Apr 052008

Cosco Busan pilot John Cota has invoked his right under the 5th Amendment of the US Constitution, which protects accused persons from self-incrimination, not to appear at the US National Transportation Safety Board hearings which start on 8th April. Through lawyers, he claims that VTS personnel were betting on whether the 65,131 tonnes container ship would hit the San Francisco -Oakland Bay Bridge on November 7, 2007.

Sideswiping the bridge’s fenders, a gash was opened in the ship’s side that resulted in a 55,000 gallon spill of fuel oil.

The two-day public NTSB hearings will follow a 7th April conference to fix the final agenda. NTSB Chairman Mark V. Rosenker, who will chair the hearing says, “This accident presents the Board with many questions, such as: Was the Cosco Busan’s bridge navigation equipment working properly? Was there adequate oversight of the San Francisco bar pilot? Did the Coast Guard’s Vessel Traffic Service exert the appropriate level of control over the Cosco Busan?”

A further issue may be the possible effect of medication being taken by Cota for sleep apnea.

Cota’s lawyers claim that the Coast Guard VTS service could have avoided the accident but did not clearly communicate their concern to Cota and that VTS personnel discussed and took bets on whether the Cosco Busan would hit the bridge, based on “waterfront rumours”. The letter also says that the Coast Guard did not warn mariners about the fog and that Cota “… prevented a worse catastrophe by his clear and cool thinking.”

Cota faces prosecution for two misdemeanors under the Clean Water Act and the Migratory Bird Treaty Act. If found guilty, Cota could face a one year prison sentence or fines totalling $115,000.  Some six members of the Cosco Busan crew, who have not been charged are in detention as ‘material witnesses’ pending Cota’s trial.

The Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun has charged Cota with misconduct and the US Coast Guard has demanded his Merchant Marine Officer’s license because it “believes he is not physically competent to maintain the license.”

Regardless of the results of Cota’s trial or the NTSB hearing, the incident will throw the spotlight on the relationship between Pilot and Master, recently the subject of a Maritime Executive editorial, As pointed out in the responses to that item, the pilkot, at least under US law, is more than merely an adviser, a master is required to obey the pilot, and the bridge crew are required to obey the pilot as if he was the master, unless there is clear indication of the pilot’s incapacity or incompetence.

By which it’s usually too late.

 Posted by at 08:43  Tagged with: , ,

Strangler In The Fridge Preview

 P&I, P&I Club, pilotage  Comments Off on Strangler In The Fridge Preview
Mar 312008

…Oops, that should have been Stranger On The Bridge, “Strangler In The Fridge” was a sort of code during production. If you want to know what we get up to when not working on Maritime Accident Casebook check out the trailer etc. for Stranger On The Bridge here.

There is a bit of form filling before you get to the link.

Cosco Busan Pilot Charged With Misconduct

 allision  Comments Off on Cosco Busan Pilot Charged With Misconduct
Dec 082007

The following has been released by the Board of Pilot Commissioners for the Bays
of San Francisco, San Pablo and Suisun:

“Today, the Board of Pilot Commissioners’ Incident Review Committee filed written charges of misconduct (an accusation) against Captain John Cota arising from his piloting of the COSCO BUSAN on November 7, 2007.

In dense fog, the ship he piloted struck the fendering system of one of the towers of the San Francisco-Oakland Bay Bridge, damaging the ship, the fendering system, and releasing 58,000 gallons of fuel oil into the waters of San Francisco Bay.

“This Board takes seriously the events of November 7th, the resulting oil spill, and Capt. Cota’s involvement as the pilot,” said Board President Knute Michael Miller. “The Board’s Incident Review Committee has carried out its investigation resulting in the charges filed today. We will proceed judiciously to determine whether Captain Cota was negligent and whether he should be allowed to continue piloting on San Francisco Bay. In the meantime, his license remains suspended pending a hearing.”

Captain Cota is charged with having reason to doubt whether the ship could safely proceed under the prevailing circumstances and proceeding on his course with insufficient information about the level of visibility along his intended route. He is also charged with proceeding at a speed that was excessive for the circumstances and failing to make full use of all available resources, including a tugboat, the Vessel Traffic Service of the Coast Guard, and his ship’s lookout. The tug remained tethered to the ship’s stern; the Vessel Traffic Service of the Coast Guard could have provided more information if Captain Cota had requested it; and the ship’s lookout could have been better instructed. The charges allege that Captain Cota’s conduct warrants the suspension or revocation of his state pilot license.

