The Case Of The Foggy Pilot


When it comes to safe navigation,
if you don’t ask a question right
you’re not asking the right question and
you won’t get the right answer.

When it comes to safe navigation,
if you don’t ask a question right
you’re not asking the right question and
you won’t get the right answer.



The Incident

It’s 0600, we’re at Pier 56 in the Port of Oakland, San Francisco, on 7 November, 2007 and the last of 2,529 containers bound for Busan in South Korea is loaded aboard the Hong Kong registered Cosco Busan and scheduled to leave the berth in one hour’s time.


Port of Oakland

Unusually, for a containership leaving Oakland, she’s fully loaded with a deep draft.

Cosco Busan, once the Cosco Cairo, is a 275 metre containership with a Chinese crew. Like the rest of the crew, the four officers on the bridge that morning had been aboard since the vessel’s ownership had changed two weeks before. For most of them, this is the first time they’ve been to San Franciso, the first time they’ve worked for the company that recruited them, Fleet Management, and the first voyage aboard Cosco Busan.

It was also the first time they’d worked together.

They’d had around 90 minutes to speak with the outgoing crew before taking over the ship and spent the next two weeks en route from Busan to the first port of call at Long Beach, California, training while they worked and carried out mandatory drills.

Because the ship has an all-Chinese crew the officers haven’t yet been given the usual training to help them deal with nationalities in which open aggressiveness is socially acceptable, a problem that Fleet Management is aware of.


Visibility was one to two ship’s lengths

This morning in San Francisco it’s foggy, with visibility reduced to one eighth to one quarter of a mile, not much more than one to two ship’s lengths.


The pilot came on the bridge with a ‘cold face’

At 0620 the pilot comes on board. One of about 60 San Francisco Bay pilots and given the designation Romeo, he has a reputation for being forceful, even aggressive, and, to the master on the Cosco Busan, he has what the Chinese call a ‘cold face’. He doesn’t look like he’ll welcome much in the way of questions. He introduces himself to the master and hands over a San Francisco Bar Pilots pilot card. The card says that if the master has any questions about what’s on the card he should ask the pilot. The master doesn’t, and doesn’t discuss the harbour pilot’s card with the other officers. He does not want to make the pilot “feel uncomfortable or unwelcome,” so he chooses not to ask the pilot about the outbound voyage.

The master asks whether the ship can leave and the pilot responds that he’ll take a look at things and see how the visibility situation develops.

Next, the officer of the watch hands over the ship’s pilot card. The pilot signs that he’s only received it and adds the name of the tug that will assist, Revolution.

At 0630 the officer of the watch, completes a pre-departure checklist, ticking off boxes to indicate that the pilot and the master had discussed and agreed on the proposed passage plan, weather conditions, un-berthing procedures, and use of the assist tug.


The pilot kept his intended route to himself and the master didn’t ask. Photo source: NASA/USCG

Seven minutes later, about 0637, the pilot radios, the vessel traffic service, VTS, and says that he plans to depart berth 56 and pass through the “Delta–Echo” span of the Bay Bridge, and then to the deep water traffic lane.


Delta-Echo span. The mounting for the racon just visible. Source: NASA/USCG

Delta-Echo span is a little more than 650 metres long between towers D and E of the San Francisco- Oakland Bay Bridge. The bridge itself passes over an island called Yerba Buena which, roughly translated means Good Grass, this is, after all, San Francisco. Either side of the Delta tower are two red-over-green conical bouys for which the standard International Hydrographic Organisation electronic symbol is a red triangle. In the centre of Delta-Echo span is a radar beacon that shops up on a radar display as a dash-dot-dash-dash, Morse Code for Y.

The pilot asks VTS about visibility around Alcatraz and the Golden Gate Bridge and is told that visibility is 1/8 to 1/4 nautical miles all the way.

Together the pilot, master and the third officer adjust the ship’s two radar displays and test the tar


Conical buoy symbols: paper chart (left) electronic chart (right)

get acquisition of the automatic radar plotting aid, ARPA, until the pilot is satisfied that the radars are working acceptably.

