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

BY John G. Denham

On Wednesday 7 November 2007, it started as a short 10 AM radio news item. A tanker hit the bay bridge and some oil was spilled. Just another boating accident. By noon it was reported that the slight contact by a container ship with the “D” tower of the San Francisco Oakland Bay Bridge was more than slight and oil in an unknown amount was spilled. By sunset there were rumors that the oil spill was a major catastrophe. The media scrambled to find information but was unsuccessful. The USCG was not fully aware of the situation and there were no available eye witnesses coming forth Finding available transportation to the scene was near impossible as fog shrouded the bay although incoming ships, ferries and tugs seemed to be moving freely near the bridge.

Lacking official news, the print press, TV and a number of blogs did an excellent job keeping interested persons informed with bits of information pried from various sources and a network of unofficial marine observers e.g., “g Captain.com,” “ flickr.com ” and ”boatingsf.com .” The lack of speculation was evident and although the reports were accurate only professionals and maritime aficionados recognized inconsistencies.

Therefore, this review will summarize what was reported and insert explanations as appropriate, including probable scenarios of what may have transpired. Regardless of facts to be determined later, all the facts may never be known without the truthful statements of those involved.

There will be hearings, investigations, inquiries and probably court trials, both in admiralty and criminal and civil justice; one to find fault, others to make financial awards. The oil spill and its management will be examined by others, ad infinitum, but most disturbing will be the knee-jerk reaction by some to propose solutions before the reason is known.

Time has since passed and we now know the culprit was not a tanker, but the 284.7 meter ( 911 foot) motor (diesel) ship COSCO BUSAN, ex- Hanjin Cairo a foreign flag containership registered in Hong Kong. The captain was Mao Cai Sun of the Peoples Republic of China and the crew was allegedly Chinese. The San Francisco Bar Pilot was John J. Cota a veteran of 27 years as a pilot. The ship was nearly fully loaded with containers and bound for Korea. The China Ocean Shipping Company (COSCO) denied any ownership or managerial responsibility for COSCO BUSAN. The name HANJIN, a Korean shipping company was prominently displayed on the ship’s side but the reported owners are Regal Stone, LTD of Hong Kong and the managing operator was Fleet Management Limited of Hong Kong.

On or about 0830 on Wednesday 7 November COSCO BUSAN allegedly traveling at about 11 knots per hour “allided” (collided with a fixed object) with the southeast corner of the fender on the D tower of the bay bridge resulting in a large puncture in the port side of the hull and fuel tank, releasing approximately 58,000 gallons of fuel. The puncture, reported as 160 feet long and 4 feet deep was located several feet above the waterline and caused no immediate problem to the ship or its navigation. Shortly thereafter, the USCG was made aware of the accident when Pilot Cota reported, “ I touched the delta tower.”

Immediately after the allision COSCO BUSAN proceeded to an anchorage west of Treasure Island and bar pilot Cota disembarked and was replaced by another pilot that reported seeing only a slight oil leakage; probably because most of the fuel oil had already spilled and was not visible due to the flood current and fog. Containment of the spilled oil was delayed due to the lack of coordination between agencies, communication problems and the lack of understanding of the magnitude of the problem..

Of interest, and unexplained is the presence of the tug Lynne Marie with a tow approaching the “C” tower from the south and the inbound ship designated Hazard B anchoring in Anchorage 9, and three other vessels anchored south of the bay bridge and none reported any oil or the smell of fumes an hour after the allision.. By noon COSCO BUSAN was again shifted to an anchorage in the south bay. Inquiries and investigations into the accident and its effect were immediately commenced by numerous agencies.

By Tuesday 14 November 2007, 7 days later, the National Transportation Safety Board (NTSB) had heard statements that COSCO BUSAN’s radar “conked out”; the captain guided the ship toward a bridge tower; the pilot and the captain relied on an electronic chart display for navigation and, when alerted the ship was heading for the tower, pilot Cota allegedly replied he knew where he was going, The NTSB, and others reported they had found the radars to be operating properly and that all bridge equipment appeared to be operating normally. In the meantime, COSCO BUSAN was unloaded and moved to a ship repair facility and placed under harbor detention by the U.S. government.

