Bay Bridge accident spurs sweeping review of practices and systems

Above, the ship sustained a gash about 200 feet long on its port side just aft of the bow. Two fuel tanks were penetrated. (Abner Kingman photos)

Since November 2007, government officials have wondered exactly what caused the Cosco Busan to run into the Bay Bridge and spill 58,000 gallons of bunker fuel into San Francisco Bay.

A better question may be, what didn’t cause the disaster?

After the Nov. 7 accident, a California state pilots’ board charged the pilot with negligence. Other investigators and maritime officials have criticized the actions of the ship’s captain, pilot and Coast Guard; rules for transiting in fog; the confusing multitude of navigation systems; the cleanup response; and even the design of the ship itself.

The National Transportation Safety Board and Coast Guard are probing the interactions between Cosco Busan’s captain and the San Francisco bar pilot who was aboard. The board is also looking into whether the radar was working properly. Issues include whether the pilot maintained situational awareness while transiting in the fog — and whether a language barrier hampered understanding between him and the Chinese crew.

A state investigation ordered by Gov. Arnold Schwarzenegger is studying the potential need for speed limits, tug escorts, sailing limitations in bad weather, more rigid vessel-traffic communications, earlier community notification of spills and faster cleanup response.

The wide-ranging probes could mean that the Cosco Busan accident will be a catalyst for industrywide changes to rules governing fog transits, standardization of navigational equipment and even mariner training.

“You can expect that policies against moving in the fog will be tightened as a result of this,” said Paul G. Kirchner, executive director and general counsel of the American Pilots’ Association. “The margin of error is so much less, and if you do have a breakdown somewhere in fog, you’re not going to catch those mistakes.”

AIS data shows the track of the vessel. (Ginny Howe illustration/Source

The NTSB said it would examine the ship’s voice-data recorder to determine whether frantic interactions involving the pilot, captain and crew resulted in confusion at the helm. The agency also was studying communications from the Vessel Traffic Service (VTS).

Investigators found no evidence of malfunctions in the ship’s propulsion or steering systems. By mid-November, Coast Guard officials attributed the accident to human error.

“There were enough skilled individuals on board this ship,” said U.S. Coast Guard District Commander Rear Adm. Craig Bone. “They didn’t carry out their missions correctly.”

Cosco Busan is a 901-foot container ship. The Hong Kong-flagged vessel is owned and operated by Regal Stone Ltd. of Hong Kong and Fleet Management Ltd.
Bone said Cosco Busan departed Oakland’s Pier 56 with a bar pilot aboard, accompanied by the escort tug Revolution.

The ship maneuvered around the dredge Njord. The outbound ship then headed for the Delta-Echo span, referring to the space between the D and E bridge pilings, three miles from the pier.

Bone said Cosco Busan was traveling through heavy patchy fog, with visibility as low as 300 feet. At 0827, the VTS operator notified the pilot that the ship was off course on its way to Delta-Echo.

The ship was traveling to the southwest, parallel to the span. Cosco Busan then made a sharp turn to starboard. A lookout warned that the ship was heading for the Delta tower.

According to radio recordings and statements by the pilot’s attorney, the ship’s radar was malfunctioning before the allision. The pilot asked the ship’s master to point to the center of the Delta-Echo passageway on an electronic chart. The pilot guided the ship on that heading.

Three minutes later, Cosco Busan’s port side sideswiped the bridge’s fendering system, Bone said. The contact tore a gash — measuring 200 feet by 14 feet — into the hull. Two fuel tanks and a ballast tank were pierced.

The result was the region’s worst fuel spill since 1988. To make matters worse, the Coast Guard initially underestimated the spill’s size. State and local government officials later accused the Coast Guard of waiting too long to notify nearby communities.

Commodore John Keever, master of California Maritime Academy’s training ship Golden Bear and an expert in navigating San Francisco Bay, said four factors make the bay a particularly treacherous waterway for commercial mariners.

-It is muddy, with an ever-changing shallow bottom, requiring vessels to remain confined in a tight channel.
-There are bridges.
-Thick fog can develop in an isolated spot while visibility looks good elsewhere.
-Difficult currents exist between the Port of Oakland and the outlet to open ocean.

A malfunctioning radar system would compound those four challenges, Keever said.

“If you were going to have some kind of (new) regulation, probably the condition that could most be attributed to this problem was the conditions they got underway in,” said Keever.

Cleanup crews work to remove oily material from the shoreline. About 58,000 gallons of bunker oil spilled. The Coast Guard did not immediately recognize the extent of the spill.

