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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

I have been amazed lately by the number of errors in both media reports and political commentary related to the the container ship Cosco Busan that allided with San Francisco’s Bay Bridge. We first reported on the confusion between the words allision and collision but that debate is mostly semantic. The errors have grown as the debate has reached a national audience.

The most troubling mistake is reports that infer or flatly state the vessel is a tanker. This mistake has been made numerous times as can be seen by doing a simple google news search for the incorrect term but most seriously in USA Today’s, America’s most widely distributed newspaper, headline (page A6 of November 12th’s edition): “Coast Guard: Tanker crew tested for substances.”

The media is not the only “informed” party making this mistake. The San Francisco Chronicle reports on a statement by San Francisc’s mayor:

Newsom 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.”

So for those in the media or with a passing interest here is a picture of an Oil Tanker and the Cosco Busan:

Tanker

Container Ship

The major difference between the two is: a tanker transports liquids and a container ship transports containers filled with solids (i.e. toys, home furnishings, industrial supplies…). So before the flood of emails arrive… if the ship that hit the San Francisco Bay Bridge was not transporting any liquids why did it have 58,000 gallons aboard? The answer is… for the same reason your car carries 24 gallons of gasoline.

The fuel spilled in the bay was all to be used by the ship’s enormous engines during the long transit back to China. Had this ship been an oil tanker the spill could have been as large as the one caused by the oil tanker Exxon Valdez… then again probably not since the oil in those ships are now required to be protected by a double hull.

Chronicle photo by Michael Macor

After visits from California powerbrokers Arnold Schwarzenegger and Diane Feinstein yesterday the head of the US Coast Guard, Admiral Thad Allen, joined the inspection team.

Here news of his visit courtesy of the San Diego Tribune;

“They talk about the fog of war. I think we had the fog of navigation going on this day,”

Allen said he himself didn’t learn the full extent of the spill until around 9 p.m. the night it happened last Wednesday, around the same time as most everybody else.

“We know that a good deal of marine accidents and casualties are human error,” he said. Coast Guard officials investigating the incident said Saturday that they had ruled out mechanical error.

“You don’t turn 900-foot vessels on a dime and given the visibility at the time I think it would be difficult to assess whether or not the bridge itself was visible,” he said, adding that would be part of the investigation, along with the vessel’s speed, communications among the crew and other issues.

So what happened that day? Who knows… we do not expect an official investigation to be completed anytime soon (think the normal 6+ months!). We are, however, willing to write down a few questions we hope some intrepid reporters with access to Admiral Allen do ask.

Questions for investigators;

We have reviewed a few big incidents in the short life of gCaptain including the grounding of the Pasha Bulker on an Australian Beach and the grounding of the Alaska Cruise ship “Empress of the North” in waters close to Juenu Alaska. In both of those situations a breakdown in communications took place.

What is the level of English competency of the captain and mate on watch?

Did the assist tug notify the pilot of the problem?

Did the master, mate (Jr. officer), anchor watch, or helmsman notice the error?

Were any problems or concerns relayed to the pilot during the pre-voyage master-pilot conference or was critical information left out of the exchange?

The bridge of a merchant ship is full of electronic aids to navigation. These devices can help investigators determine the cause of an incident IF they are looked at in a timely fashion.

What does the course recorder, a device that records heading directly from the gyro compass, say and does it collaborate the pilot’s timeline of events?

Did the Cosco Busan have an ECDIS (an electronic chart display) or did it rely solely on paper plotting? If the answer is no, what was the interval between fixes? Was all the equipment properly set-up? Was parallel indexing used?

In the AIS plots (if they are determined accurate) we see strong use of right rudder at the time it should have been apparent they missed the turn.

Could the pilot have completed a 360 degree turn away from the bridge and make a second attempt at the correct angle?

In conclusion, investigators should shy away from providing quick answers despite media protests and avoid singling out an individual in this incident. An incident might occur because the helmsmen failed to take a required training course a year back or due to a improperly installed antenna 6 years back or a policy decision 15 years previous. Most likely it was caused by all of the above and 100 additional errors that combine to form what marine incident investigators call an error chain. Remove one error in the chain and the allusion would not have occurred.

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?

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.

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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.

