Orange Sun Report Puts Squeeze on Bridge Management

 Accident report, allision, collision, contact  Comments Off on Orange Sun Report Puts Squeeze on Bridge Management
Dec 102009

image Atlanship, owner of the 33,000 gt fruit juice carrier Orange Sun, should provide its officers with training in the principles of bridge resource management that encourage and emphasize correct and unambiguous communication, information management, role responsibility, and contingency planning, says the US National Transportation Safety Board report into the vessel’s collision with the non-self propelled 61 metre dredger New York in Newark Bay, New Jersey.

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Pilot Body Criticised For Failures Post Cosco-Busan

 Accident, allision, competence, contact/allison, pilotage  Comments Off on Pilot Body Criticised For Failures Post Cosco-Busan
Dec 022009

imageCalifornia’s State Auditor has discovered that the Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun licensed a pilot 28 days before he received a required physical examination; he piloted vessels 18 times during this period. Currently, the pilot who conducted the containership Cosco Busan into the San Francisco – Oakland Bay Bridge alleged under the influence of medication is serving a 10 month term in a prison.

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Alternative Energy Puts The Wind Up Navigators

 allision, contact/allison  Comments Off on Alternative Energy Puts The Wind Up Navigators
Oct 282009


MAC is a believer in the Everest Paradigm in accident prediction: Just as Edmund Hilary and Sherpa Tensing conquered Everest because it was there, accident happen because they can. Although there has yet to be a major incident involving offshore wind turbines or wave energy device, it will happen one day, which makes a recent risk alert by Steamship Mutual rather timely.

MAC is certainly not being crisis-mongering. Det Norske Veritas warns: “Placing wind farms at sea close to busy shipping lanes are inherently risky. It is crucial that these risks are identified and mitigated to prevent serious accidents and their subsequent impacts.

“A collision between a ship and a wind turbine could result in production loss from a single turbine or the entire wind farm if the transformer module is damaged. In serious cases, a collision may result in loss of life and oil spills.

“As only a limited number of offshore wind farms have been built so far, there are no international published rules for ship navigation close to the installations. However, offshore wind farms can be treated as offshore platforms with respect to surrounding ship traffic.”

The UK’s Maritime & Coastguard Agency has issued a Maritime Guidance note on the issue, which can read here.

Britain’s Maritime Accident Investigation Branch has expressed the concern: “With the rapid growth in the offshore wind industry, there is concern that its safety culture may not be as mature as, for example, the offshore oil and gas industry.”

Indeed, following the MAIB investigation into the Harald/Octopus grounding in poorly charted waters during the carrying of an experimental wave energy device, the British Wind Energy Association, BWEA, was not only the sole organisation to reject a MAIB recommendation regarding that particular incident but the only one to reject any MAIB recommendation that year, 2007.

Such a rejection would seem to reinforce MAIB’s fears regarding safety culture in the alternative energy incident.

MAIB Report – Banging Knuckles

Maritime Safety & Security News – 29 August 2009

 allision, contact, fire, oil tanker, Sinking  Comments Off on Maritime Safety & Security News – 29 August 2009
Aug 282009

Tuna boats collide in broad daylight
The Daily Astorian
At 3 pm Wednesday the US Coast Guard responded to a collision between two fishing vessels 85 miles west of the Columbia River.

Accident In Bahamas Leaves NCL Passenger Dead
Read more in our Privacy Policy A passenger on board a Miami-based Norwegian Cruise Line ship has died following an accident in the Bahamas.

Barge hits bridge in Hammersmith
Hounslow Chronicle
The wheelhouse of the craft was ripped off by the collision and the skipper suffered a gash to the head which needed 12 stitches.

Empty oil tanker sinks near Suez canal
The vessel had a capacity of 59000 tonnes but was only carrying its own fuel supply of around 60 tonnes, they added. Authorities from the canal,

25 saved after vessel catches fire in Murrells Inlet
Twelve additional people were saved by efforts from the South Carolina Department of Natural Resources. All aboard the ship were transported to Captain

A loaded freighter ship ran aground in the San Joaquin River on Thursday night just east of Solano County, according to the US Coast Guard.

