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Perusing ” A failure in XXX Resource Management” I must accept the authors concern. Although encompassing, the point is understood: the maritime industry has problems. It is mostly people and a close second is political and management oversight. Regardless of license, experience and qualification every mariner has the right and personal obligation to warn of impending danger. The author, in personal style, expressed concerns and opinions. For that impressive step, appreciation is warranted and any factual argument by those not agreeing should be espoused and considered; i.e., open a pilot house window and let in some fresh air.

COSCO BUSAN. Captain Sun and Pilot Cota have created an awareness that bad thing can happen and that determining responsibility and fault(s) is evidently not simple. The suspects are government, officials, owners, managers, operators, public committees, associations and the primary target, ship board persons. How many errors were committed may not be known, but the probability that only Captain Sun and Pilot Cota are alone responsibile is suspect.

Since America was only a gathering of colonies, commerce has been the sustaining life blood of economic and political survival. To impede commerce with redundant and useless laws, a political solution, is to deny growth and deter competition. There is a need for the maritime community, local, regional, national and international to clean-up their respective acts. Pilotage, in general as a service, not just a business is in a universal state of confusion as to qualification, competency and what is acceptable seamanship. Money alone is not the panacea, personal dedication and skillfullness come to mind.

As an accepted process licensed pilots, in most cases are found competent by virtue of their tested local knowledge. Licensed officers are also examined and based on a percentage score, licensed. That process has been historically accepted , however reliability and proficiency in the myriad of tasks required to be performed is not. A master, acting as co-pilot may not be equally qualified or competent as the person directing the navigation of the vessel, and therefore errors in judgment may be overlooked. The public is unaware and yet public safety is of concern. How many similar errors are repeated before the law of averages kicks in?

The history of pilotage is replete with cases where mandated local licensed pilots were not considered competent to moor and undock vessels; a specialized skill. Not to say they were not, but owners and managers were concerned and cautious; and they pay the bills.

The comparison of the pilots role versus the masters alludes to the increased burden for masters while the duties of pilots has changed little. Both are presently compensated at their worth, but in any grouping there is an average. Each has undergone various forms of training and then turned lose to practice, essentially without evaluation. Although copious dollars are spent on training individuals, the bridge teams may not be. An untrained team lacking discipline is a gang. Although not specifically pronounced the role of owners, managers and operators must include responsibility for any failure to verify that employees are qualified and competent and perform in the manner required by rule. A vessel found undermanned, crewed with unqualified persons or lacking operational proficiency is unseaworthy and local authority, as a matter of public policy, should be responsible to detain it. - John Denham

For a business to be successful you need hard work, willingness to accept risk and a touch of luck. For gCaptain the bit of luck was someone else’s misfortune, namely that of John Cota, Pilot of the ill fated container ship Cosco Busan.

Historically pilots don’t assume liability for incidents occurring regardless of fault. This is the case because historically a pilot’s job was to serve as a local advisor, expert in the location of reefs, buoys, current patterns and the flow of traffic within a port. The handling of the ship and command of the crew was left to the person that knew them best, the captain. So what has changed?

First ships and cargo have been standardized. In the past ships brought every cargo needed to sustain the businesses located in and around a port city. Fuel, raw material, imported goods and the myriad of miscellaneous material needed for the growth of an American city floated in on the hulls of a wide variety of vessels. Today ports specialize in certain types of cargo. Industrial cities have bulkers arriving daily while energy hubs, with refineries and pipeline terminals, primarily welcome tankers. Oakland’s specialty is containers and the city welcomes boxes that leave daily on trucks and trains bound for the warehouses of America’s retailers.

Not only do individual ports welcome similar types of ships the vessels themselves are closely matched. Naval architects have shared ideas and small domestic shipyards have long since been driven out of business by a much smaller number of large overseas yards that can put together ships at a rate approaching that of World War II. The vessels they build not only look alike but have similar handling characteristics and docking features.