On 6 December 2007 the Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun accused pilot Cota of misconduct. Cota was allowed 15 days to respond, but was granted an extension due to the severity of the case. Pat Moloney the Executive Director of the Commission and Gunnar Lunderg, a member, inquired into the incident and had sufficient concern and evidence to accuse Cota of misconduct, imprudence, non-compliance with numerous rules, regulations and laws.

Although presently not accused of violating Rule 2 of the Navigation Rules ( Rules of the Road), Cota et al., will probably be accused of failure to comply with the Rules, specifically:

2 (a) Nothing in these rules shall exonerate any vessel, or the owner, master or crew thereof from the consequence of any neglect to comply with these Rules or of the neglect of any precaution required by the ordinary practice of seaman, or by the special circumstances of the case.

The USCG requested Cota surrender his federal license and pilotage endorsements for reasons of “physical incompetence” implying mental or physical problems. An extension was granted with the provision Cota’s USCG license be held by counsel; the USCG pilotage endorsement is made on a Merchant Marine Officers license. The pilot commission had already suspended Cota’s California state pilots license; a separate license. I was disclosed that Cota was under treatment for a sleep disorder and using a number of prescribed medications and he had been cited for driving under the influence in 1999, and has a history of behaviorial activity and ship handling errors.

On 21 December after repairs were completed and being considered seaworthy COSCO BUSAN was released from harbor detention and allowed to proceed to a port in Asia after posting a $7.5 million bond ( Bottomary Bond). No mention was made of the officers and or crew, but on 19 March it was learned that the Captain, Chief Engineer and some crew members have been detained in the U.S. at an unknown locations by some government agency.

As January approaches an unexpected and hopefully beneficial side effect of the oil spill is developing. Along with the efforts on locating and cleaning up the spilled oil valuable data is being collected on the tides and currents of the local waters. A large (15 to 20 foot) section of the protective fender on D tower has floated ashore in half Moon Bay; 6 weeks later and over 30 miles distance by water.

Some of the perplexing unanswered questions have recently been clarified, but not completely resolved, namely:

1..How does a veteran pilot “lose situational awareness” while transiting an 800 foot wide channel with three fog horns loudly proclaiming their positions and while passing close to a navigation buoy with an installed bell chiming its presence?

2. Why did Cota order “PORT 10″ at Buoy #2a.?

3. Why did VTS report BC was on heading of 235 and Cota stated he was on 280?

1. To lack “situational awareness” is interpreted to mean one is lost, confused and or in doubt. An experienced alert pilot should be aware of his location and circumstances within a reasonable area of probability providing he has concentrated on the navigation and movements of the vessel i.e., one mentally visualized the vessels track. However, if distracted or other wise occupied ( attempting to understand an electronic chart, adjusting the radar, communicating with others and the affect of medication in a stressful situation) one’s mental dead reckoning might be lacking.
In aggravation, the sudden awareness that one has lost situational awareness can create shock. If the lack of situational awareness occurs with the simultaneous alleged loss of radar information along with a total lack of visual reference, it is possible that in the confusion one’s judgement falters.

Bewildered, confused and in doubt and not aware of the local audible aids available ( horns, bells ) and probably encountering a first time unexpected experience, one might have difficulty colating information and guidance. The captain does have the ultimate responsibility and authority and if he is concerned for the safety of his ship, it is his duty to act. The U.S. courts have supported two conflicting views: it is inappropriate to do nothing and if in doubt, stop.

2. Departing the Oakland Outer Harbor Channel when abeam Buoys #6 or #4 one can take a nearly straight course to D-E mid passage adjusting for a flood current e.g., gyro course Cn 279 Cog 270. At ½ speed ahead (11 knots) the applied leeway can be reduced. When near buoy #2A, Cota orders PORT 10, that he does not recall, however there is no significant course alteration recorded by AIS for 1,226 yards; at that point a left turn is recorded, steadying up on an average Cog of 243 for 2946 yards, when VTS notifies UNIT ROMEO he is on course 235.

AIS records ship heading as gyro (Cn), GPS Magnetic Track (16 E Variation) and GPS True Track (Cog). It is probable VTS was reportng the GPS Magnetic heading. CB’s most southerly heading
recorded were 219 magnetic; 237 Cog and 246 gyro. While on this leg Cota ordered several rudder commands and full ahead on the engine.