It’s 0650 is ready to depart. The pilot tells the master that they can go as soon as a tug and barge have passed. The master responds “yeah, yeah, yeah”.

A moment later the pilot contacts the VTS and tells them that Cosco Busan will depart as soon as the tug and barge are clear.

A half hour later the pilot says: “You can single up, Captain, if you want.” and the master gives the order to single-up.

The pilot and master leave the third officer and a helmsman on the bridge and move out to the bridge wing from where the pilot radios the tug Revolution and says that he’s planning to move the tug to the stern once underway “just for insurance”.

At 0800, with tug Revolution on the port quarter using one line, the Cosco Busan’s 2,700 horsepower bow thruster moves her away from Pier 56. As she does so, one of team team on the bridge expresses concern: “American ships under such conditions, they would not be underway”. Since the port is still open, the master assumes that it is still safe to depart, and, besides, he’s never know a master to over-rule a pilot.

Keeping lookout on the bow is the Bosun, who’s equipped with a handheld radio, at the stern is the second officer.

About 0805, the pilot and the master come in from the bridge wing and after the vessel eases off the dock, the pilot has the tug shifted to the stern as planned.

About 0810, with the tug trailing behind on about 100 feet of slack line, the Cosco Busan makes headway out of the Inner Harbor Entrance Channel on a heading of about 288°. The pilot plans to keep the tug trailing behind the Cosco Busan it is through the Bar Channel.

For the next 10 minutes Cosco Busan proceeds outbound at about 9 knots then the pilot orders “half ahead” bring her up to 13 knots. The visibility is just enough for him to see the flashing lights on two buoys pass by to port, then it closes down again so that, when he reaches it, he can’t see the Number One Bouy marking the northern boundary of the entrance to the Bar Channel as the ship passes it.

As usual, the pilot sets the variable range marker ring to a third of a mile. By keeping the ring on Yerba Buena island the ship should come to the centre of the Bay Bridge.


Pilot sets the VRM to 1/3 mile


Yerba Buena Island

At 0819 the Bay Bridge appears on radar.

Then the pilot turns his attention to the electronic chart. He sees a symbol he’s not familiar with, a red triangle, and asks the master what it is, the master says “it’s on the bridge”. He doesn’t say where on the bridge and the pilot doesn’t ask.


The pilot asks about the red triangles – a red flag

About now the pilot should release the tug Revolution, its assistance of the tug is no longer required and, the pilot knows that the tug master has another assignment at 0830, but the pilot has forgotten the tug is there.

It’s now about 0823, with the Cosco Busan on a heading of 282° and was traveling about 10 knots. The pilot asks for 10° port rudder to begin a turn to the southwest.

Over the next two minutes, on the radar display, the VRM ring overlaps Yerba Buena island but the pilot doesn’t see it. On the radar screen the upper end of the bridge appears to widen for a couple of minutes before returning to normal. Believing there is something wrong with the radar display, although he says nothing about it to anyone on the bridge, the pilot’s moved to the electronic chart display.


The VRM overlaps Yerba Buena, the pilot doesn’t see it.

They’re a mile from the Bay Bridge on a heading of 253 degrees and the pilot is confused. He believes that the red triangles mark the centre of the bridge span. He’s a well-experienced pilot and he is going to put the Cosco Busan accurately where he thinks it should be.

At 0825 the pilot orders midships, then gives a heading of 250 degrees, then 245 degrees, followed a moment later by 10 degrees port rudder, then 20 degrees starboard. He orders the engine to full ahead.

Cosco Busan is now almost parallel to the bridge on a heading of 241 degrees with a course over ground of 255 degrees. Finally, the vessel is on a heading of 262 degrees and a course of 235 degree at 10 knots. She’s about one third of a mile from the Bay Bridge.

