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April 11, 2008


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,” “ ” and ” .” 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.
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.

(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

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