Police blame alleged human error for Bali sea accident
Jakarta Post
involving a ship that capsized off Badung Strait in Bali, was allegedly caused by human error. The Wednesday sea accident left nine passengers dead and

Families of seafarers exposed to high risks of HIV
Philippine Star
MANILA, Philippines (Xinhua) — Being married to a Filipino seafarer for 12 years, Edna (not her real name) has grown accustomed to numerous difficulties

Shippers lament maritime industry’s low contribution to economy
The level of piracy in our territorial waters is almost rivalling Somalia’s. Somalia is a failed state, while Nigeria is the giant of Africa.

Seadrill looking into cause of Timor Sea oil spill
Oil & Gas Journal
21 oil spill involving the Montara platform off West Australia in the Timor Sea. Seadrill’s West Atlas jack up drilling rig is operating under contract to

US finds water pollution near drill sites 27 August 2009

US government scientists have for the first time found chemical contaminants in drinking water wells near natural gas drilling operations, fueling concern that a gas-extraction technique is endangering the health of people who live close to drilling rigs.

US plans land-based UAV patrols to combat piracy
Stars and Stripes
“I believe the main focus would be maritime security and counterpiracy operations,” said Navy Capt. John Moore, commodore of Combined Task Force 67 in

Singapore – preventing and suppressing acts of piracy

The Singapore Maritime and Port Authority (MPA) issued a circular forwarding various IMO guidance and advice on preventing and suppressing acts of piracy and sea robberies on ships. Shipping Circular No. 23 of 2009 (8/14/09).

Advance in offshore drilling hails from landlocked Alberta.
The ship will initially be servicing wells producing for onocophillips. "Platforms can sink 65 wells in a grid, then cost a million dollars to move,

Norwegian mayor sends letter by pipe 27 August 2009

A mayor of a town in western Norway has sent a message to another local politician in the UK via the Langeled natural gas pipeline.

Maritime Safety & Security News –28 August 2009

 allision, collision, contact, piracy, pirates  Comments Off on Maritime Safety & Security News –28 August 2009
Aug 272009

Man falls into cargo ship hold
Brazosport Facts
The fall appeared to have been an unfortunate accident, Houston said. Police do not believe foul play, drugs or alcohol played a role in the fall.

Ship hits Gwadar Port berth
The Nation, Pakistan
Sources were of the view that the mysterious ship collision had caused serious structural damage to the blocks supporting piles of the said jetty,

Boat is abandoned after collision
BBC News
The crew of a catamaran have abandoned their vessel after it was involved in a collision with a fishing boat off the coast of Cornwall.[/column] Continue reading »

Jul 242009

John Clandillon-Baker, who edits the UK Pilots Magazine sent us this:

Ref your “Foggy Pilot” article your readers  may be interested in the editorial ( which deals with some of the issue raised) and the feature on piloting in fog that I did for the April issue of the Pilot which can be read at the following links:
The unprecedented jail sentence of John Cota has set an alarming precedent of criminalising a pilot and this is the topic of my editorial and feature for the July issue which I have just finalised. I usually upload content onto the website a few weeks after the print edition has been received by members so will advise you when I post it.

Communication, Cosco Busan And Sex With A Duck

 allision, containership, maritime accidents, NTSB, Oakland, oil spill, pilotage  Comments Off on Communication, Cosco Busan And Sex With A Duck
May 092009

What, you might wonder, would bring together the NTSB, the IMO, the contact of  the Cosco Busan with the San Francisco-Oakland Bay Bridge and a senior loan officer at a bank in Spokane, Washington, having sexual relations with a Mallard duck?

The NTSB has just released the full report of the Cosco Busan incident and among the issues is that of communications, problems of which are involved in about one in five maritime incidents.

That’s why it is good practice to confirm that information has been understood and that its importance is appreciated.

On the Cosco Busan the voyage data recorder recorded the following conversation between the Pilot and the Master:

Pilot:  “What are these… ah… red [unintelligible]?”
The master responded, “This is on bridge.”

The pilot then said to the master, “I couldn’t figure out what the red light… red… red triangle was.”

The Pilot took this to mean that the red triangles marked the centre of the span when, in fact they indicated the buoys marking the bridge support which the ship later hit. The Master did not realise the importance of the question.

