Some more events unfolded yesterday in the case of the Cosco Busan allision with the San Francisco Bay Bridge.  Fleet Management Ltd., the vessels operating company, plead guilty to two misdemeanor criminal charges and admitted it was partly to blame for the spill of 53,000 gallons of oil into San Francisco Bay.

If accepted, the guilty plea would also expose Fleet Management Ltd. to damages for the costs of the November 2007 spill and cleanup.

Fleet Management has also been charged with six felonies for allegedly concealing its navigation plans for the Cosco Busan and fabricating documents after the spill to interfere with the investigation. Its trial is scheduled for Sept. 14.

Source: San Francisco Chronicle

Analysis of the Analysis
By John G. Denham

Recently three ponderous documents have been published  that may eventually affect pilotage, ship management and hopefully bridge resources management (BRM): USCG report on the allision involving the COSCO BUSAN; NTSB report on the same and the public submission by John Meadows and K&L lawyers representing pilot John Cota.

In examining the reports I arrived at the conclusion that the author(s) are mostly legal people, and therefore compose legally but not nautically. In my up-bringing, I was exposed to a knowledgeable senior officer named that assigned me to review a collision report. “Normally,” he said, “I seek an officer with some personal experience in these thing, but they don’t seem to be around much, therefore as you seem to be somewhat involved. Look this over. Pick out the B.S.” He felt the best experts on accidents were those with actual experience. In three earlier published articles the conduct of bridge team management was presented, the procedures for handling pilots was discussed and the role of persons in command was explained. I have experienced all that and at times did not do too well. Since I have learned a lot from others’.
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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

Carl Nolte of the San Francisco Chronicle writes:

According to a report released Thursday by the state pilot commission…

“There was unequivocally pilot error,” said Gary Gleason, an attorney for the state Board of Pilot Commissioners, which is appointed by the governor to regulate ship pilots in San Francisco, Suisun and San Pablo bays.

John Cota was in control of the 901- foot-long container ship Cosco Busan when it smashed into one of the towers of the Bay Bridge on Nov. 7. The crash caused a 220-foot long gash in the side of the ship and punctured the ship’s fuel tanks. More than 50,000 gallons of heavy fuel oil spilled out, fouling 26 miles of shoreline and killing more than 2,000 birds.

Gleason presented the report to the seven members of the commission and closed with a recording of Cota’s voice, made on the Cosco Busan just after the accident.

“Oh, yeah, it’s so foggy. I shouldn’t have gone,” the pilot said. “I’m not going to do well on this one.” As Cota spoke, the mournful sound of the ship’s fog signal was heard in the background.

Continue Reading…

You can find the full pilot commission report HERE.

OPA 90, the legislation enacted after the Exxon Valdez incident mandated double hull technology, essentially wrapping a second hull around the first, on all newly built tankers. While this has been mostly effective and (had it been mandated for use on container ships) would have prevented last year’s San Francisco Oil Spill, it fails to protect the environment during catastrophic groundings. Mo Husain of MH Systems, Inc. has recently worked on perfecting alternative means of “loss of containment” prevention. He tells us:

CONCEPT MADE SIMPLE
Imagine a Straw…

The underpressure concept is best understood by making an analogy with which most people can identify. Imagine sipping water half-way up through a straw and sealing off the top of the straw with your fingertip. A simple principle of hydraulics allows the water to be held in the straw at this level until the finger is released.

This same principle allows oil to be contained within the hull should a rupture occur in the tank. When a tanker is loaded, the oil level inside the tank is higher than the surrounding seawater level. This causes a higher pressure to exist inside the tanker due to hydrostatic pressure. Normally, when a hull is ruptured, the pressure inside forces oil to flow out up to the level of the surrounding seawater (discounting density). Using AUPS, this complete loss would not occur.

