Damage to the Cosco Busan after an allision with San Francisco's Bay Bridge.

John Cota, the former San Francisco ship pilot who shot to notoriety after crashing the M/V Cosco Busan into the Bay Bridge on a typical foggy morning in November 2007, would like his license back.

According to the San Jose Mercury News, Cota and his team of lawyers are working through the Coast Guard appeals process to try to renew his mariner’s license, in hopes of once again sailing commercially.

The Coast Guard, however, thinks differently.

After obtaining information through a FOIA request, the California newspaper reports the Coast Guard denied his appeal in February citing that Cota “did not meet the medical standards and the professional qualifications requirements for renewal” and another kernel of information; his criminal record from his conviction in the Cosco Busan spill.

The NTSB final report on the 2007 allision found that John Cota had “degraded cognitive performance from his use of impairing prescription medications”, among other contributing causes, but also mentioned a the U.S. Coast Guard’s failure to “provide adequate medical oversight of the pilot in view of the medical and medication information that the pilot had reported to the Coast Guard” as a contributing factor.

In July 2009, Cota was sentenced to 10 months in prison after pleading guilty to two misdemeanor charges of illegally discharging oil in the bay and killing thousands of birds.

The newspaper report adds that Cota has been working shoreside for a tug company and hopes to regain his license and work as a tug captain, “or something else.”  Cota and his team are considering all options that will allow him again to sail commercially, including considering a lawsuit.

The newspaper report from the San Jose Mercury News can be found HERE.

To read the evidence click HERE.

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:

The pilot of the container ship that struck the Bay Bridge in 2007 and spilled 53,000 gallons of fuel oil pleaded guilty today to federal water pollution charges in an agreement that calls for him to serve two to 10 months in prison.

Capt. John Cota, 61, admitted in a San Francisco courtroom that he acted negligently in piloting the 901-foot-long Cosco Busan in a heavy morning fog Nov. 7, 2007. He also admitted failing to disclose all the prescription drugs he was taking when he renewed his federal and state pilot’s licenses in 2006 and 2007.

But his negotiated plea agreement nearly fell apart when a prosecutor read a lengthy account of Cota’s alleged misdeeds and his lawyer protested that it was full of inaccuracies.

“An incompetent, untrained crew and mistakes by the Coast Guard” contributed to the accident, defense attorney Jeffrey Bornstein told U.S. District Judge Susan Illston.

Illston reproached Assistant U.S. Attorney Jonathan Schmidt for “arguing for the grandstand,” but accepted Cota’s guilty plea to misdemeanor charges of violating the Clean Water Act and the Migratory Bird Act. She scheduled sentencing for June 19.

Besides imprisonment, the plea agreement includes a fine of between $3,000 and $30,000. Cota, a vessel pilot for 26 years, has surrendered his license and said in his plea agreement that he would not reapply until January 2010. Read More…

The question remains… What are the implications for the maritime industry?

Read gCaptain’s series topic links:

• John Cota
• Cosco Busan Incident

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.

In its determination of probable cause, the Safety Board cited three factors: 1) the pilot’s degraded cognitive performance due to his use of impairing prescription medications; 2) the lack of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the short voyage; and 3) the master’s ineffective oversight of the pilot’s performance and the vessel’s progress.

Contributing to the cause of the accident, the Board cited 1) the ship’s operator, Fleet Management, Ltd., for failing to properly train and prepare crew members prior to the accident voyage, and for failing to adequately ensure that the crew understood and complied with the company’s safety management system; and 2) the U.S. Coast Guard for failing to provide adequate medical oversight of the pilot.

“Given the pilot’s medical condition, the Coast Guard should have revoked his license, but they didn’t; the pilot should have made the effort to provide a meaningful pre-departure briefing to the master, but he didn’t; and the master should have taken a more active role in ensuring the safety of his ship, but he didn’t,” said Rosenker.  “There was a lack of competence in so many areas that this accident seemed almost inevitable.”

As a result of its investigation, the Safety Board made a total of eight safety recommendations. In its five to the U.S. Coast Guard, the Board recommended that it 1) ask the International Maritime Organization to address cultural and language differences in its bridge resource management curricula; 2) revise policies to ensure that, in its radio communications, the Vessel Traffic Service (VTS) identifies the vessel, not only the pilot; 3) provide guidance to VTS  personnel that defines expectations for when their authority to direct or control vessel movement should be exercised; 4) require mariners to report any substantive changes in their health or medication use that occur between required medical evaluations; and 5) ensure that pilot oversight organizations share relevant performance and safety data with each other, including best practices.

The Board recommended that Fleet Management Limited 1) ensure that all new crewmembers are thoroughly familiar with vessel operations and company safety procedures; and 2) provide safety management system manuals in the working language of the crew.

The Safety Board also recommended that the American Pilots’ Association remind its members of the value and importance of a verbal master/pilot exchange, and encourage its pilots to include the master in all discussions involving the navigation through pilotage waters.

Two safety recommendations on medical oversight previously made to the U.S. Coast Guard as a result of an accident in 2005 were closed due to improvements the Coast Guard had made in its reporting procedures.

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

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

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Note: I was reluctant to write this article but strong imputes came with the US Coast Guards issuance of NAVIGATION and VESSEL INSPECTION NAVIC NO. 04-08 (details HERE). Upon discovering that John Cota took various medications under the care of a qualified physician it was soon clear this issue would be pushed by the Coast Guard brass. gCaptain asked a number of Coast Guardsmen and industry leaders about the impending regulation and we were told repeatedly that a list of medications and conditions would not be published, just guidance for medical professionals. We are deeply concerned that this NVIC and the push to give VTS power to override a captain’s decision are progressing while the true causes for the incident are not being published. If you disagree with any points mentioned here or see other underlying problems I ask you to leave a comment below or contact me directly at 805-456-8644.  -John

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.

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)

Click here to view the embedded video.

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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.

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