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’. [Continue Reading →]
Earlier today, the National Transportation Safety Board released its final report on the allision of the M/V Cosco Busan with the Delta Tower of the San Francisco–Oakland Bay Bridge on November 7, 2007, resulting in the release of 53,500 gallons of fuel oil into San Francisco Bay.
The final report reflected sentiments expressed at the NTSB’s hearing on the accident in February as well as opinions reflected here on gCaptain. This included determination of probable cause, in which the Safety Board cited three factors:
the pilot’s degraded cognitive performance from his use of impairing prescription medications;
the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the accident voyage, and;
the master’s ineffective oversight of the pilot’s performance and the vessel’s progress.
First revealed on gCaptain’s Professional Mariner Forum (LINK) last week, the news is now official…John Cota, pilot of the Cosco Busan, has plead guilty to charges and faces jail time. The San Francisco Chronicle tells us: [Continue Reading →]
Washington, DC - The National Transportation Safety Board determined today that a medically unfit pilot, an ineffective master, and poor communications between the two were the cause of an accident in which the Cosco Busan container ship spilled thousands of gallons of fuel oil into the San Francisco Bay after striking a bridge support tower.
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 container ship 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. [Continue Reading →]
Today, the National Transportation Safety Board (NTSB) held a public board meeting on its investigation into the Cosco Busan allision. The goal of which, was to formally cite the probable cause of the accident and to make recommendations on improving safety.
UPDATE: Two animations presented today in the board meeting have been posted on the NTSB website and can be found HERE.
The first animation tracks the path of the M/V Cosco Busan on a nautical chart at 20 times real speed with the start time 08:00 and end time of 08:30 or time of the allision.
The second animation is of the same chart in real time from 08:26 to 08:30. Displayed this time is an inset of the radar along with the bridge voice recorder comments and the time they occurred. Both animations are narrated.
We should be seeing a synopsis of today’s hearing shortly. Below of some of meetings finding that were reported earlier.
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.
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
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.
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