VTS calls on the radio and asks whether the pilot still intends to pass under the Delta Echo span. While they are talking, the pilot turns to the master, points at the electronic chart and says: “This is the centre of the bridge, right?” and the master confirms it.

For two more minutes, the pilot gives rudder orders that will place Cosco Busan very precisely in front of the red triangles that he thinks is the centre of the Delta-Echo bridge span.

The pilot has forgotten about tug Revolution behind him.

Then suddenly, the bosun, on the bow, radios in Mandarin: “The bridge column, the bridge column”, the master sees it too, as Delta tower emerges from the fog, then the pilot says “Yeah, I see it” he orders midships, then hard a-port to swing the stern away from the tower.


VTS record of the route of the Cosco Busan

At 0830 Cosco Busan makes hard contact with the protective fender of the bridge, tearing a hole through her No. 2 water ballast tank and the Nos. 3 and 4 port fuel tanks.

The pilot reports that he’s touched the Delta span and guides the vessel to an anchorage as heavy fuel oil leaks from the damaged tanks to produce to worst pollution incident in San Francisco’s history, a long clean-up, and millions of dollars in fines.

It is only then that the pilot’s confusion over the meaning of the electronic chart symbols comes to light. Talking to a crewmember afterwards the Master says: “.“He should have known—this is the center of the bridge, not the center of the channel.”

How Did It Happen?

Now, there are some issues that we are not going to deal with in this podcast. Knowing whether or not the pilot’s judgement and perception were affected by the medications he was taking isn’t going to help you on your own bridge. You don’t usually get to pick and choose your pilots. You’re not going to know what pills they’re taking or what the effects might be. You have to deal with the fact that a pilot may not be up to par and take measures to minimise the problem.

Onshore managers also aren’t going to know anything about the pilot either. Decisions made onshore can affect outcomes as they did in this case.

We often hear about risk assessment onboard but risk assessment is just as important when making decisions onshore. For instance, Fleet Management knows the problem of the cultural issues that arose in this case: Certain nationalities are reluctant to question an authority figure, like a pilot, even when they know he or she is wrong and even less likely to do so when that authority figure behaves forcefully, as in this case. The company gives training to deal with what it calls the power gradient but didn’t think it was immediately necessary on a ship with a single nationality crew. If they had viewed it as a risk assessment issue they might have examined the likelihood that the master would have to deal with someone who was not Chinese and might have an attitude, and that likelihood was very high on this voyage to ports in the United States.

Much of the ship’s documentation was in English but the working language was Chinese. That didn’t help the officers and crew become familiar with, for instance, the company SMS procedures in the short time they had since joining the ship.

Then there were the business pressures that meant that after a 90 minute handover in Korea, a crew that had never worked together on a ship they’d never been on before to a destination they’d never been to using equipment they weren’t familiar with, were expected to navigate safely.

The chief officer and the third officer said they had not received any training from Fleet Management on the master’s standing orders, on passage planning, or on bridge team management. The chief officer also said that he had never before worked on a ship with an electronic chart system. According to the second officer, before the voyage, neither the ship’s master nor Fleet Management superintendents had provided him with any training, instruction, or guidance on the master’s standing orders or on Fleet Management’s Bridge Procedures Manual.

All of this created an environment in which there was progressively less leeway for error.

Another issue is that the VTS referred to the vessel by the radio designator of the pilot, Romeo, rather than the name of the ship. The pilot did not mention this to the master. This effectively took the master, who was responsible for the safe navigation of the vessel, out of the loop and made it that more difficult for him to monitor the VTS-pilot communications.

At the same time, the master could not monitor what the pilot was doing because he did not know the pilot’s intentions, he didn’t ask for them and the pilot didn’t tell him. That’s a very common situation and it’s one that should never, ever happen. When you’ve got a pilot a pilot on board, you absolutely have to know what he or she wants to put your ship and how.

Of course, it does help if there’s a passage plan, but there wasn’t one. There usually isn’t in cases like this.

