleet and then, in 2024, an article was published in the CMA CGM Group monthly quality safety, security and environment management report. This article was directed to company designated persons ashore and briefly outlined the incident and the misconfiguration of the pump bypass valve as the likely cause.

CMA CGM further advised the ATSB that the ‘steering gear failure’ procedure (Engine-650) was rewritten as the ‘emergency steering procedure’ and was to be assessed by the company technical committee with expected release fleetwide in March 2025. The proposed procedure defines emergency steering and clearly outlines the change of steering control from the navigation bridge to the steering gear room.
ATSB response

The ATSB welcomes the action taken by CMA CGM in response to the safety issue. However, as the updated procedure is in draft and review stages the ATSB will monitor progress with this action and the safety issue until assurance is received that the changes have been implemented and address the safety issue.
Action status Closed

Organisation response

Date received 15/07/2025
Organisation CMA CGM
Response text

In July 2025, CMA CGM provided a safety action update that included the following:

  • A copy of the fleetwide ship specific cards index showing inclusion of the retitled Engine-650 – Emergency Steering Procedures card
  • Photographs of the inclusion of the updated card in 2 example fleet ship document lists
  • Copy of fleet circular (‘Experience feedback form’) relating to the updating of the procedure. The circular included details of the amendments to make and the advice to ‘Insert ship’s specific procedure for direct controlling of the steering gear’ in the ‘Emergency steering procedure’ section.
  • Copy of an exemplar ship modified procedure showing changes that included:
    • Retitled procedure (Emergency Steering Procedure)
    • Definition of ‘Emergency Steering’ as ‘steering the vessel from steering gear room in the event of bridge control failure’
    • Immediate actions to take on the bridge to test the steering gear and prepare for change to steering gear room control
    • Ship-specific emergency steering procedures including relevant photographs and diagrams.
ATSB response

The follow-up actions taken by CMA CGM show that ATSB safety issue regarding ‘procedures and guidance for steering gear operation across its fleet were ambiguous and did not clarify the different terminology to those commonly used by the industry’ has been addressed and changes implemented throughout the fleet.

These actions will reduce the likelihood of a similar incident, due to misunderstanding and misapplication of steering gear emergency operational procedures, occurring in the future.


 
ATSB response date 04/08/2025