It would appear that at or near buoy #4 Cota became confused and disoriented.

Maritime history is replete with accidents, however there are only a few new situations; most bridges over navigational waterways have been hit. Mark Twain alluded ”Bridges, they are e hit because they are build in the wrong places.” Maritime libraries are overloaded with manuals, text books, magazines and published articles presenting, in many cases redundantly, data on preventing collisions with all manner of things, including bridges. Most leading maritime periodicals dedicate a section to maritime accidents as a reminder of the risks and hazards in the business. Several journals publish daily email bulletins highlighting the bad news. In writing maritime articles one uses the word hazards to describe navigational problem areas; when imprudent mariners approach them they become dangers.

Congress actively follows the maritime industry and all its problems; hitting bridges being only one. As a result of their efforts Title 33–NAVIGATION AND NAVIGABLE WATERS specifically addresses what “the owner, master or person in charge of a vessel —shall ensure.” Part 164.11 is explicit in the requirement for pilots (a person directing the movement and navigation of a vessel). Therefore it has been presented that Cota and the ship captain were at least aware of the regulations and did make an attempt to satisfy the requirements.However there appears to be a lack of cognizance of the hazards and risks one may encounter in limited visibility and the procedures one is to follow, specially when in doubt.

To become a San Francisco Bar Pilot today, is more complex than 26 years ago. A demanding program is in place as candidates have different back grounds, education and experiences than those of earlier years. Experience in maritime parlance is: what one usually obtains immediately after it is needed, and of course there are two types of experience, some good, some bad. Recently in an editorial piece, the head of the bar pilots described the process for being a bar pilot but did not cite any procedure to monitor procedural compliance, physical conditioning and life style, and training in emergency procedures. Ironically he mentioned increasing protection on bridges. That said, there has been an allusive change in piloting. Since the advent of radar in ships (now almost every ship has at least two) the importance and reliance on local knowledge has diminished. Pilots no longer rely on familiarity of sound from buoys, horns whistles, bells and sirens located near prominent places and hazards. Or, when in fog, and by duty sounding the horn, one should often listen for the echo that warns of obstacles. Total reliance on electronic support has diminished the wizened local knowledge of the pilot. Simulator training concentrates mostly on electronic visual indicators and aids.

“The Pilot ”

I’m tied of hearing praises for those deep sea sailor-men.
Without our tugs to nurse them in and pull ‘em out again.
I’d like to see some oft-shore salty navigate from here to Martinez town
with fog so thick that land is unseen port, starboard , up and down.
Don’t overlook the pilot for his simple chore
for laying courses by sound from shore to shore.(1)

Regulations require a pilot:
1. Report on board ready for duty and be knowledgeable of the expected operational and environmental conditions, assistance available, and the characteristics of the vessel employed to pilot.
2. Verify the readiness of the vessel to proceed to sea.
3. Be aware of the operational capabilities of the ship and any limitations of its propulsion system.
4. And, verify that all required tests have been satisfactorily completed and recorded.

The “ordinary practice of seaman “ requires a pilot be aware of the function each assisting crew member will provide him in safely guiding the vessel to its destination.

“ To succeed, however in anything one should go understanding about in his work and be prepared for every emergency.”(2)

One may conjecture, if all the above was accomplished how can an allision occur. An initial assumption might be, “They were intoxicated or otherwise impaired.” Reported tests soon after the allision did not support that assumption. Therefore the remaining conclusion is: there was a failure on the part of the person directing the movement and navigation of the vessel. From the information presented it appears that Cota was not ready for duty, knowledgeable of the expected operations and environmental conditions, cognizant of the assistance and equipment available and displayed indications of doubt.

From reports: The pilot reported aboard at 0600. His readiness is unknown as it has not been reported and no information has ben presented to indicate a process to verify one’s physical and mental readiness to perform the demands of pilotage. . The usual verification process is conducted by the ship’s master. Cota departed his home in Petaluma at 0400 and arrived on board directly from there. On board he had over an hour to familiarize himself with the ship and its equipment.

Prior to departing from the dock he contacted the USCG Vessel Traffic System (VTS) and was informed of the traffic conditions, visibility and any possible hazards and, discussed it with the master. The final decision to unmoor and proceed is the master’s however the owners representative and the operations manager have input, although seldom sought.

