According to the US National Transportation Safety Board (NTSB) report the probable cause of the sinking was loss of watertight integrity due to watertight doors  left open by the crew. Also contributing to the accident was the master’s decision to continue fishing operations despite severe weather warnings issued two days before and the owner’s failure to ensure that the stability information provided to the master was accurate and current.

“No mandatory stability standards applied to the Katmai.” stated the report pointing fingers at the US Coast Guard’s lack of standards for vessel of this type and size. According to investigators in 1991 the Coast Guard said it would establish stability standards for vessels under 79 feet but, in the 19 years since, no such standards have been issued. This lack of standards lead some owners to infer that up-to-date stability information is unimportant for vessels less than 79 feet long. Vessels such as the Katmai.

Also in question was the master’s experience. Surprisingly the 40-year-old captain of the Katmai did not hold a Coast Guard merchant mariner license and was not required to be licensed because the vessel was less than 200 gross tons. He also admitted that he had no formal training in vessel stability and did not operate the boat under an Safety Management System, nor was he required to.

Fatigue was also a factor. During questioning, the master said he felt fatigued during the accident voyage, stating, “You get used to it.” At the time of the incident he had been awake for approximately 22 hours.

“I don’t think that’s the professional behavior we expect of people. He’s not there to read the paper,” said Robert Sumwalt, a member of the NTSB. “The pilots were not acting as a team. They were acting as two individuals who happened to be onboard the same ship.”

The investigators also found systemic problems with the communication guidelines used by the local pilot’s association,
Sabine Pilots, but were generally pleased with the containment and clean up activities that prevented the 462,000 gallons of oil from drifting down the river.

This information came from a public session held today in Washington and the NTSB is set to release its final report on the Jan. 22, 2010 collision in Port Arthur of the tanker Eagle Otome and towboat Dixie Vengeance. While no one was hurt in the incident, the collision breached the tanker, causing oil to spill into the Sabine-Neches.  This subsequently resulted in  the Coast Guard shutting down the waterway for five days and significant economic loss for the region.

The last spill of this size occurred on June 8, 1990, when the Italian tank vessel Fraqmura was lightering the Norwegian tank vessel Mega Borg and an explosion occurred in the pump room of the Mega Borg. The two ships were in the Gulf of Mexico, 57 miles southeast of Galveston Texas in international waters, but within the U.S. exclusive economic zone. As a result of the explosion, a fire started in the pump room and spread to the engine room. An estimated 100,000 barrels of Angolan Palanca crude was burned or released into the water from the Mega Borg during the next seven days.

Testimony and evidence presented at Coast Guard hearings of last year’s spill are clear that both vessels were aware of each other’s proximity and they initially thought they would be able to pass one another safely. The audio from “black box” VDR on the vessel reveals that moments before the collision, they had a calm conversation and even shared an off-color joke. Capt. Pallava Shukla, master of the tanker, denies this state of ease instead testifing that he became increasingly concerned about the ship’s situation because of “very, very poor visibility.”  Shukla also claims that prior to the collision, he noticed his ship was turning too sharply and he tried to help the pilot check the vessel’s yaw.

There were two pilots aboard the tanker, as is mandatory when maneuvering such ships through the narrow waterway. Sabine Pilot, Capt. Charles Bancroft, testified that he told the tugboat he was heading toward a bridge and while the weather initially appeared normal, forces in the channel turned out to be some of the strongest he had faced in his career. Maneuvers that had worked previously — increasing rudder speed and pushing the engine to increase water flow around the ship — didn’t work this time, Bancroft said.

When it became clear to Bancroft that the tanker was getting too close to the tugboat, he ordered the engine stopped and the anchor thrown in attempt to rapidly stop the ship.

The following is a press released issued by the National Transportation Safety Board regarding the fatal July 2010 “Duck Boat” incident in Philadelphia.

Washington, DC – The National Transportation Safety Board (NTSB) today determined that the mate operating a tugboat near Philadelphia on July 7, 2010, failed to maintain a proper lookout while towing a barge up the Delaware River. The investigation revealed that the mate was inattentive to his duties while navigating the vessel because he was distracted by his repeated use of a cell phone and lap top computer while communicating with his family who were dealing with a family emergency. Further, rather than being in the upper wheel house as expected, the tugboat mate was navigating from its lower wheel house where visibility of the channel ahead was limited.

