NTSB On Cosco Busan: Unfit, Ineffective, Incompetent

 allision  Comments Off on NTSB On Cosco Busan: Unfit, Ineffective, Incompetent
Feb 192009

Investigators for the US National Transportation Safety Board claim that the pilot conducting the Cosco Busan was unit, the master “ineffective” and the crew poorly trained.

The NTSB has issued the following statement:

“The National Transportation Safety Board says 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 at $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.

A synopsis of the Board’s report, including the probable cause, conclusions, and recommendations, will be available on February 19 on the NTSB’s website, www.ntsb.gov, under
“Board Meetings.” The Board’s full report will be available on the website in several weeks.


NTSB to Academies: Up Cadet's Game

 accident reporting, maritime accidents  Comments Off on NTSB to Academies: Up Cadet's Game
Feb 092009

Empress of the North

grounding site

Location of the grounding

Maritime academies in the US have been told to ensure that their cadets understood their responsibilities as licensed officers when they assume their first navigational watch as professional mariners. The advice followed the publication of the US National Transportation Safety Board’s report on the grounding at night of the 300-foot passenger vessel Empress of the North in May, 2007, while under the command of a third mate who had graduated from the California Maritime Academy less than three weeks before.

The officer was not familiar with the bridge equipment or procedures. Neither the Master nor Chief Mate had reviewed the route with him, discussed the steering modes, or critical equipment such as radar. One particular hazard, Rocky Island, required the Officer Of the Watch to make a critical decision.

He was initially assigned to the midnight to 0400 watch, his first navigational watch, with the senior third mate. The day before the accident the senior third mate fell ill. The master decide to maintain the planned watch but to add the vessel’s most experienced helmsman in an attempt to mitigate the junior third officer’s inexperience.

During the passage, the third officer gave effective command to the helmsman. He later told investigators” My understanding was he (the helmsman) would be in control of the boat, and I would be there because I have a license.”

The road to the rock

An inexperience officer left navigation to the helmsman

About 0130 on Monday, May 14, 2007, the Empress of the North, grounded on Rocky Island, which was illuminated by a flashing green navigation light. The US Coast Guard and several Good Samaritan vessels assisted in evacuating the passengers and nonessential crewmembers and safely transporting them back to Juneau. No injuries or pollution resulted from the accident, but the vessel sustained significant damage to its starboard underside and propulsion system.

Say the NTSB: “the junior third mate failed to understand and fulfill his responsibilities as a licensed officer… Newly licensed third officers will often find themselves on a ship they have never sailed on, in an unfamiliar waterway they have never transited before, and in the company of a master and crew they have never served with before. These circumstances do not, however, absolve them of their responsibility to take charge as the officer of the watch when so assigned .. His (the junior third officer’s) expressed confidence… suggests that he did not fully appreciate his duties and responsibilities and what was required to fulfill them.”

In a letter, the NTSB urges maritime academies: “teach your students the circumstances of this accident, including their responsibilities as newly licensed officers to prepare themselves for assigned duties and to express their concerns if placed in situations for which they are unprepared.

NTSB Empress of the North report


New Third Mate Grounded Empress, Master's Decision 'Poor'

 accident reporting, Ferry, grounding, NTSB  Comments Off on New Third Mate Grounded Empress, Master's Decision 'Poor'
Jul 242008


Washington, DC – The National Transportation Safety Board has determined that the probable cause of the grounding of the Empress of the North was the failure of the officer of the watch and the helmsman to navigate the turn at Rocky Island, which resulted from the master’s decision to assign an inexperienced, newly licensed junior third mate to the bridge watch from midnight to 4:00 a.m. The third mate was not familiar with the route, the vessel’s handling characteristics, or the equipment on the vessel’s bridge.

“The flawed decision making in this accident created the potential for a catastrophic disaster,” said NTSB Chairman Mark V. Rosenker. “Those in leadership positions need to make sure they consider every option possible when making critical decisions that could put lives at risk.”