On departing the Oakland Outer Harbor channel and entering the Oakland Bar Channel (an 800 foot wide maintained channel with shallow water on each side, marked by three navigational buoys and extending less than a mile) the pilot applied leeway to off set the flood current ( initially reported as 2.0 knots and later as 1.0 knot) and increased to half-speed or about 11 knots in order to make the transit through the bar channel. In about 7 minutes COSC BUSAN should have reached the western end of the bar channel and continuing on would pass mid span D-E Towers. However the unexplained PORT10 rudder order apparently set a chain of events in operations that caused Cota to become confused, disoriented and in doubt.

COSCO BUSAN’s location at this time is approximately equal-distant from the fog horns on Yerba Buena Island, D tower and E tower that have distinctive signals and the #1 navigation bell buoy. The pilot stated he lost confidence in the radar(s). Regardless there is an abundance of reliable sound information, however one must consider the operational environment in the COSCO BUSAN. The Pilot House is located in the after 1/3 part of the ship’s structure, far removed from the bow and overlooks 16 rows of containers. The Pilot’s station as per most bridge resource management ( BRM )schemes is in the Pilot House, near the controls ( steering, engine, radar and communications). This arrangement precludes the person directing the navigation (Pilot) from alternating in and out of the Pilot House while involved in limited visibility. If perchance one seeks to listen for audible navigation resources ( horns, bells, whistles etc., ) the ambient noise level from electric driven blower motors and other ship noises can make that impossible, and, a long period away from critical electronic data is not advisable. Therefore maintaining a look out by all available means, is not operationally feasible. A bow lookout, may also be hindered by similar noises. It should be noted that Chart 18650 corrected to 11/10/2007 does not indicate fog horns on D and E towers that are maintained by the state of California.

The reported visibility was .1 mile or 600 feet and by some less100 meters. The distance from the navigation bridge to the bow of COSCO BUSAN is about 586 feet. Track data developed and reported by Automatic Information system (AIS) indicates COSCO BUSAN’s initial track from departure from the Outer Harbor Channel was a direct line to D-E mid span. Until approaching #1 buoy to starboard the ship was on track although being affected by 1 or 2 knots of flood current. To safely pass the #1 navigation buoy the ship should have been close to the buoy and therefore it should have be seen. Although buoys are not recommended as the most reliable navigation aid, buoy number 1 is reliable and as required, its passing should be noted. Therefore, the position of the ship should have been determined.

When in limited visibility pilots normally navigate by radar i.e., they concentrate on the radar presentation on an appropriate range scale that provides an electronic presentation of any nearby land, obstructions ( bridges and spans between towers) buoys and approaching vessels. Underwater hazards such as rocks and shoals are not shown on radar –SONAR does that. Radar piloting is demanding. A pilot must closely observe the radar presentation as glancing elsewhere can diminish one’s ability to detect anomalies and distract attention. With buoy #1 and the Yerba Buena Island fog horn ( both within hearing range) on the starboard side the pilot needed only to continue on course D-E mid span.

Why the PORT 10 order? There are several possible scenarios: 1. The pilot ordered the rudder command and it was misunderstood. 2. The BRM team, after discussion directed the helmsman to use 10 degree left rudder. A frequent pilot error when “conning” a vessel is to mistakenly consider that every order-command or utterance is heard and obeyed. Not so! A competent pilot will consciously verify his directions are acknowledged and properly executed.(3).

What might have transpired in this case is the pilot was engaged in radar navigation and was also attempting to understand the electronic chart. On entering the bar channel Cota noted the ships location relative to the island, buoy and bridge on the radar and as the rudder command was executed, the radar allegedly malfunctioned. Pilot house confusion is not uncommon when things go wrong. The procedures required by 33 CFR Part 164 et al., dictate necessary procedures to prevent most ship accidents, but if compliance is not enforced, trouble awaits. The VTS did question COSCO BUSAN’s intentions and was allegedly informed the pilot knew what he was doing.

