NTSB issues Cosco Busan findings

"There was a lack of competence in so many areas that this accident seemed almost inevitable," said Acting National Transportation Safety Board Chairman Mark V. Rosenker yesterday when the NTSB announced its determination in the Cosco Busan case.

The board said that a medically unfit pilot, an ineffective master, and poor communications between the two were the cause of the November 2007 accident in which the containership spilled thousands of gallons of fuel oil into the San Francisco Bay after striking a bridge support tower.

The NTSB determination came one day after a federal judge rejected an attempt by ship manager Fleet Management to fend off criminal charges in the casel by blaming state and federal authorities for licensing the pilot. The San Francisco Chronicle reports that Fleet Management Ltd., charged with criminal negligence and falsifying documents, sought records from the state Board of Pilot Commissioners on pilot John Cota. But U.S. District Judge Susan Illston said that Fleet Management "cannot disprove its own negligence simply by demonstrating that the negligence of other actors was another ... cause." (READ THE SAN FRANCISO CHRONICLE REPORT)

In a summary released yesterday the NTSB noted that on November 7, 2007, at about 8:00 a.m. PST, in heavy fog with visibility of less than a quarter mile, the Hong Kong- registered, 901-foot-long containership M/V Cosco Busan left its berth in the Port of Oakland destined for South Korea. The San Francisco Bay pilot, who was attempting to navigate the ship between the Delta and Echo support towers of the San Francisco-Oakland Bay Bridge, issued directions that resulted in the ship heading directly toward the Delta support tower. While avoiding a direct hit, the side of the ship struck the fendering system at the base of the Delta tower, which created a 212-foot-long gash in the ship's forward port side and breached two fuel tanks and a ballast tank.

As a result of striking the bridge, over 53,000 gallons of fuel oil were released into the Bay, contaminating about 26 miles of shoreline and killing more than 2,500 birds of about 50 species. Total monetary damages were estimated to be $2 million for the ship, $1.5 million for the bridge, and more than $70 million for environmental cleanup.

"How a man who was taking a half-dozen impairing prescription medications got to stand on the bridge of a 68,000-ton ship and give directions to guide the vessel through a foggy bay and under a busy highway bridge, is very troubling, and raises a great many questions about the adequacy of the medical oversight system for mariners," said Acting Chairman Mark V. Rosenker.

In its determination of probable cause, the Safety Board cited three factors:

1) the pilot's degraded cognitive performance due to his use of impairing prescription medications;

2) the lack of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the short voyage; and

3) the master's ineffective oversight of the pilot's performance and the vessel's progress.

Contributing to the cause of the accident, the Board cited

1) the ship's operator, Fleet Management, Ltd., for failing to properly train and prepare crew members prior to the accident voyage, and for failing to adequately ensure that the crew understood and complied with the company's safety management system; and

2) the U.S. Coast Guard for failing to provide adequate medical oversight of the pilot.

"Given the pilot's medical condition, the Coast Guard should have revoked his license, but they didn't; the pilot should have made the effort to provide a meaningful pre-departure briefing to the master, but he didn't; and the master should have taken a more active role in ensuring the safety of his ship, but he didn't," said Rosenker. "There was a lack of competence in so many areas that this accident seemed almost inevitable."

As a result of its investigation, the Safety Board made a total of eight safety recommendations.

In its five to the U.S. Coast Guard, the Board recommended that it

1) ask the International Maritime Organization to address cultural and language differences in its bridge resource management curricula;

2) revise policies to ensure that, in its radio communications, the Vessel Traffic Service (VTS) identifies the vessel, not only the pilot;

3) provide guidance to VTS personnel that defines expectations for when their authority to direct or control vessel movement should be exercised;

4) require mariners to report any substantive changes in their health or medication use that occur between required medical evaluations; and

5) ensure that pilot oversight organizations share relevant performance and safety data with each other, including best practices.

The Board recommended that Fleet Management Limited

1) ensure that all new crewmembers are thoroughly familiar with vessel operations and company safety procedures; and

2) provide safety management system manuals in the working language of the crew.

The Safety Board also recommended that the American Pilots' Association remind its members of the value and importance of a verbal master/pilot exchange, and encourage its pilots to include the master in all discussions involving the navigation through pilotage waters.

A synopsis of the full NTSB report is available HERE