UPDATE: BoatingSF has a new animation that can be found here: COSCO BUSAN’S TRACK - UPDATED

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Our friend John of VesselTrax.com submitted this link to our Maritime News Discoverer. Click on the picture below and watch as the Cosco Busan leaves the dock and embarks on its fateful voyage.

From BoatingSF.com:

Path of the Cosco Busan Hitting the Bay Bridge

The animation below shows the Cosco Busan as it leaves the Port of Oakland on November 7, 2007, and hits the Bay Bridge at 8:30 am on its way to the Golden Gate.

The Cosco Busan is the bright red arrow. (Hover over a ship to see its information.)

You can see that the ship was traveling at an acute angle to the bridge and then turned sharply, directly into the center tower of the bridge. (The towers are highlighted with red dots to make them more visible.)

No cleanup ships show up in our AIS records. It is not clear whether they arrived later, did not have their AIS transponders on, or if for some reason our receiver did not detect their signals. (Coast Guard ships generally do not turn on their AIS transponders, so they do not show up.)

Click here for FULL ANIMATION

Stay Tuned as our licensed ship captain John Konrad is preparing a play-by-play video of this AIS data. In the meantime CLICK HERE for the SFGate’s excellent coverage of the incident.

UPDATE 2:

You can find a complete article on how this animation was made HERE.

In covering the recent San Francisco Bay Bridge incident I have noticed most (but not all) of the news articles have made a small error in terminology. In describing the incident where the Cosco Busan hit the Bay Bridge many prominent news organizations referred to event as a collision when in fact it was an allision.

For clarification: A vessel collides with another moving vessel…. A vessel allides with a fixed object (unless it is submerged) and is presumed at fault.

Marine Dictionary - Allision

For those interested in learning more about the incident here are some good links;

• San Francisco Bay Bridge - gCaptain coverage
• Ooops! Container Ship Collides with SF Bay Bridge
• Bridge Left Undamaged
• Chief Engineer Underestimates Environmental Impact
• Two Coasts - Two Allisions | MAREX
• Official Coast Guard Cosco Busan Updates (right column)
• Shipping firms to pay for oil spill
• San Francisco Shuts Beaches After Ship Spills Fuel
  

For future articles stay tuned with our Maritime News Discoverer’s Upcoming Links

Here is a photo of the environmental damage;

Kurt Rogers / San Francisco Chronicle

Update: [Continue Reading →]

Speaking at the Ninth Seminar of Marine Industries in Noshahr, deputy head of Ship-Making and Offshore Industries Company said that all stages of the ship’s manufacturing has taken place in Iran and by Iranian experts. The new ship to is capable of carrying 2,200 containers and is projected to be completed in March 2008.The Ninth Seminar of Marine Industries opened in Noshahr on October 24. (Source: PressTV.ir)

Related Links:

Iran to Buy 52 ships by 2010

This amazing photo of the ms Hjördis comes to us via Fred Fry’s weekly must read; Maritime Monday.

The picture above, by Ship Spotter Frederik, is of the Elly Maersk. Along with her sister ships the Emma, Evelyn, Eleonora, Estelle and Ebba Maersk she is the largest Container Ship in the world and the last of these giants scheduled to be built. She is also equipped with the largest engine in the world. Marine Link tells us:

On August 25, 2007 Odense Steel Shipyard presented its latest newbuilding, an 11,000 TEU container vessel, for the A.P. Moller - Maersk Group.

Like her five predecessors, Elly Maersk will be part of the series of the world’s largest container vessels, and she will like her sister vessels set new standards for safety and environment. Environmentally friendly silicone paint covers the hull of the vessel below the waterline – reducing water resistance and cutting the vessel’s fuel consumption by 1,200 tons per year.

With its 14-cylinder Wärtsilä RT-flex diesel engine which develops 110,000 bhp, Elly Maersk will enter Maersk Line’s worldwide service after delivery. Read More…

We have mixed emotions regarding ships of this size but, like the rest of the world, are impressed and amazed by her sheer size.

Related links:

• Video of her Maiden Voyage
• Track the Elly Maersk
• More Photos
• Fire on the Emma Maersk
• Emma Maersk photos video

How did this happen? According to Cargo Law:

January 2000 the vessel was attempting to turn in the area in front of the Maersk Container Terminal, Oakland so as to berth port side to the dock and have the vessel facing outbound.

- Would you believe it happen again just 6 months later?

First Allision (Maersk Tampa)

Second Allision (Glasgow Maersk)