On May 14, 2007, the 300-foot passenger vessel Empress of the North, operated by Majestic America Line, grounded on a charted rock at the intersection of Lynn Canal and Icy Strait in southeastern Alaska, about 20 miles southwest of Juneau. The vessel was negotiating a turn west out of Lynn Canal into Icy Strait on its way to Glacier Bay, the next stop on a 7-day cruise, carrying 206 passengers and 75 crewmembers. The vessel struck the rock, known as Rocky Island, which was illuminated by a flashing green navigation light.

Passengers and crewmembers were evacuated safely without injuries. The vessel sustained damage to its starboard underside and propulsion system.

In the report adopted yesterday, the Board noted that because of the senior third mate’s illness, the master replaced him with the new junior third mate for the midnight-to-4:00 a.m. watch. The third mate held an unlimited, any-ocean third officer’s license but had never before stood watch on the vessel or traveled the waters of Lynn Canal.

The master had ample time to consider the watchkeeping assignment, the Board stated. However, the Safety Board investigators found no evidence that the master considered other options and did little to prepare the junior third mate for his first underway watch.

The third mate lacked any knowledge of the route and should not have been left to make this critical maneuver on his own, the Board said. The Safety Board concluded that the master jeopardized the vessel’s safety by allowing the third mate to stand a bridge watch before he was familiar with the route and the bridge equipment.

As a result of its investigation of this accident, the Safety Board recommended that state and U. S. maritime academies use the circumstances of the accident to teach students about their responsibilities as newly licensed officers. The Safety Board also recommended that the Passenger Vessel Association inform its members about the circumstances of the accident.

A synopsis of the Board’s report, including the probable cause and recommendations, is available on the NTSB’s website, www.ntsb.gov, under “Board Meetings.” The Board’s full report will be available on the website in several weeks.

Nov 152007

Once the US National Transportation Safety Board has produced the transcripts of the voyage data recorder from the Cosco Busan (Formerly the Hanjin Cairo, the Hanjin name remains on the ship side) we’ll have a better idea of who said what to whom and when. Currently only the pilot’s version of events is available and it is raising a number of questions.

A malfunctioning radar appears to have been an element, though not the cause, of the incident and so far there has been no indication regarding the second radar on the ship’s bridge. Given that there was poor visibility, was the speed of the vessel excessive? Should departure have been delayed until the fog cleared.

The pilot was not familiar with the ECDIS equipment onboard, which does not appear to have malfunctioned. When the pilot asked the Captain to point out the centre of the bridge span the captain allegedly pointed to the bridge support and the pilot navigated accordingly.

With an apparently malfunctioning radar and a lack of familiarity with the primary method of navigation,  did the pilot seek to confirm the vessels position with the VTS and/or the accompanying tug?

VTS informed the pilot that the ship was off course, which the Pilot disputed and shortly afterwards a lookout shouted a warning that there was a bridge support ahead and the vessel went hard right and allided with the Delta bridge support.

There also appears to have been a lack of detail in the master/pilot exchange when the latter took conduct of the vessel, as the pilot’s lawyer admits. Would the missing information have been enought to prevent the incident?

There may also have been communications problems between the American pilot and the bridge team who were Chinese. Of there were, to what extent did they reduce the pilot and the bridge team’s situational awareness?

It is not uncommon for pilots to ‘go it alone’ rather than work with a bridge team with whom communication is problematic. This increases the workload on the pilot and reduces his situational awareness. Had the pilot and the bridge team undergone bridge team/bridge rsource management training?

Incidents such as this rarely have a single cause, or a single responsible individual. They are usually the result of systemic problems with Bridge Team Management, leadership, culture and navigational practices.

It will be a while before we know the full story of the Cosco Busan, but we’ll hit that bridge when we get to it.


Case No. 3 – The Case Of The Wandering Monarch

 Bermuda, cruise liner, grounding, maritime accidents, NTSB, podcast  Comments Off on Case No. 3 – The Case Of The Wandering Monarch
Jul 032007

A cruise liner with 1,500 souls aboard, the most dangerous waters around the US coast and a GPS that tell lies to the autopilot for 36 hours with nobody noticing. Guess what happens next…

The Case of the Wandering Monarch

Listen to the podcast and read the illustrated transcript here