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