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.

While it has subsequently come to light that a passage plan for the pilot assisted portion of the voyage did not exist, the outcome would have probably been the same had there been one. Why? By many accounts, pilotage is still a “one-man-show” in most parts of the world. The intended route is almost inevitably “in the pilot’s head” and a “team approach” is in theory only. Under this paradigm, if the pilot, for any reason, loses situational awareness or makes the wrong decision, the team cannot correct, object or challenge. I have found, in my ten years as an accident investigator, that while crews and pilots are generally well informed of BRM techniques, they do not apply them when a pilot has the con.

I am aware of only one pilotage jurisdiction that has radically changed the way they do business. For ships arriving off Brisbane, bridge teams, and in particular the OOW, can expect to be treated differently by the pilot – they can expect to be treated as an effective member of the navigation team. Brisbane pilots have, for some years, introduced the following procedures;

• On boarding, the pilot asks to see the ship’s passage plan and the pilot takes the bridge team through his own passage plan during which time any variances in the two plans are discussed and resolved.

• The pilot will not take over the con of the vessel until the courses on the ships charts and the pilot’s passage plan are the same. Any variances are amended on the ship’s charts (paper), ENC, and radar.

• The OOW is asked to confirm with the pilot each alter course position as they approach to within 7 cables of the position as well as the mark used to alter course and the next course.

• The bridge team is encouraged to use the pilot’s Portable Pilot Unit (PPU) for comparison purposes – but not as a prime means of monitoring the ships position. The PPU is used as an aid to navigation, independent of the ship’s equipment.

This last point is reassuring as we now see a proliferation of pilotage authorities adopting the use of PPUs by their pilots. While this is not in and of itself a bad thing, if the bridge team is excluded from this equipment we would only be entrenching and validating the “one-man-show” paradigm.

Brisbane pilots must be congratulated for breaking the mold and showing the way forward to a better way of pilotage. Yet, their innovation was not without some resistance. When first developed, a number of their pilots were convinced they could never get foreign crews to competently participate in such an exercise. These preconceptions have proven quite wrong! Today, some six years along, Brisbane pilots have been pleasantly surprised by the competency and cooperation of ship’s crews. And the corresponding response from crews has been one of enthusiasm and a sense of genuine participation in the pilotage operation.

Some jurisdictions, such as those with short pilotage runs (but not exclusively so), may try and rationalize away these procedures as not practicable for their area. But in today’s world of electronic charts, DGPS, centralized vessel traffic control, and easy electronic communication, these are only feeble excuses – a death clutch to the old way of doing things. For a majority of pilotage areas today, there is no reason why standardized pilotage passage plans cannot be transmitted to the vessel beforehand so as to be noted on the charts, electronic or otherwise. When the pilot boards the vessel, any last-minute corrections or changes can be agreed upon, thus proceeding without delay – and everyone is singing from the same song sheet!

In a published report by the Transportation Safety Board of Canada (TSB) one can review circumstances similar to that of the Cosco Busan. While downbound in the river at night and while under pilotage, the container vessel Horizon was allowed to continue past the pilot’s customary course alteration point (see “A” in diagram) by approximately three cables, or, in other words by 50 seconds at a speed of 15 knots.

Vessel Horizon positions before and after grounding (from TSB report M04L0092)

No correction or challenge by the OOW was forthcoming as the vessel passed the pilot’s customary course alteration point and plowed into the mud bank on the south side of the River.

Suffice it to say that bridge ergonomics, BRM, as well as pilotage practices and procedures have a ways to go before the precise navigation of a large vessel by a pilot and crew of two or more can be accomplished in a seamless, complementary and consistent manner. With the proper planning, intended courses can be adhered to and mistakes, if made, corrected in time to avoid nasty consequences.

Additionally, maybe vessel bridges will have to change –possibly reduced in size and with a more ergonomic and compact layout to bring the team together. Better all-round visibility would be a great advantage as well. Since BRM was inspired by the air industry’s “cockpit resource management”, maybe so too should the designers of ship’s bridges be inspired by the airplane cockpit.

TSB report M04L0092 – Grounding of the Container Vessel Horizon, 2004.

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This post submitted by Paul Drouin is a condensed version of an article written for the September 2008 edition of Seaways Magazine and can be found HERE.

Captain Paul Drouin has over a decade of marine accident investigation
experience. He is a graduate of the Canadian Coast Guard College (class
of 81) and a licensed Master Mariner (Unlimited). After serving for 15
years on all manner of Coast Guard vessels (five as master), Paul moved
to a shore job as Marine Superintendant before beginning his
investigator duties in 1998. He is also founder of SafeShip, a company
dedicated to safer ships and safer crews. He lives in Lac-Beauport,
Quebec with his wife and daughter.

Paul’s website: www.safeship.ca
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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

Prior to being asked to comment the Chronicle’s lead maritime reporter contacted our friend Captain Kelly Sweeny who discussed industry wide problems with marine technology. The article states;

Sweeney said the AIS is “occasionally unreliable,” has blind spots such as when a ship is behind islands or structures, and is “antiquated” when compared with modern electronics.

Rewinding to my conversation with the reporters, the first question asked was; “Captain Sweeny believes the system used by San Francisco’s Vessel Traffic Service (VTS) is antiquated, do you agree?” After requesting further clarification I was asked why the pilot’s data on his Electronic Chart Display was trusted over VTS’s radar and AIS information.