The system equalizes the pressure inside and outside the tanker at the rupture point by applying a slight underpressure of 2 to 4 psi in the ullage space of the tank. As oil flows out, it is replaced by seawater up to the rupture point only. Oil loss is held to a minimum as all oil above the rupture point will remain in the tanker. In the event of an accidental grounding bottom rupture, AUPS would prevent virtually all oil spillage from the tanker.

For a comprehensive look at this system click HERE and for the work Mo is doing on Ballast Water Treatment visit his company’s blog found HERE.

Also see our related post History’s 10 Most Famous Oil Spills.

Pilotage Paradox

by Paul Drouin

The Cosco Busan accident, as with many others that have the same root cause, can be categorized into what I call the pilotage paradox. For on the one hand, we wish to confide the safety and con of the vessel to the pilot, yet on the other insist it is the crew and captain that are ultimately responsible and accountable for the safe conduct of the vessel.

In the seven minute interval between leaving the inner harbour and striking the bridge pylon, the pilot gave 13 helm orders without the slightest indication on the bridge of the Cosco Busan that anything was amiss. We know this because the National Transportation Safety Board (NTSB) has left an amazing amount of information on their public docket website, including transcripts of the bridge voice recordings.

Leaving berth 56 (Port of Oakland) and passing under the San Francisco-Oakland Bay Bridge is a relatively simple matter, even under blind pilotage conditions, as only two course changes bring you through the span. The Delta-Echo span of the bridge is wide, with a horizontal clearance of 673 meters, and is equipped with a RACON dead center of the span. For the Cosco Busan, winds were light and the vessel would be stemming the flood current as it passed under the bridge. This maneuver should not give an experienced 3rd Mate cause to sweat, much less an experienced pilot.

Under keel clearance was not great for the Cosco Busan, however, and as a consequence hydrodynamic forces on the hull caused by the flood tide would have been strong as the vessel’s sidebody came to obstruct the flow, which was setting at approximately 130° (T) near the bridge and anywhere up to 168° (T) further from the bridge. [Continue Reading →]

Today’s AP wire tells us:

The U.S. Justice Department filed a lawsuit six months ago accusing the pilot and the owner of the Cosco Busan of breaking environmental laws when the ship struck a bridge support and spilled 53,000 gallons of toxic oil.

In legal papers filed Thursday, Hong Kong-based ship owner Regal Stone argues that the episode was caused by what it called the gross negligence and willful misconduct of the United States.

The company says the government should not have granted Capt. John Cota licenses because he was not medically fit for duty. (Full Story)

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BYM Marine and Maritime news is reporting:

A federal grand jury has returned an indictment charging John Joseph Cota, a U.S. Coast Guard and California licensed ship pilot, with making false statements to the Coast Guard concerning his medications and medical conditions in 2006 and 2007. The false statements arose from annual physical examinations that pilots are required to complete every year to maintain their pilot’s license.

Cota, who was the pilot of the Cosco Busan, was previously charged with negligently causing the discharge of approximately 50,000 gallons of oil in San Francisco Bay from the 65,131-ton container ship when he caused the ship to collide with the San Francisco Bay Bridge on Nov. 7, 2007.

The grand jury’s indictment supersedes and includes charges brought previously by a criminal information that charged Cota with violating the Clean Water Act (CWA), as amended by the Oil Spill Act of 1990, and the Migratory Bird Treaty Act by causing the death of protected species of migratory birds.

The full post is here.

Those with medical concerns at sea should also check Global Rescue’s Medical Extraction Insurance for Mariners

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This post was written by Richard Rodriguez, Rescue Tug Captain, and US Coast Guard approved instructor for License Training. You can read more of his articles at the BitterEnd of the net.

Not Being John Cota

by Bob Couttie

“Capt. Cota acknowledges the lack of situational awareness and does not expect it to happen again.”
Board of Pilot Commissioners for the Bays: Investigation into the grounding of the M/V Pioneer…on 20 February 2006.