“They couldn’t see the bridge,” he said. “The electronic devices were not able to give them the timely information they needed to make their decisions.”

The state Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun suspended the pilot’s state license and, on Dec. 6, charged him with misconduct.

The Board of Pilot Commissioners accused the pilot of “having reason to doubt whether the ship could safely proceed under the prevailing circumstances and proceeding on his course with insufficient information about the level of visibility along his intended route.”

According to the board, the ship was traveling at a speed that was excessive for the conditions, and the pilot failed to use the tugboat, a lookout and the VTS to their fullest extent.

“The tug remained tethered to the ship’s stern,” the board said.

One day later, the Coast Guard asked the pilot to turn in his merchant marine officer’s license, stating “he is not physically competent” to keep the license.

Keever said investigators eventually may identify mistakes by several parties.

“There’s no question that fault is going to be placed with the vessel,” Keever said. “There’s going to be a number of things that weren’t done right. Some of it could have been the Coast Guard and Vessel Traffic. You have the pilot and captain, and maybe other of the ship’s officers who didn’t do things quite correctly, adding to the confusion.”

Although ship’s officers are required to speak and understand English, a language barrier can still exist on the bridge, especially during a crisis.

“The English language skills of a crew of a ship may be a lot different when things get a little hairy,” Kirchner said. “When the ship is in extremis, the language skills deteriorate. When the crew are fatigued, the language skills deteriorate. There are ways to communicate non-verbally. Every pilot deals with foreign crews (and is trained to) develop a command presence to calm everybody down.”

So much bunker fuel spilled from Cosco Busan because its fuel tanks are located in a vulnerable position, along the side of the hull beginning just aft of the bow.

In 2006, the International Maritime Organization banned the construction of new ships with fuel tanks installed along a single hull. The new rule takes effect in 2010. Cosco Busan was built in 2001.

“That was an oddity where that fuel was carried on that ship,” Keever said. “That was amazing to me. Those were pretty forward.”

The IMO is also studying ways to standardize electronic navigational and radar displays. The pilot’s lawyer has said Cosco Busan’s captain may have misread the electronic chart. Navigational displays are manufactured with dozens of different formats.

“The S-mode is something that may have value,” Kirchner said. “You press a button and everything reverts to a standard position.”

San Francisco’s Harbor Safety Committee, the Board of Pilot Commissioners and other stakeholders are likely to discuss new restrictions barring transits in certain foggy conditions, said Capt. Peter McIsaac, president of the San Francisco Bar Pilots.

“We’re going to identify some critical maneuvers, and one of those would be going in and out of Oakland. It’s a cross-current situation there,” McIsaac said. “If you have any problems with radar, bad things can happen.”

Kirchner expects weather restrictions to be considered in other foggy U.S. harbors, too. Commercial interests, however, may stand in the way.

“Pilots are always being pressured by ports and terminals and ship operators to move in fog, and no one wants to share in that decision,” Kirchner said.

Members of Congress have asked the Department of Homeland Security’s inspector general to investigate the Coast Guard’s role in the spill and response, including alleged delays in crew drug testing. Sen. Barbara Boxer, a California Democrat, proposed widening the role of the VTS in emergencies, giving the VTS power to command a ship master to modify the speed or direction of the vessel. Coast Guard officials and other maritime officials resisted the idea.

The ship struck fendering lining the Delta tower, one of five supporting the bridge. The ability of the fendering system to protect the bridge from a ship impact without slicing the hull is an area investigators may explore.

“Even in Norway, where they always have professional mariners in their VTS, they still do not direct traffic,” McIsaac said. “They realize that command of the vessel has to stay on the bridge of the ship.”

Keever said the Cosco Busan incident could prompt maritime regulators to begin installing high-tech visibility sensors in the vicinity of ports, similar to devices already in widespread use at airports.

The accident could even usher in the appointment of government-employed experts to do periodic check rides to observe bar pilots, Keever said. It could be a corps of experienced ship masters and former pilots. They would determine whether each pilot is physically able, has kept up with new navigation technology and is alert and dynamic enough to maintain situational awareness and to interact with crew.

A month after the allision, Cosco Busan was undergoing soft-patch repairs at the BAE Systems San Francisco Ship Repair yard. NTSB investigators planned to question the entire Chinese crew.

A U.S. District Court arrested the ship in response to a class-action lawsuit filed on behalf of fisherman and others who suffered financial damages due to the spill. The Justice Department and state agencies also sued Cosco Busan interests to recover spill cleanup costs.

By Professional Mariner Staff