The Cosco Busan incident shows several common factors in incidents when there is a pilot aboard: Lack of a passage plan, a poor or non-existent master-pilot exchange, a master who couldn’t monitor the pilot because he didn’t know his intentions, so couldn’t ensure that the vessel was being navigated safely and who was reluctant to question the pilot.

Then there were those revealing questions that didn’t get the right answers:

The big one was “what are those red triangles?”. That alone should have raised a red flag. They were standard International Hydrographic Organisation symbols which indicate a conical buoy on an electronic chart display. Given that the pilot was onboard because of his intimate knowledge of his domain, knowledge that should have enabled him to identify them even if he had not seen the symbols before, this should have been a matter of concern to the master.


Conical buoy visible in satellite picture


The red triangles marking the buoys

It was certainly a good reason for the master to clarify the pilot’s intentions, which he didn’t.

The master answered that they were “on the bridge”, which was a “where” answer to a “what” question. The master knew what the symbols meant and if hw had said “They’re buoys marking the bridge supports” or “they’re conical buoys” it would probably have been a useful enough response that if he’d given it, I probably wouldn’t be telling you this story. He could also have called up information about the buoys on the display but given the training deficiencies on the Cosco Busan he may not have been familiar enough with the equipment.

In fact, the answer was useless because it didn’t say where on the bridge, so the pilot assumed that they marked the centre of the span, but didn’t confirm that with the master.

The next significant question came when the pilot is talking to the VTS and says to the master “This is the centre of the bridge, right?”. It was an ambiguous question. If he had asked “is it the centre of the span” or better still “Is this the centre of the channel” he’d have probably got the right answer, which was no and there might have been time to take avoiding action.

Video: NTSB Animation


So, how do you avoid bumping a bridge?

A berth to berth passage plan is not just a mandatory bit of paperwork, it’s a good way of getting information out of crusty and uncommunicative pilots.


Course plotted on ship’s chart after the incident.

Draw up the passage plan, mark it on the paper chart or the feed it into the electronic chart display. Now, not only have you met your mandatory obligations and complied with what’s probably already in your company SMS, but you’ve got a diplomatic way of finding out what he’s planning to do with your ship. He’s an advisor, ask for his advice: How well does the passage plan fit with his intentions?

Now you can brief the rest of the bridge team about what’s supposed to happen and when so you and they can help make the pilot’s job easier. Of course, it makes it also makes it easier for you to monitor what he or she is doing and if what he’s doing doesn’t match what he’s told you you can ask why. A master should always be willing to challenge a pilot if he departing from what’s been agreed but it doesn’t have to be an aggressive challenge. That’s part of bridge team management and the pilot is part of the bridge team while he’s aboard.

Do remember the golden rule: If you feel that something’s not quite right, even if you don’t know what it is, something is probably wrong. If you’re on the bridge, speak up, ask for clarification, don’t wait for someone else to talk about it because they might just be waiting for you to say something.

Monitor what the pilot is doing, monitor his radio communications. If something doesn’t make sense, or you feel uncomfortable, say something.

When you’re asked a question, make sure you not only give an answer, but an answer that’s actually useful and unambiguous.

And if you’re doing the asking, remember that asking a question right is just as important as asking the right question. Otherwise, you could be in a fog.

This is Bob Couttie wishing you safe sailing.

Download NTSB Report

  One Response to “The Case Of The Foggy Pilot”

  1. The VTS was monitoring the progress of the ship, and they had already established the fact that the ship would pass very close by or hit the bridge, minutes before the impact. In fact, according to the NTSB report, two persons there were watching a zoomed in screen, and commented to each other that the ship would probably hit. But they failed to give a CLEAR warning.
    Giving clear warnings in situations like this is the very reason of existence of any VTS.

    One general remark: it is not the task of the ships operator to train the crew in generic things like bridge team management and passage planning, this is the task of the (approved) maritime schools. The ships operator has to verify that the crew is qualified, and I have to say that in this case the operator (fleet management) did more then a lot of other companies.