Bay pilot John Cota’s week it wasn’t, starting April 8, 2008. Since the US Department of Justice has already charged him on two criminal counts, an act likely to hinder a helpful investigation, his lawyers advised him to claim the protection under the Fifth Amendment of the US constitution against self-incrimination and declined to give testimony at the public hearings of the US National Transportation Safety Board, a protection ironically, which the US government does not want extended to non-US seafarers.

The ship’s crew, currently detained as ‘material witnesses’ for Cota’s trial did not give testimony, either.

Much of the second day of the hearing was occupied by evidence on Cota’s medical condition and previous history of alcohol abuse - he was tested for alcohol immediately after the incident and found clear. After the incident, the US Coast Guard asked Cota to surrender his mariner’s license because “the listed potential side effects of those medications and how they may or may not have some impact upon his judgment, his ability to function, cognitive ability,” said Chief of the Regional Exam Center, George Buffleben.

A medical witness, Dr. Robert Bourgeois, told the hearing “I wouldn’t want anyone taking those medicines and having to make decisions in a safety-sensitive position”. When askled if he would let his children board a bus with a driver using such medication, he said “my kids would not be on that bus”.

John Cota, call sign Romeo, was evaluated for renewal of his license in January 2007 under a system that is currently undergoing changes. However, this does call into question the effectiveness of the medical examination process.

This does not necessarily mean that Cota was suffering impairment. If he was, the hearing was told, it would be difficult for the master or officers to tell whether or not he was so impaired as to present a hazard. Under US legislation ship’s officers are required to obey the orders of the pilot unless he is clearly incompetent or incapacitated.

There has been much comment about alleged problems with the radar, AIS and ECIDS, with Cota saying that the latter was confusing. It is clear for the VDR transcript that he was struggling with both. The pilot who had conducted the Cosco Busan inbound, Captain Nyborg, had no problems with radar or AIS, and these were found to be working after the incident.

He also had little problem communicating with the Captain, Mao Cai Sun, nor with the helmsman.

Captain Nyborg did notice a problem with the ECDIS, with the track being offset to the west. Nyborg disembarked the Cosco Busan and later went to the pilot conference centre for a monthly meeting. From there he saw the ship coming away from anchorage 7 and moving towards anchorage 9, “I was surprised because I recognized her as a ship I put in Oakland, and it would be very unusual for that ship to be coming to the wrong direction unless something had happened or something was wrong, like if they had a breakdown or something” said Nyborg. Other pilots present told Nyborg about the allision.

“I tried to remember where, you know, what issues I might have had with it, and what my, you know, if I had any difficulties or, you know, bad helmsman or anything like that. Nothing stuck out in my mind except that I, I remembered that, gee, I think that ECDIS display was showing a poor course as far as — a poor planned route through Delta Echo span, and I wondered if they had tracked the same deal coming outbound,” he told investigators.

Cota arrived at the meeting looking shaken: “(He) actually sat down within 3 or 4 feet of me, and I scooted my chair over and out of concern asked him, John, how you doing? He described how he was doing. Oh, my God, John, what happened? And, and he was visibly shaken. And I said you know what you should look into that - you should look into this ECDIS display because I believe it was, it was running West of where it should have been on my inbound. And of course I didn’t need it, but if you relied on it at all maybe it ought to be something that is investigated.”

Surprisingly, or prehaps not considering the possible emotional impact of the event, Cota forgot about the meeting: “John called me last night, and he had actually — didn’t recall me telling him that. He’s like there’s rumor around that you saw this or saw that, and I’m like, John, I talked to you at the meeting. Didn’t you remember that meeting? He said, no. I was really rattled, and I probably talked to people I didn’t, I don’t remember talking to. And that’s very understandable, you know,” said Nyborg.

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Bob Couttie has written for a number of maritime industry publications, including the prestigious Lloyd’s List International daily newspaper and Lloyd’s Ship Manager magazine. His reportage on problems with ship’s officer certification examinations in the Philippines in the late 1990s influenced the adoption of computerized examinations for ship officers by the country’s Professional Regulatory Commission.

Bob currently writes and produces podcasts for The Maritime Accident Casebook