Pilots have also taken on a larger number of tasks. The pilots of San Francisco Bay were at one point responsible only for bringing vessel from the bar to an area close to the dock. Docking pilots moored the ships. This is still done in many ports like New York and serves to limit the number of skills and thus training, experience, etc… required.

While the daily experience gained by pilots on similar types of vessels, combined with additional tasks increasing their knowledge of vessel dynamics their counterparts, the ship captains, have seen a different reality. Tracking of ships, satellite communications, professional weather routing and other advancements have resulted in increased oversight and management of a captains duties. Regulatory changes have resulted in an increase in paperwork all needing the masters approval and oversight. The amount of time available to learn the capabilities and shortcomings of a ship and her crew.

Pilots and ship captains have also diverged in one other aspect, training. The result of ship incidents and the subsequent investigations spark motivation for change and the need for more training more often than not tops the list of recommendations for improvement. While improved training of crews is desperately needed we must look at how the training of captains and pilots differ. Captains are regulated by a multitude of domestic and international authorities each requiring a specific courses that must follow a set curriculum. Companies often increase the amount of training with internal courses organized by ship managers and Human Resource departments.

Pilots, on the other hand, are regulated by local authorities who look to pilot commissions to dictate requirements. These commissions are often populated by the very pilots they seek to regulate creating a minimum standard much lower than that required of a captain. This does not sound like the a positive dynamic but, in ports with truly competitive pilot application processes, the bar is raised at the point of entry obviating the need for training and regulation to address the lowest common denominator. Pilots are also highly visible in their local communities and subject to high levels of personal scrutiny when incidents occur. John Cota’s wife, for example, was a Peteluma councilwomen well know in political circles. The self desire to be seen as skilled professionals and enjoyment of a loose regulatory structure, not fear of incarceration, drive a desire to be good at what they do…. This drives training structures that work.

I won’t dive too deep into the differences between the two training structures but I will say that once required training is completed by a ship’s captain there often is not the budget, time or energy to participate in training that exceeds the bare minimum. The oversight of this required training limits the freedom of maritime schools to offer unique solutions or even change course when new ideas are introduced within the community. Pilots have the opportunity to work closely with training providers to tailor courses to their needs and have more freedom to seek non traditional means of training.

With daily experience gained on similar types of ships, improved training and self regulation it was only a matter of time before the proficiency of our nations pilots past that of captains in navigating inland waters. Captains have increasingly relied on this experience to get their ships docked safely.

So with pilots becoming increasingly more proficient and new technology continually being developed to assist them how could the Cosco Busan allied with the Bay Bridge?

Like the large majority of catastrophic events caused by man it’s an insidious compilation of events that cause the incident. This error chain leaves many to blame but I feel compelled to highlight the primary failures and, yes, assign blame. So here goes; the individual most responsible for the incident has yet to be named!

John Cota made two crucial errors; a willingness to proceed (even rush) under adverse conditions and refusal to fully utilize resources available to him, namely electronic charting systems. Captain Sun also made two critical mistakes; acceptance of the position and willingness to proceed on the day of the incident. The high level of proficiency and low incident rate of our nations pilots helps to explain Cota’s decision and Captain Sun’s trust of his decision to proceed that morning but does not explain either’s willingness to proceed knowing one important fact; the entire vessel crew was replaced just two weeks prior.

It is rarely disputed that one of the greatest recent advancements in the safe operating of vessels has been the industry’s embrace of Bridge Resource Management but how can a bridge team operate using these principals if they have not had time to explore each others strengths and weaknesses? How can a team learn a vessel with only two weeks aboard her? And how can team members share vessel and interpersonal knowledge if there is no continuity?

John Cota made critical errors that directly resulted in the incident but the most profound error he shares equally with Captain Sun; a lack of courage. In regards to Captain Sun the profanity of this decision is compounded by the mariner shortage which provides ample opportunity for mariners to leave companies that make unwise decisions. For Captain Cota it’s making the decision to work aboard a vessel with no hope of fully utilizing BRM despite having a pilot association with a history of supporting pilots who stop unsafe jobs.