My answer was “VTS’ AIS system is susceptible to the delay inherit in the VHF transmission of AIS data” BUT, to be honest my initial gut reaction was, “no AIS is not antiquated… it was fully implemented less then 3 years ago”, I quickly corrected myself. My second answer was quoted in the article and reads;

“The maritime industry is slow to act on electronic devices,” said Capt. John Konrad, who runs a Web site called gCaptain. “By the time they get approvals on electronics, they are obsolete.”

Why the quick change of opinion? It’s because I love AIS.

This technology, properly called Automatic Identification Systems, allows me to overlay important data on my radar displays. It also allows me to contact a ship with a zero cpa (collision course) with great ease. For example, prior to AIS I would have to say “Calling the vessel in position x.xx degrees N, x.xx degrees west on a course of 267 and speed of 6knots this is the xxx on channel 16″ where now I simply look up the ship’s name and say “This is the xxx calling yyy on channel 16″. Furthermore the AIS display gives me the vessels MMSI number which opens up new and creative ways to avoid collisions. Finally, my AIS digital read-out really saved the day (and my career?) when our radars, as the Cosco Busan’s Pilot John Cota said “conked out”.

That was not my only hesitation. San Francisco Pilots are some of the most respected individuals in our profession (a dream job for myself) and I only have positive things to say about my dealings with VTS. So could they be wrong in their choice of equipment? It seemed unlikely.

In defending VTS and the Coast Guard’s systems another respected expert, Rear Adm. Craig Bone – Coast Guard district commander, commented on questions raised by myself and others. In covering today’s hearing The Chronicle reports;

Bone said he could think of no excuse for the crash. He denied reports by maritime sources claiming the electronic systems the Coast Guard uses are out of date. The pilot equipment and onboard navigational equipment are some of the most advanced, he said.

“There is no basis in my mind for this to have ever occurred,” Bone said. “Something on that ship had to go terribly wrong. It was totally preventable.”

So the question becomes; “If AIS is a loved safety improvement endorsed by maritime experts worldwide why does Captain Kelly (and myself!) consider it antiquated?”

The reason is because we can do better! In the world of cutting edge technology solutions are available now that would have given Cota and VTS a much better chance of avoiding the incident. The problem, that I suspect is an industry wide tendency, is two fold. First we are so far behind the technology curve small improvements, like AIS, seem large and exciting. Second, most licensed captains are Luddites (my self included) who want to make sure a new system is reliable before implementing it aboard ships.

I come to this conclusion because, despite my writings on the need to improve shipboard technology (most notably HERE and HERE), I initially had the same reaction as Adm. Bone but quickly changed my mind. Why? Because Capt. Kelly is correct, our systems are antiquated and when new lifesaving improvements become available we must break away from the statement that has been rehearsed by ship captains for centuries; “Only history will tell if this is a good idea”. Exciting changes are happening worldwide and improvements in communications (the number one failure in all good incident chains) are leading the way. We must change with the times and embrace technology as the benefit is a reduction of incidents and a preservation of the environment and human life.

For more information on this topic visit our Archives.

Still agreeing with Admiral Bone? Take a look at technology used by Tampa Pilots or Maine Pilots, upcoming portable ECDIS units, the VTS tracking system in Valdez, well documented problems with AIS Ask yourself “Can I send an area specific sitor message via GMDSS” or “Why can my son video chat with a pen pal in China while I’m having trouble raising a vessel 1000 yards away… and closing?”

Captain John Konrad is a USCG licensed Master Mariner of Unlimited Tonnage currently working aboard an 835′ship in the Gulf of Mexico. Since graduating from SUNY Maritime College he has sailed 4 of the world’s oceans and reports from his ship via satellite.

In other news The San Jose Mercury News tells us;

The International Maritime Organization saw the Cosco Busan oil spill coming: Last year, it banned new ships from being built with their fuel tanks along the hull beginning in 2010.
In effect, the U.N. agency determined that increasingly large, fast ships that carry as much fuel as a small oil tanker should not carry that fuel along the side of the vessel, directly behind a single-layer hull.
One UC-Berkeley engineering professor compared the design to the Ford Pinto, the 1970s car that gained a reputation for gasoline tanks that could explode in rear-end accidents.
“I think the Pinto is the perfect example,” said Bob Bea, who is also a former oil tanker captain. “We need to recall them and retrofit. Put them (fuel tanks) inside.”

Built in 2001, the Cosco Busan is among the growing number of bigger, faster container ships that have “winged tanks” – fuel tanks arrayed along the sides of the ship.
The IMO convention, adopted in March 2006, requires that by 2010 all new ships with an oil fuel capacity of 600 cubic meters or more must have their fuel tanks deeper inside the ship and behind two walls. That rule affects most large commercial ships, and would have affected the Cosco Busan.
Bea said few are aware of the action taken by the London-based IMO, even within the shipping industry, because the licensing bodies that put those regulations into effect have yet to write and distribute information about it.

The IMO convention applies only to new ships, or those that undergo major modifications. It does not phase out winged tanks, meaning it is likely that container ships with winged tanks will be around for decades.
“We have a fleet full of those damn things out there, and they are exposed and so are we,” Bea said.
The Cosco Busan is capable of carrying 5,500 20-foot containers, about half the capacity of the world’s largest container ships, which carry the equivalent of trains 70 miles long across oceans at 25 knots, or about 30 miles per hour. Continue Reading…

To follow gCaptain’s coverage of the incident CLICK HERE.

To view a photo slideshow of the incident CLICK HERE.

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.

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

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.

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? Simply because it’s an increase focus of incident investigation and watchkeeping.

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.

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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.