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.
[Continue Reading →]
Related Posts:
Tags: · cosco_busan, ntsb, USCG
Read the ful synopsis HERE
Via NTSB.gov
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 →]
Related Posts:
Tags: · cosco_busan, john-cota, ntsb, san_francisco_pilots
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.
[Continue Reading →]
Related Posts:
Tags: · cosco_busan, john_cota, ntsb
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 →]
Related Posts:
Tags: · accident, allision, bay bridge, cosco-busan, cosco_busan, disaster, Marine Incidents, maritime pilots, maritime safety, ntsb, oil, safety, San Francisco, san franscisco bay
The Windoc blocks the canal. Alex Howard
In August 2001 the Bulk Carrier Windoc was lined up on the Welland Canal’s Bridge 11 in Ontario Canada. After recieving the flashing amber approach light indicating that the bridge operator was aware of the vessel the captain lined up on the centerline and maintained a speed of 5 knots. Minutes later while the vessel was half way through the bridge started descending.
The Bridge Team’s Story
When the vessel was approximately halfway under the bridge, the third officer observed that the bridge signal lights were solid red and the lift span was descending. At 2053, the master sounded a few blasts on the ship’s whistle. The master, without identifying himself or the bridge in question, called the TCC on VHF channel 14 about the lowering of the bridge. The master quickly stopped the engines and ordered an evacuation of the wheelhouse.The master and third officer left the wheelhouse by the starboard navigation bridge wing. As they proceeded down the external bridge access ladder, the span of the bridge struck the vessel in way of the wheelhouse front windows, subsequently destroying the vessel’s wheelhouse and funnel. The wheelsman remained at his station in the wheelhouse and lay down on the deck as the bridge span passed overhead. He freed himself from the debris and descended by the deckhouse stairwell alive.
Miraculously no one was killed in the event. [Continue Reading →]
Related Posts:
Tags: · Bridges, canada, cargo ship, collision, damage photo, death, fire, Firefighting, ntsb, ship, ship photo, ship photographs, survival, windoc, youtube
Video of TSB report on sinking of Queen of the North. Click on the blue ‘Start Presentation’ button. (its slow loading).
It also has video simulation of the incident and chart & radar data from retrieved hard drives from the ship. Alternatively you can read the full report HERE.
(Ed. note: Thanks to BitterEnd reader Rod Pugh for leading us to this link.)
___________________________
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.
Related Posts:
Tags: · canada, ntsb, queen of the north, Video
This is National Sleep Awareness Week and the NTSB wants to share information on Crew Endurance Management. They write:
Endurance involves the body’s ability to maintain performance within safe limits while enduring psychological, environmental, and physiological challenges, Stevens said. Health, nutrition, stress, sleep, work schedules and noise levels all affect crew operations.
The issue in any situation involving transportation, whether it’s airplane, train, even a car or truck, is the fatigue issue, said Walter Blessey, chief executive officer of Blessey Marine Services in New Orleans. If someone goes to sleep when they’re involved in steering or running a piece of equipment, there can be serious consequences – maybe death.
Crew endurance management systems (CEMS) involve four categories:
* environmental factors, which are the effects of ambient temperature, noise and vibration on the human body;
* operational factors, which are the effects of company and boat policies;
* physiological factors, which are the effects of sleep, diet, exercise and shifts on the body and performance;
* psychological factors, which are the effects of stress and working conditions on performance.
Why is this an Important topic? Click this photo for the answer:
For more information visit the following links:
Related Posts:
Tags: · CEMS, Endurance Management, ntsb, sleep, USCG, watchstanding
Cosco Busan Photo by Noah Berger/Associated PressOctober 15th 2003 the Staten Island ferry crashed into a concrete pier killing eleven people and leaving 71 injured. It was later determined that the captain lost consciousness while at the ship’s controls. He had taken the painkillers Tramadol and Tylenol PM, both of which can cause drowsiness as a side effect. Since that time the United States Coast Guard has put increased scrutiny on the medical records of all licensed mariners, a review process that could get more stringent as details emerge regarding medication taken by the Cosco Busan’s pilot.The Associated Press tells us:
The ship pilot who was at the helm when a freighter spilled 58,000 gallons of fuel into San Francisco Bay in November suffers from a sleep disorder and was on prescription medication to ward off drowsiness, people close to the investigation told The Associated Press.Investigators want to know whether the disorder — or even the medication itself — contributed to the accident.Federal officials and others, speaking on condition of anonymity, said John Cota has sleep apnea, a breathing condition that can disrupt sleep all night long and leave sufferers severely fatigued during the day. Sleep apnea is blamed for countless auto accidents every year in which drivers nodded off at the wheel.Cota, 59, was also said to be taking a sleep-apnea drug whose known side effects include impaired judgment.Prescription drugs are “certainly a part of our investigation,” said G. Ross Wheatley, chief of investigations for the Coast Guard’s San Francisco sector.The disclosure has raised questions among members of Congress about the Coast Guard’s licensing practices and whether Cota should have been deemed fit for a job in which he was responsible for guiding giant cargo ships in and out of port and through the dangerous waters of the bay.Under Coast Guard policy, a sleep disorder can be grounds for disqualification, but is not automatically so. Continue Reading…
Those with medical concerns at sea should also check Global Rescue’s Medical Extraction Insurance for Mariners
Related Posts:
Tags: · bay bridge, cosco-busan, cosco_busan, investigation, john-cota, licensing, medical, ntsb, sleep, sleeping pills, USCG
The preliminary report on the Empress Of The North grounding and subsequent abandonment (no fatalities) was released by the NTSB today. The BBC reports;
Marino Cattiotti was put in charge for four hours because another navigator was ill, the National Transportation Safety Board report said.