“This is yet another example of the deadliness of distractions,” said NTSB Chairman Deborah A. P. Hersman. ”Distraction is a safety concern across all modes of transportation.  Regardless of the reason, it’s not okay to multi-task while operating a vehicle – whether it’s calling, texting, or surfing the web.”

The accident, which occurred at approximately 2:37 pm, involved an empty 250-foot-long sludge barge, The Resource, that was being towed alongside a 78.9-foot long tugboat, the Caribbean Sea. The barge collided with the DUKW 34, an anchored amphibious passenger vehicle, which sank in approximately 55 feet of water. There were 35 passengers and two crew members onboard the DUKW 34 and five crew members onboard the Caribbean Sea. Two DUKW 34 passengers were killed; 26 passengers and one crewmember suffered minor injuries. No one on board the Caribbean Sea was injured.

The investigation also revealed that maintenance personnel from Ride The Ducks International, LLC, the DUKW 34 owner and operator, did not ensure that the surge tank pressure cap was securely in place before returning the vehicle to passenger service. This allowed the engine to overheat, leading the DUKW 34 master to stop the vessel and anchor in an active channel.

Further, NTSB investigators found that while Ride The Ducks International, LLC, had written procedures for safe operational practices and emergency situations, the master of DUKW 34 did not take all actions appropriate to address the risk of anchoring in an active navigation channel.  The NTSB determined these omissions contributed to the accident.

The NTSB issued recommendations to both Ride The Ducks International, LLC, and K-Sea Transportation Partners L.P., to review its management program and develop improved means to ensure that the company’s safety and emergency procedures are understood and heeded by all employees in safety- critical positions. The NTSB also issued recommendations to the U.S. Coast Guard to increase focus on and oversight of inappropriate use of cell phones and other wireless electronic devices by on-duty crewmembers in safety-critical positions so that such use does not affect vessel operational safety.  Additionally, the NTSB issued a recommendation to the American Waterways Operators to encourage their members to ensure that their safety and emergency procedures are understood and adhered to by their employees in safety-critical positions.

A synopsis of the NTSB report, including the probable cause, findings, and safety recommendations, is available at: http://go.usa.gov/WAJ.

The full report will be available on the website in several weeks.

Source: NTSB

Today the NTSB sent out a warning against the sue of cell phones on the bridge of ships. The Coast Guard quickly followed with a similar warning writing:

The U.S. Coast Guard is reviewing a National Transportation Safety Board recommendation Wednesday that the service develop policies on the use of cellular phones on Coast Guard vessels as well as issue a safety advisory to the marine industry on the possible dangers of crewmember use of electronic communications devices such as cell phones, smart phones and personal data assistants.

The Coast Guard issued guidance July 16, 2010 to its personnel prohibiting the use of these devices by operators of Coast Guard boats and also restricted their use by other crewmembers.

“While cell phones and texting devices have become ubiquitous in everyday life, the internal Coast Guard policy issued in July prohibits their use on Coast Guard boats without the permission of the coxswain, said Lt. Cmdr. Chris O’Neil, a Coast Guard spokesman. “The policy also strictly prohibits the use of these devices by the coxswain, or the operator, of a Coast Guard boat.”

Cell phones and texting devices may be useful communication tools if boats lose a marine radio signal or as alternate means of communication to a marine radio.

The Coast Guard takes the NTSB recommendations seriously and will provide a response to the letter upon a thorough review.

The NTSB recommendation comes amid investigations into two collisions involving Coast Guard boats but does not draw any conclusions that the use of electronic devices was a cause of those accidents.

NTSB and Coast Guard investigations into those two accidents are ongoing.

What are your thoughts on the use of cell phones and mobile internet devices aboard ship?

Earlier today, the National Transportation Safety Board released its final report on the allision of the M/V Cosco Busan with the Delta Tower of the San Francisco–Oakland Bay Bridge on November 7, 2007, resulting in the release of 53,500 gallons of fuel oil into San Francisco Bay.

The final report reflected sentiments expressed at the NTSB’s hearing on the accident in February as well as opinions reflected here on gCaptain.  This included determination of probable cause, in which the Safety Board cited three factors:

1. the pilot’s degraded cognitive performance from his use of impairing prescription medications;
2. the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the accident voyage, and;
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 failure of Fleet Management Ltd. to adequately train the Cosco Busan crewmembers before the accident voyage, which included a failure to ensure that the crew understood and complied with the company’s safety management system, and
2. 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

New Recommendations

As a result of the investigation, the Safety Board made the following safety recommendations.