Despite all the differences pilots and captain’s share two similarities beyond their proficiency in moving large objects; a lack of courage and unwillingness to embrace changing times . The real failure, however, rests with the individual who’s final approval was required to sweep aside the need for continuity and replace the entire crew of the Cosco Busan in one single sweep. Unfortunately, he is unlikely to ever stand trial. The best we can do is extend the concept of BRM to broader ship management. It’s not until captains broaden their horizons from the ship’s bridge to vessel & intercompany resource management that incident rates will once again fall.

-John [Continue Reading →]

More on accidents and why.

By John G. Denham

A pilotage pardox presently exists because of the lack of explanations as to the “root cause” of accidents; basically, a failure to comply with existing rules. There are more rules than there are ships. Piloting is a function of navigation, but it requires an understanding of who is directing the navigation of the vessel i.e., an employed pilot not a ship’s officer, or a ship’s officer licensed to pilot. (33CFR Part 164.11). Standards for duties and responsibility for persons in charge of a vessel (persons piloting) have been legally established in Atlee v N.W. Packet Co., (1874) ,88 U.S. 389, 22l.ed. 619.

By law, custom, tradition and attitude many pilots that have not experienced the U.S. courts continue to perform as “one man shows.” However one must recognize the difference between a river pilot and a bar/harbor pilot: e.g navigating the San Francisco Bar Channel and the ports on San Francisco Bay and the pilots that navigate to Sacramento and Stockton, California. In the later case, a river pilot is “directing the navigation” This is not to say that the route to and from sea is a “piece of cake”, it is not.

The view that transiting the Oakland Bar Channel is a “relatively simple matter” is misleading in that the bar channel is nearly perpendicular to the currents and the published predictions are frequently inaccurate. Therefore, in limited visibility a person directing the navigation must rely on radar navigation to determine set and drift as it occurs because as one transits the bar channel the effect of the current changes. Experience in this case dictates: in fog, one concentrate on radar navigation.

Hearings, inquiries and investigation seldom develop the “root cause” of accidents because they have limited experience, knowledge and are mostly guided by bureaucratic constraints and therefore if fault is found, they send the culprit to ship handling training. Why, because there is no other appropriate remedy available.

No one knows what actually occurred except the Captain of COSCO BUSAN and pilot Cota i,e: why so many rudder orders? What passage plan was discussed? Was the track plotted on the chart 588 accepted by the pilot and Master? The NTSB hearing produced exceptional testimony and information however, no analysis or report has been produced, but professional mariners and second guessers have theories. Under keel clearance does have a maneuvering effect in current and changing water depths, but probably not relevant in this case. Using only NTSB data at time 08 27 37 Cosco Busan there appears no feasible alternative course change to the right.

Most importantly, is the mostly common practice of pilots and ships not using BRM as a safety feature in voyages and navigation practice. Although taught, stressed and published BRM is not universally followed. There are reasons, some valid, but all are resolvable. .

Many ports have a relatively calm and secured bay for pilot operations that allow discussion. Not so at the ocean boarding stations at some west coast pilot stations, however there is no rule that one should proceed at full speed until ready.

Essentially, if the BRM is to be accepted and function as per its purpose, then the owners, managers and professional pilots must mandate implementation. The simple solution ” if the BRM is not functional the vessel is not seaworthy” JGD

Our recent post Was the titanic sunk by a small key? elicited some great response from our readers. Surprisingly, the best ones had little to do with the titanic itself and more to do with the cause of all maritime incidents… the error chain. First a recap from the original post:

While some point to the ship’s excessive speed, the vessel’s design or the positioning of the ship’s compass as the cause of the incident the facts clearly show the titanic sunk as a direct result of the accident chain>. In other words the titanic sunk, not due to one large error but a combination of small errors that linked together caused the tragic circumstances. Remove one small link in the chain and the incident is avoided.

It is interesting to note that a string of small errors caused by human error is the cause of most large maritime incidents. The lesson to be learned….. next time you make a mistake aboard ship listen for the voice in the back of your mind and quickly ask yourself; is this an isolated incident or indication of larger problems?