Later, as things unravelled:

Pilot: [unintelligible] you said this was the center of the bridge.
Master: Yes.
Pilot: No, this is the center. That’s the tower. This is the tower. That’s why we hit it. I thought that was the center.
Master: It’s a buoy. [unintelligible] the chart.
Pilot: Yeah, see. No, this is the tower. I asked you if that was [unintelligible]. . . .
Captain, you said it was the center.
Master: Cen… cen… cen… center.
Pilot: Yeah, that’s the bridge pier [expletive]. I thought it was the center.

Says the NTSB report “Shortly after this conversation, the master can be heard saying, in Mandarin, “He should have known—this is the center of the bridge, not the center of the channel.”

In many Asian cultures ‘yes’ does not necessarily mean an affirmative, oner can pick from a range of meanings that would not naturally occur to a Westerner.

(The curiosities and confusion of language are touched upon in Bob Couttie’s new, lighthearted book, Chew The Bones, which you can buy from Amazon and the proceed of which will help support MAC)

In a recommendation letter to US Coast Guard commander Thad Allen the NTSB wrote: “The Safety Board therefore recommends that the Coast Guard propose to the IMO that it include a segment on cultural and language differences and their possible influence on mariner performance in its bridge resource management curricula.”

It’s tempting to think that closely allied languages like English and American present less opportunity for confusion, but you would be wrong. Take this example from Snopes’ wonderful Urban Legend site:

“Armstrong proceeded to shag ducks…”

You can read the rest of the story here. While mallards are known to have a somewhat ‘out there’ sex life, sex acts between humans and 10 days old ducklings are further out than most would want to go.

Apparently ‘to shag’ in American means to catch baseballs, to us Brits it has a rather different connotation.

The lesson is clear: communication is transmitting information, receiving information and understanding information. It’s vital to double each each part of that process, that the communication is understood and verified.

Otherwise, you could end up being shagged by lawyers, and not like a duck.

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,, under
“Board Meetings.” The Board’s full report will be available on the website in several weeks.

Kition vs I-10: Once More Unto The Bridge…

 allision, collision  Comments Off on Kition vs I-10: Once More Unto The Bridge…
Nov 012008

Kition: Back one turn...

As lawyers fiddle in their briefs in preparation for the trial of San Francisco pilot John Cota, another bridge contact incident has come under the spotlight with the release of the US National Transportation Safety Board’s report on the Panama-registered 243 metre tanker Kition – Interstate Highway 10 bridge pier incident on 10 February 2008. Loss of situational awareness, poor judgment and a hazardous manoeuvre by the pilot, Captain J. Strahan jr., led to the accident, concludes the report.

It was the pilot’s first time to take a ship from the Apex Oil terminal on the west bank of the Mississippi River at Port Allen, Baton Rouge, Louisiana. He had never been involved in an incident involving pilot error since becoming a pilot in 2002.

The vessel was moored port side to with the bow facing upriver. On departure she would have to be turned to face down river. Due to the hazards represented by the bridge pier, warnings are given in the Coast Pilot, normal pracrice is to either drop down through the bridge and turn the ship or go about a mil upriver to a former ferry landing to turn. Instead, the pilot turned the vessel off the dock. As he did so the ship swung to starboard and hit the I-10 bridge pier.

Damage to the bridge is estimated at $8m and to Kition, $726,500. Incidents involving ships under pilotage average $850,000 in insurance settlements.

Several lesson arise from the incident: Captain Strahan did not usually volunteer his manouevering intentions to ship’s masters unless they asked, a poor practice. Inadequate master-pilot exchanges are a signature of poor bridge resource management in incidents nvolving vessels under pilotage. While the lack of an adequate exchange may not lead directly to an incident they do indicate underlying systemic problems which increase the chances of an accident.

So, always ask a pilot what his intentions are and go over his passage plan. The master-pilot exchange establishes the bridge team relationship necessary for safe navigation.

An earlier report by the New Orleans Baton Rouge Steamship Pilot’s Association, which has oversight of pilots, also identified ineffective communications between the pilot and the attending tugs and failure to readjust his decisions s cirsumstances changed.

An important of situational awareness is evaluating how changing circumstances affect decisions already made and adjusting to those changing conditions. It is a dynamic process. What often happens is that, having made a decision one stays with it and over-looks or rationalises conditions that conflict with that decision.

It is important to continuously compare what is happenoing in a changing situation to the decisions made.