To the U.S. Coast Guard:

1. Propose to the International Maritime Organization that it include a segment on cultural and language differences and their possible influence on mariner performance in its bridge resource management curricula. (M-09-1)
2. Revise your vessel traffic service policies to ensure that vessel traffic service communications identify the vessel, not only the pilot, when vessels operate in pilotage waters. (M-09-2)
3. Provide Coast Guard-wide guidance to vessel traffic service personnel that clearly defines expectations for the use of existing authority to direct or control vessel movement when such action is justified in the interest of safety. (M-09-3)
4. Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. (M-09-4) Supersedes M-05-5
5. Establish a mechanism through which representatives of pilot oversight organizations collect and regularly communicate pilot performance data and information regarding pilot oversight and best practices. (M-09-5)

To Fleet Management Ltd.:

1. When assigning a new crew to a vessel, ensure that all crewmembers are thoroughly familiar with vessel operations and company safety procedures before the vessel departs the port. (M-09-6)
2. Provide safety management system manuals that are in the working language of a vessel’s crew. (M-09-7)

To the American Pilots’ Association:

1. Inform your members of the circumstances of this accident, remind them that a pilot card is only a supplement to a verbal master/pilot exchange, and encourage your pilots to include vessel masters and/or the officer in charge of the navigational watch in all discussions and decisions regarding vessel navigation in pilotage waters. (M-09-8)

Previously Issued Recommendations Reclassified in The Report

To the U.S. Coast Guard:

M-05-4
Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations.

Safety Recommendation M-05-4, previously classified “Open—Acceptable Response,” is reclassified “Closed—Acceptable Alternate Action” in the “Coast Guard Medical Oversight of Mariners” section of the report.

M-05-5
In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers.

Safety Recommendation M-05-5, previously classified “Open—Acceptable Response,” is reclassified “Closed—Acceptable Action—Superseded” in the “Coast Guard Medical Oversight of Mariners” section of the report.

Download full report

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.

Back in November we worked with a number of organizations to bring you the path of the Cosco Busan on the day of its allision with San Francisco’s Bay Bridge (article link). Today, in response to Paul Drouin’s article “Pilotage Paradox – A Look Into The Cosco Busan Allision“, our friend Professor Kurt Schwehr  has compiled the radar images of the incident on his blog. Take a look:  LINK

You can find our full coverage of the incident on our tag page: Cosco Busan Articles.

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.

——–

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
———

In August 2001 the Bulk Carrier Windoc was lined up on the Welland Canal’s Bridge 11 in Ontario Canada. After recieving the flashing amber approach light indicating that the bridge operator was aware of the vessel the captain lined up on the centerline and maintained a speed of 5 knots. Minutes later while the vessel was half way through the bridge started descending.

Click here to view the embedded video.

The Bridge Team’s Story

When the vessel was approximately halfway under the bridge, the third officer observed that the bridge signal lights were solid red and the lift span was descending. At 2053, the master sounded a few blasts on the ship’s whistle. The master, without identifying himself or the bridge in question, called the TCC on VHF channel 14 about the lowering of the bridge. The master quickly stopped the engines and ordered an evacuation of the wheelhouse.The master and third officer left the wheelhouse by the starboard navigation bridge wing. As they proceeded down the external bridge access ladder, the span of the bridge struck the vessel in way of the wheelhouse front windows, subsequently destroying the vessel’s wheelhouse and funnel. The wheelsman remained at his station in the wheelhouse and lay down on the deck as the bridge span passed overhead. He freed himself from the debris and descended by the deckhouse stairwell alive.

Miraculously no one was killed in the event.

For detailed information on the incident visit:

• Transportation Safety Board (TSB) of Canada’s Report
• The TSB’s brief synopsis
• TSB Photos of the incident.
• Huge list of Windoc Related Photos
• Photos of the bridge before incident.

Damage To The Wheelhouse

Remains of the Ship’s Radar

The Windoc During Better Days:

Video of TSB report on sinking of Queen of the North. Click on the blue ‘Start Presentation’ button. (its slow loading).

It also has video simulation of the incident and chart & radar data from retrieved hard drives from the ship. Alternatively you can read the full report HERE.

(Ed. note: Thanks to BitterEnd reader Rod Pugh for leading us to this link.)

___________________________

This post was written by Richard Rodriguez, Rescue Tug Captain, and US Coast Guard approved instructor for License Training. You can read more of his articles at the BitterEnd of the net.