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.