Pilot lost situational awareness in thick fog, NTSB told

Cosco Busan leaves San Francisco Bay following repairs for damage incurred when the ship hit the San Francisco-Oakland Bay Bridge on Nov. 7. A patch aft of the ship’s port bow shows where the accident ripped a 200-foot-long gash in the hull that penetrated a fuel tank, leading to an oil spill.

The bar pilot on the bridge of Cosco Busan lost situational awareness in a thick fog just before the containership struck the San Francisco-Oakland Bay Bridge, according to testimony at a National Transportation Safety Board hearing.

None of the ship’s officers protested the pilot’s decision to sail even though they were amazed that he was getting underway from the Oakland dock in visibility that was as low as one-eighth of a mile, witnesses said at the April hearing.
A medical expert testified that a combination of medications the pilot was prescribed should have disqualified him from having a Coast Guard license.
Cosco Busan, a 901-foot container ship, scraped a bridge pier on the morning of Nov. 7, 2007. The contact with the bridge carved a 200-foot-long hole into the ship’s side. The subsequent 53,000-gallon fuel spill was the worst in San Francisco Bay in two decades.
The NTSB hearing examined why the San Francisco bar pilot misread a standard nautical chart during the voyage; the behavior of the ship’s crew and the vessel traffic service; the quality of the chart and radar images; the Coast Guard’s response to the spill; and the overall regulation of state and federal pilots.
The testimony included the following:
• Dr. Robert M. Bourgeois, a Louisiana physician with expertise in assessing the health of mariners, said the Coast Guard never should have renewed the bar pilot’s license in January 2007. The then-59-year-old pilot reported at least four medicine prescriptions for ailments including glaucoma, kidney stones and sleep apnea.
Bourgeois said some of the medications adversely affect “cognitive function†and can result in “delayed reaction time.†Mixing the drugs compounds the side effects. “I wouldn’t want anyone taking these medications and having to make decisions in a safety-sensitive position,†Bourgeois said.
• The Chinese crew had misgivings about sailing in the fog, according to translations from the voice data recorder. The vessel traffic service had reported visibility of one-eighth to one-fourth of a mile.
“The fog is so heavy,†the captain said.
Other crewmembers said:
“What a thick fog!â€
“We can still sail? Never see this before.â€
“For American ships with such conditions, they would not be underway.â€
• Fleet Management Ltd. of Hong Kong had taken over as manager of Cosco Busan just two weeks before the accident. The company’s general manager, Capt. “Aga†Nagarajan, said the ship’s master relied on the pilot’s local knowledge and had no cause to overrule the pilot’s decision to sail in the fog.
“The Coast Guard had not shut down the port. The master might have assessed that if the port is open and the pilot says it’s good to go … he might have followed the advice of the pilot and got underway,†Nagarajan said.
A captain would seize control from a pilot only if the pilot was “manifestly in distress or manifestly incompetent,†he said.
• The ship’s radar was in good working order — but before sailing, the ship’s crew left the radar on an inappropriate setting.
“It was never taken out of auto sea mode. We end up seeing the gain at a really high level,†said Michael Hughes, manager of U.S. product support and training with manufacturer Sperry Marine.
Hughes noted that the higher gain setting would mean that “you get a little more clutter†but that the image of the bridge and buoys would still be “an interpretable picture.â€
• A vessel traffic service employee inquired about the pilot’s intentions as the Cosco Busan approached the bridge at an unusual angle, but the VTS stopped short of directing the pilot to change his course. The VTS intentionally avoided additional, potentially distracting radio chatter, said Coast Guard Lt. Cmdr. Kevin Mohr, the sector’s chief of waterways management.
The pilot “clearly and calmly indicated that he still intended to go through the Delta-Echo span. … It gave the impression that the pilot at least knew where he was,†Mohr said.
“A radio call from the vessel traffic service I don’t believe would have helped at that time,†he said.
In the immediate aftermath of the accident and under questioning later, the pilot repeatedly said he misread a paper chart showing the bridge span and piers.
Recordings of the voices on the bridge shed light on the confusion and misunderstanding between the pilot and the crew. Dismayed after striking the bridge — and amid the sound of rustling of papers — the pilot said, “You said this was the center of the bridge.â€
“Yes,†said the captain.
“No, this is the center. That’s the tower,†the pilot said, pointing to the chart.
The captain again pointed to the standard markings denoting piers and buoys and mocked the pilot in Chinese.
“Sorry, captain. I misunderstood the chart. I thought that was the center. Everyone’s going to start descending on me so quickly now,†the pilot said later. Speaking on a cell phone, the pilot said, “Yeah, it’s foggy. I shouldn’t have gone.â€
• As a direct result of the Cosco Busan disaster, the bay’s Harbor Safety Committee has changed the rules for getting underway in fog. If visibility is less than half a mile at the dock or at a critical maneuvering area, large ships may not get underway. Incoming vessels will be instructed to go to anchorage or choose an alternate route.
The pilot refused to testify at the NTSB hearing because he faces federal charges of criminal negligence and environmental crimes. He has pleaded not guilty.

Two weeks after the NTSB hearing, a federal grand jury added a new accusation. The pilot was charged with two counts of making false statements to the Coast Guard regarding medications he was taking in 2006 and 2007. The pilot’s lawyer called the charges irrelevant because tests after the bridge collision showed that the pilot was not under the influence of drugs or alcohol.

By Professional Mariner Staff