First a note… I am publishing this short clip ahead of my next article because of its importance!

While preparing our upcoming “questions for investigators” article on the Cosco Busan incident we were asked by more than one party a question along this line; with communications failure being a leading cause of incidents and the crew of the Cosco Busan being Chinese of limited english skills (they required translators during the investigation) why do incidents of this type not happen more often?

The answer is Bridge Team Management.

Ok… so what is BRM? Simply because it’s an increase focus of incident investigation and watchkeeping.

Revisiting a previous post I state:

  • Bridge Team (or resource) Management (called BRM in the industry) is a process to use all of your available resources during critical operations. It came from the airline industry which found an alarming number of accidents happened despite prior warning from the equipment or crew…. mostly by captains with military backgrounds and a “I can do this” attitude who did not fully use critical information from either the equipment or junior personnel.Boiled down it’s a class all officers must take in both teamwork and processing the large amounts of data (lookout reports, radar, radio comms, gps charting, weather information….) that pours into the bridge.
  • Here’s a more official answer:The Bridge Team Management course introduces the concept of a navigation team to ship masters and watch officers and frames their decision making process toward establishing watch conditions during the course of the voyage. Bridge Team Management techniques will emphasize decision making based upon conditions related to workload and potential threat to the vessel. The intent of the program is to define the individual task and responsibilities of the various team members while developing a situational awareness to prevent individual errors.

In stating the importance of this post I am looking at the media reaction to the incident. In reporting disasters the public is often not satisfied until a single individual is blamed…. quickly. This was the case in the Exxon Valdez oil spill, Tampa Skyway Bridge Disaster and even in the early reports on the Empress of the North grounding where fault was placed on the Jr. Officer on watch who was only weeks out of the Maritime Academy. In the Empress of the North incident gCaptain broke from traditional media and laid the blame on management techniques rather than the “green” officer and we are happy to report he was recently clear of all charges (as was Capt. Hazelwood of the Exxon Valdez).

It is clear to us the Cosco Busan allided with the Bay Bridge because of a breakdown in Bridge Team Management. For example while VTS contacted the ship questing its course did the mate on watch, captain, helmsman or assist tug captain also voice concern? Was the equipment operational and set up properly? As the primary fault for the Exxon Valdez incident was not with Captain Hazelwood (he was cleared of charges and his license was reinstated) John Cota, Pilot aboard the Cosco Busan is not solely at fault for this incident.

The team failed the Cosco Busan not the ship’s Chinese Captain or American Pilot alone. Lets just hope the court of public opinion does not convict either person before the long and thorough investigation is completed. Otherwise they might stand the fate of Captain Hazelwood, cleared of charges and fully licensed to pilot a ship but unable to find a company willing to hire him.

________

Asking yourself how a ship 131 wide could have such trouble in a channel 737 metres wide? Read a more unbelievable story HERE then watch the amazing slideshow HERE.

UPDATE: Bob Couttie of the Maritime Accident Casebook has a very interesting article along similar lines. You can find it HERE.

UPDATE 2:
Criminal probe opened in Bay oil spill

The entire crew of the cargo ship that sideswiped a bridge, causing San Francisco Bay‘s worst oil spill in nearly two decades, has been detained as part of a criminal investigation, a Coast Guard official said Sunday.

Capt. William Uberti said he notified the U.S. attorney’s office on Saturday about issues involving management and communication among members of the bridge crew: the helmsman, the watch officer, the ship’s master and the pilot.

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  • http://www.maritimeaccident.org Bob Couttie

    I hate to sound quibbely but I would suggest that there is a difference between bridge team management and Bridge Resource Management. The former is largely about the management of the human element, the wetware on the bridge, the latter would include the management of other resources such as radar, GPS, and all those things that go beep.

    Having read more than the average number of accident reports I fully agree, the key problem is bridge resource management especially the relationship between the pilot and the OOW.

  • http://www.maritimeaccident.org Bob Couttie

    I hate to sound quibbely but I would suggest that there is a difference between bridge team management and Bridge Resource Management. The former is largely about the management of the human element, the wetware on the bridge, the latter would include the management of other resources such as radar, GPS, and all those things that go beep.

    Having read more than the average number of accident reports I fully agree, the key problem is bridge resource management especially the relationship between the pilot and the OOW.

  • http://gcaptain.com John

    Bob, you’re right (of course) and I played around with the wording quite a bit… in the “previous post” link you can see the difference in wording. I avoided any official distinction because, despite USCG reports of no equipment failure, I’m not convinced the stuff that goes beep was properly set up by the bridge team. For example a simple Parallel Indexing line on the radar *might* have been enough to avoid the incident.

  • http://gcaptain.com John

    Bob, you’re right (of course) and I played around with the wording quite a bit… in the “previous post” link you can see the difference in wording. I avoided any official distinction because, despite USCG reports of no equipment failure, I’m not convinced the stuff that goes beep was properly set up by the bridge team. For example a simple Parallel Indexing line on the radar *might* have been enough to avoid the incident.

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  • http://www.maritimeaccident.org Bob Couttie

    Aha, good old parallel indexing, prominent by its absence on so many incidents, along with constant radius turns.

    Much would depend on the radar signature and ranges, I suspect.

    Looking at the animation of the AIS data it looks almost as if it was trying to get through the other span.

    This one will run and run.

  • Capt. Mike

    From sfgate.com

    Newsom (San Francisco’s Mayor) saw the disaster as an even larger statement on the weakness of America’s dependence on oil.
    “We can do better than large oil tankers coming in and out of the bay of San Francisco, and move to a more energy independent future,” he said at Crissy Field. “We’ll continue to have these kinds of disasters inevitably if we continue to have more tankers come in and out to feed our addiction.”

    Is this guy a complete idiot? I’m asking only because my son know the difference between a tanker and a container ship

    http://www.sfgate.com/cgi-bin/article.cgi?file=

  • http://www.maritimeaccident.org Bob Couttie

    Aha, good old parallel indexing, prominent by its absence on so many incidents, along with constant radius turns.

    Much would depend on the radar signature and ranges, I suspect.

    Looking at the animation of the AIS data it looks almost as if it was trying to get through the other span.

    This one will run and run.

  • Capt. Mike

    From sfgate.com

    Newsom (San Francisco’s Mayor) saw the disaster as an even larger statement on the weakness of America’s dependence on oil.
    “We can do better than large oil tankers coming in and out of the bay of San Francisco, and move to a more energy independent future,” he said at Crissy Field. “We’ll continue to have these kinds of disasters inevitably if we continue to have more tankers come in and out to feed our addiction.”

    Is this guy a complete idiot? I’m asking only because my son know the difference between a tanker and a container ship

    http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/11/12/BAO2TB3AV.DTL&tsp=1

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  • guest

    I see your latest article is not the first to blame BRM. Good job staying ahead of the curve!

  • guest

    I see your latest article is not the first to blame BRM. Good job staying ahead of the curve!

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