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| U.S. Coast Guard patrol boats established a security zone around Cosco Busan after the 901-foot containership struck a support tower of the San Francisco-Oakland Bay Bridge while maneuvering in fog on Nov. 7, 2007. (Photos courtesy U.S. Coast Guard) |
The National Transportation Safety Board (NTSB) blames the Cosco Busan disaster on a wide-ranging lack of attention to safety by the bar pilot and ship operator and oversight failures by the U.S. Coast Guard.
In a report issued in February, the NTSB said the pilot never should have been on the job guiding a ship in fog while taking several medications that impair judgment. The investigators said that pilot and master never underwent a proper exchange and that ship operator Fleet Management Ltd. failed to train its crew properly.
The Coast Guard’s medical reviewers should not have allowed the pilot even to keep his license, the NTSB said. “There was a lack of competence in so many areas that this accident seemed almost inevitable," said Mark Rosenker, the NTSB’s acting chairman.
Coast Guard investigators, in a report issued a month after the NTSB report, drew similar conclusions about the cause of the casualty. The Coast Guard called its own instructions for pilots’ medical reviews “inadequate."
Cosco Busan, a 901-foot containership, struck a San Francisco-Oakland Bay Bridge tower and ripped a 220-foot-long gash in its hull. The accident occurred on Nov. 7, 2007, in a thick fog and resulted in a spill of 58,000 gallons of fuel into the bay (PM #121). The environmental cleanup cost more than $70 million.
Visibility was between 200 yards and a quarter-mile when Cosco Busan departed its berth at Oakland. While outbound at 11 knots, the pilot had trouble understanding the ship’s electronic chart system. A conversation with the master about it resulted in a misunderstanding over the location of the bridge tower.
The NTSB ruled that the probable cause of the accident was the failure to navigate safety in restricted visibility. One reason was “the pilot’s degraded cognitive performance from his use of impairing prescription medications," the report said.
The NTSB heard testimony that the pilot was prescribed as many as 11 medications in the year preceding the casualty for several ailments, including depression, back pain, sleep apnea and alcoholism. Many of those medicines cause impairment, especially in combination.
“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," Rosenker said.
In March, the pilot pleaded guilty to federal pollution charges. He will serve two to 10 months in prison and pay a fine of $3,000 to $30,000.
The pilot’s lawyer, Jeffrey Bornstein, said Cosco Busan was “unseaworthy" because its crew was improperly trained, and the Vessel Traffic Service failed to warn the ship that it was off course. He said the NTSB and Coast Guard erred in stating that the pilot’s medications were a likely factor in the accident.
Bornstein said his client admits to taking only three medicines prior to the accident — Provigil for sleep apnea, the glaucoma drug Alphagan and thyroid treatment Synthroid. A post-accident drug test indicated no illegal drugs or alcohol.
“What is absolutely inappropriate and unfounded in the (NTSB) report is the reference to him being under the influence of drugs. It is clearly not true," Bornstein said.
The NTSB investigators said there was “an 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." Cosco Busan’s captain and crew were Chinese.
The NTSB also cited “the master’s ineffective oversight of the pilot’s performance and the vessel’s progress." A contributing factor was Fleet Management’s “failure to properly train and prepare crew members prior to the accident voyage, and their failure to adequately ensure that the crew understood and complied with the safety management system."
In the Coast Guard report released in March, investigators said the pilot exhibited overconfidence. “He did not review the ship’s chart or discuss his own plan with the master" before getting underway, the report said. During an interview with investigators after the casualty, he “likened piloting a ship from the estuary to sea as the equivalent of •driving a bus from my driveway.’"
The Coast Guard report also highlighted the pilot’s failure to reduce speed in the poor visibility as one of his “most serious errors." The pilot failed to ask for more frequent fixes, and the master never mentioned a concern about either issue.
The estimated damage to the ship was $2 million, with $1.5 million in damage to the bridge. The pilot still faces several criminal and civil charges for allegedly causing the environmental damage. The fuel spill contaminated 26 miles of shoreline and killed more than 2,500 birds of 50 species, government officials have said.
The NTSB additionally cited “the 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."
Said Rosenker: “Given the pilot’s medical condition, the Coast Guard should have revoked his license, but they didn’t."
The Coast Guard report acknowledged that its procedures for reviewing pilots’ annual physicals were “inadequate." Guidelines — published in 1986 — are outdated and “lack guidance on sleep disorders." The Regional Examination Center that renewed the pilot’s license should have referred his case for further medical review, the report said.
“There is substantial evidence that the pilot has significant health problems and takes medications that individually had the potential to medically disqualify him to hold Coast Guard-issued merchant mariner credentials," the Coast Guard investigators wrote.
“The degree to which these contributed to the cause of this casualty is unknown, but the multiple examples of impaired sensory perception, impaired cognitive processing, and impaired short-term memory failures by the pilot are suggestive of impaired performance caused by medical and pharmacological human factors," they said.
The Coast Guard report said a physician had once warned the pilot not to take some of his medicines within a 24- hour period before working on a vessel. The pilot, however, admitted that he had taken one of those medications on the morning of the Cosco Busan casualty.
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| Cosco Busan leaving San Francisco Bay on Dec. 20, 2007, following repairs to a 220-foot-long gash in its hull. The accident resulted in a spill of 58,000 gallons of fuel. Cleaning up the oil spill cost over $70 million. |
The Coast Guard has said recent reforms to its medical review process should prevent such licensing-renewal mistakes and inconsistencies from happening in the future. Last year’s new Navigation and Vessel Inspection Circular specifies ailments and medications that require medical waivers. Reviews are now being handled in one central location, at the National Maritime Center rather than at various Regional Examination Centers.
In the months following the accident, various rules were changed to ensure safer navigation in San Francisco Bay. The Harbor Safety Committee and Coast Guard identified nine critical maneuvering areas where vessel movements are now restricted when there is heavy fog. The Vessel Traffic Service has clearer instructions on its ability to control vessel movements when safety is on the line.
The San Francisco Bar Pilots this year will acquire laptops with Rose Point navigation software, so pilots no longer need to rely solely on ships’ electronics that may be unfamiliar to them. A new state law established third -party medical screening under the authority of the Board of Pilot Commissioners.
Capt. Peter McIsaac, president of the San Francisco Bar Pilots, said maritime transportation is much safer as a result of the improvements.
“You try to take as much risk out if it and put as much in your favor as you can," McIsaac said. “The main thing is the clear guidance on transiting in fog." The nine areas encompass those with “cross-currents, hard points and narrow spots. Essentially, you don’t transit those areas when there is less than a half-mile of visibility."
McIsaac differs with the NTSB investigators on one aspect of the report. “They did not find departing in fog to be a contributing factor," he said. “It was a factor. … There were a number of pilots who elected not to get underway that day."
The NTSB report recommends that the Coast Guard: • Propose that the International Maritime Organization study the effect of cultural and language differences on bridge-resource management.
• Require mariners to report “in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations."
• Establish a way for pilot oversight organizations to communicate pilot performance data and best practices. Addressing Fleet Management, the NTSB recommended that all crewmembers be thoroughly familiar with safety procedures before the vessel leaves port. Manuals should be in the crew’s working language.
Hong Kong-based Fleet Management’s managing director, K.S. Rajvanshy, didn’t respond to a request for comment. The NTSB recommends that the American Pilots’ Association inform its members of the circumstances of the Cosco Busan accident. It should remind members that the pilot card is only a supplement to the verbal master/pilot exchange. Officers in charge of the navigation watch also should be included in navigation discussions.