More than 200 people were evacuated when the Empress of the North hit a rock 25 miles (40km) from Juneau.
The report called the designation of Mr Cattiotti as navigator “imprudent”.
Hull ripped
Mr Cattiotti was fresh out of a maritime academy, the National Transportation Safety Board preliminary report said.
It was his first voyage on the ship.
The report said instructors believed that “placing a recent graduate of the school with no watch experience outside of a training environment, on watch, at night, in pilotage waters, in an unfamiliar vessel, without any additional preparation and/or supervision, was imprudent”.
Mr Cattiotti had said he had not taken part in any drills or had any training on the Empress of the North.
Not that this is a surprise to gCaptain readers as we reported such in gCaptain’s 16th ever post, “Alaska Cruise Ship – New Mate, Wrong Turn” and also HERE back in May. What’s surprising is we have received insider knowledge that the Coast Guard had asked the young mate to voluntarily hand over his license and “find a new profession”. While this is standard operating procedure following an incident it is worrisome in cases like this. We are, however, happy to report that the young mate made the right choice in not handing over his license and is looking (or has found) a new job. No word on the Captain’s state of employment though.
Related Posts:
Tags: · alaska_cruise_ship, Empress Of The North, empress_of_the_north_grounding, Lifesaving Incidents, maritime_academy, national_transportation_safety_board, ntsb
Coast Guard Photo By CWO Scott Epeprson
I thought I would list a few podcasts, interviews and audio files that relate to the Cosco Busan Incident and the resultant oil spill in San Francisco Bay. If you find any more of interest please leave a comment with link below.
Our first file (click on the player below) is a very informative hour long discussion I heard on the radio earlier today. It is from KQED’s Forum and is nationaly syndicated by NPR. (Direct Link)
With a criminal probe now launched by the U.S. attorney in San Francisco into Wednesday’s crash of the container ship Cosco Busan, Forum looks at whether oil spills are preventable.
Host: Michael Krasny
Guests:
 |
Debbie Hersman, board member of the National Transportation Safety Board |
|
Paul Rogers, resources and environment writer with the San Jose Mercury News and managing editor of QUEST, KQED’s weekly science and environment program |
|
Rear Admiral Craig Bone, the U.S. Coast Guard’s top official in California; and George Miller, Democratic congressman from California’s Seventh District. |
|
Robert Bea, professor of civil engineering at the University of California at Berkeley |
First is the audio file from the US Coast Guard Commandant , Admiral Thad Allen’s meeting with the San Francisco Chronicle. (Direct Link)
Coast Guard talks with Chronicle
Coast Guard Commandant Adm. Thad Allen and Rear Adm. Craig Bone spoke to The Chronicle Monday morning about the oil spill and the Coast Guard’s response time to the incident. Here’s what they had to say:
Also see our related post History’s 10 Most Famous Oil Spills.
KQED Forum - Cosco Busan Oil Spill:
Play Now |
Play in Popup |
Download
Coast Guard talks with Chronicle:
Play Now |
Play in Popup |
Download
Related Posts:
Tags: · accident, admiral, audio, bay, bay_bridge, coast_guard, commandant, Container Ship, cosco_busan, Craig_Bone, Debbie_Hersman, forum, kqed, Maritime Expert, MARPOL Incidents, npr, ntsb, oil_spill, Paul_Rogers, podcast, Robert_Bea, San Francisco, USCG
gCaptain On Twitter
gCaptain On Facebook
gCaptain On LinkedIn