The alleged failure of the radar (s) at this critical point is not unique. Frequently with high performance radar systems and those using ARPA enhanced symbols produced by the receiver-micro-processor may become overwhelmed with returning signals from nearby by land masses, steel structures and small surface contact e.g., the island, D tower, D-E Span, and buoys. Briefly the radar presentation may become confused but as the vessel changes its position relative to the objects, the processor will sort things out and it will clear and settle down. Gain control as it effects FTC and STC functions can over react. There are two other possible scenarios: In moments of changing navigational situations one might decide to change range scale to obtain a better radar presentation and in so doing, if unfamiliar with the equipment, one can easily push or turn the wrong button. And, ship engineers are constantly in the process of maintaining an efficient plant operations. It is a practice in some ships to shift the electrical generation or distribution of electrical systems from in-port operation to at sea operations before clearing a port. Such an action can cause a temporary interruption of service. Radar presentations are not instantaneous as antenna rotation governs the presentation.

Further, Cota is alleged to have ordered a speed change to full speed three minutes prior to alliding with the bridge tower fender. In emergencies, bold and courageous measures are sometimes appropriate. Regardless, a pilot lacking knowledge of the ships position relative to the nearby tower and familiarity with its maneuvering characteristics is ill prepared to expertly maneuver a 900 foot, deeply loaded ship in a 1 to 2 knots of opposing current. Therefore it might be considered as an imprudent act. Alternatives, i.e., such as stopping, continuing on westward or turning in place are only hypothetical, unless one’s location is known. The courts have many times supported two conflicting philosophies; 1.To do nothing is inappropriate, 2. If in doubt, stop!

Presentations and statements confirm that the tug REVOLUTION tethered astern had been forgotten, another indication of Cota’s physical condition. With COSCO BUSAN at half speed an assisting tug can do little and at full speed, if still tethered astern, less; also her radar would most probably be blanked by COSCO BUSAN.

Radar plays a significant role in defensive ship handling, i.e., avoiding danger. The displayed radar presentation is electronically manipulated and its video presentations are governed by the antenna rotation. What one views can be 20 seconds after the fact i.e., it is history. The VTS radar has the same delay problem and if something occurs out of sight (Cota reporting a slight contact with the bridge) there is no immediate means for verification.

April 28, 2008 has been published as the date for an Administrative Law Judge (ALJ) hearing. ALJ are mostly lawyers acting as full time judges that are employed by a government agency. They hear testimony, find facts, apply law and with independence and discretion submit their advisory findings; in this case to the Bar Pilot Commission. The NTSB has held a two day agenda packed meeting presenting significant useful information, some included herein.

The U.S. Attorney on 19 March filed an accusation against Cota for violating the Clean Waters Act and the Migratory Bird Treaty Act; both misdemeanors with fines and jail time. Cota responded with not guilty. This pre-emptive action has placed Cota et al., in jeopardy causing them to not appear at the NTSB non-punitive hearing. The ALJ hearing may produce some interesting arguments of why pilot Cota is or is not guilty of misconduct etc., that the ship was deficient and crew members incompetent and that the USCG failed to provide adequate assistance Thereafter the USCG will probably proceed with a hearing against Cota’s federal license. When that is resolved it may be followed by admiralty or civil court proceeding involving suites in persona (Cota and Cosco Busan crew members) and in rem (owners and operator of COSCO BUSAN , the USCG and may be the Bar Pilots and the State of California the bridge owner). At each level there will be appeals. It is not yet apparent that negotiations can resolve some of the financial quests of all parties, but that is feasible. The list of claimants has yet to be finalized. San Francisco so far intends to sue over 100 John Does.
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As this unfortunate accident and the follow up proceedings unwind, I will continue to update this article. JGD

John Denham is a retired USN Captain, Licensed unlimited Master and Pilot, maritime academy teacher,and author with extensive experience as a marine consultant. He is also author of The Assistant and DD 891.

References:
(1) A paraphrase on the works of James A.Quinby, The Street and the Sea.
(2). Joshua Slocum, Sailing around the world alone.
(3) Merchant Marine Officer’s Handbook, Fifth Edition chapter 9 Shiphandling.

Additional reference material:
a. Organizing and Managing the Bridge Team Organization. Naval Institute Proceedings, September 1994
b. Care and Feeding of Ship’s Pilots. Naval Institute Proceedings, August 1993.
c. Why Didn’t I Slow Down. Naval Institute Proceedings, January 1996