Shrivan states; “Now I understand how important keys can be in ships” to which Fred Fry replies; “Keys are important. Keys are power!”

This comment reminded Jim of a quote from his Captain: “Give a man key with a clipboard and you’ll find out what kind of person he is. Give them in the morning and you’ll know by lunch.”

Things start to get serious around comment number 20 where Bob Couttie writes:

In the past I’ve used ‘error chain’ and ‘domino effect when discussing accidents but, at the risk of getting too theoretical I think both are inadequate since they are basically descriptions of single-point failure (A chain fails when a single link fails, a domino falls over when its neighbour hits it).

The best physical description I think is the wooden tower game, “Jenga” or “Topple” in which players take turns removing blocks from a stack. The first few extractions don’t do much harm but as the process continues the stack becomes more and more unstable until one reaches a point where removing any block at all will cause the stack to fall over.

If you think of the tower as ’safety’ and the individual blocks as the elements, precautions, procedures that make up safety, you’ve got a fairly good visual model for how accidents happen.

Kennebec Captain replies in agreement and points us to this post on his blog:

A more helpful model is the Swiss Cheese Model first proposed by British psychologist James T. Reason (nice name!).

This site (Dukes.edu) has a nice graphic of the S.C. model.

The Swiss Cheese Model provide a positive method of reducing risk, rather then seeking to break some invisible chain, one simply adds layers, or increases the effectiveness of the existing layers (making the holes smaller). As an example, one could add a layer of crew training, or seek ways to improve the effectiveness of existing training, or use additional care during passage planning.

On a well run ship you can observe the Swiss Cheese Model in action Each near miss, representing a hole in one layer, is evaluated and if needed procedures are modified. Near misses, lessons learned, Bridge Resource Management, careful passage planning can all be seen as adding layers of cheese. Of course it may not be called that. Another name for the application of the Swiss Cheese model is - good seamanship.

So from the Titanic to Swiss Cheese I enjoyed the comments… thanks to all who participated!

The San Francisco Chronicle has published the Pilot’s Report on the Cosco Busan Incident. Here are the parts of interest to mariners;

Meadows said problems also cropped up in “bridge management,” the communication between the pilot, who had years of experience on the bay, and the ship’s officers, who had never navigated the bay in the Cosco Busan. All were supposed to work together and exchange information on how to successfully navigate the harbor.
“While some information was exchanged, perhaps it could be said it wasn’t a full transfer of information. It was enough for the pilot to work with the master and get the ship ready for sea,” Meadows said.

We have previously reported on bridge management also know as Bridge Team Management or BRM.

gCaptain’s BRM related articles;

• Cosco Busan - Bridge Resource Management
• Environmental Catastrophe Possible Averted - M/V Pasha Bulker
  
• Pasha Bulker Incident Report - Nearly Unbelievable
• What Went Wrong Aboard the MV Pasha Bulker? (Telstar Logistics)

The article continues;

The Cosco Busan’s radar “conked out” twice - first before departure and again as the ship was near the lighthouse on Yerba Buena Island.

Cota was forced to rely on an electronic chart display, showing the track of the vessel and its speed, plus charts of San Francisco Bay. Meadows said the pilot told him he was “not familiar” with the electronic system on the Cosco Busan. “They are all different,” Meadows said.

Cota asked Mao Cai Sun, the captain of the Cosco Busan, to point on the display to the center of the bridge span between the Delta and Echo towers on the western side of the Bay Bridge.

“The master pointed that out,” Meadows said. “In fact, several times during the trip. That’s what the pilot was heading for.”

…

“The pilot had to go along with what the master indicated on the electronic chart display was the center of the span,” Meadows said. “That turned out to be the tower instead.”

We have received email asking; Should the vessel have left without a working radar? and Did the second radar work? …unfortunately those are questions we can’t answer. You will have to wait until the NTSB investigation report is complete.

Read the full SF Chronicle article HERE.

Related Maritime Blog Posts;

Pilot Terror by Bob Couttie