Captain Cota will have 15 days in which to file a written response with his defenses to the charges and to request a hearing.

If the pilot requests a hearing, the Board will decide whether it will hear the case or submit the matter to an Administrative Law Judge for a hearing. That decision may come as early as the Board’s next meeting scheduled for December 13, 2007.
A hearing may be scheduled as early as January, depending on the defenses raised by the pilot and any requests for continuances to accommodate witnesses or access to evidence needed by either side to present their case.

If the pilot does not request a hearing, the Board may act on the charges without a hearing.

 Posted by at 07:48  Tagged with: , ,
Dec 032007

John Clandillon-Baker at UK Pilot Magazine sent me a link to the collision/allision between the general cargo ship Karen Danielsen and the Great Belt Bridge in Denmark that’s very timely given the call for ships to obey VTS Operators in the same way that aircraft obey air traffic controllers. In this case the Croatian Chief Officer fell asleep alone on the ship’s bridge and sadly died in the incident. The area was covered by a VTS system but, at the critical moments, the VTS operator was distracted and didn’t know the ship had hit the bridge until he heard a Mayday on the VHF.

Karen Danielsen

The Karen Danielsen before… 

KD Bridge
This was the bridge

Karen Danielsen after

…and after. The Chief Officer, the single watchkeeper on the bridge, died. 

The official report concludes that VTS could not have prevented the collision. John’s magazine article says: “In my opinion there is a bit of whitewash over the finding that the VTS could probably not have prevented this disaster since the investigators have seemingly revealed that no operators were monitoring shipping on the relevant display for over 30 minutes. If it is considered unlikely that the operator could have prevented the collision even if he had been keenly monitoring the ship it does rather beg the question why bother with having the VTS and expensively manning it since it is seemingly not fit for purpose?

“One common factor amongst all the VTS centres that I have visited is that VTS operators are allocated many administrative duties which inevitably distract the VTS operator from monitoring the displays. If the procedural changes introduced in the Danish Belt centre following the collision were implemented as general VTS policy the increase in manpower required to separately cover the administrative functions could have a significant impact on cost effectiveness of VTS.

You can read his article here.

An otherwise occupied VTS operator also played a role in the grounding of the P&O-Nedlloyd Magellan in Southampton Water, as mentioned in a previous post.

Despite the inevitable howls of protest and indignation from the industry the paradigm shift from VTS as advisers to VTS as controllers is sure to come. It will probably be the biggest change since VTS system began in Liverpool in 1948. Clearly, those who manage VTS will have to pull their socks up, too.

One issue that tends to be overshadowed in the Karen Danielsen case is fatigue. The Chief Officer had been working for 11 hours, taking breaks only for meals. As it happens, new crew had joined the ship on the day of the collision. None were involved in the accident but john has some forceful comments about how they joined the ship:

“…investigators noted a disturbing factor around how crew changes are now undertaken in total contravention of the Working Time Directive which results in ships’s personnel joining the vessel in an already extremely fatigued state. The report notes:

The 2nd officer together with four other new crew members joined the vessel around 1000 hours on 3 March 2005 after travelling by mini-bus from Split in Croatia to Svendborg, in Denmark. This was a direct drive of 26 hours, they were accompanied by two drivers and a crew manager from the manning agency. Upon arrival at the ship they went through their respective handovers and the departing crew members left to return to Croatia with the same mini-bus shortly after 1400 hours on 3 March. The joining crew went straight on duty upon arrival at the vessel.

Due to the busy work schedule planned for the 3rd March, all on board, both existing and newly joined crew worked throughout the day on the 3 March 2005.

I understand that this appalling disregard of the ‘Human Element’ is apparently now common practice as a means of saving the cost of hotel bills and air fares.

Says it all, really.

New Podcast – The Case Of The Confused Pilot

 grounding, pilotage, podcast  Comments Off on New Podcast – The Case Of The Confused Pilot
Nov 282007

Pilotage and bridge team management have come to the fore this month with the allison between the Cosco Busan and the San Francisco-Oakland Bridge so the latest MAC episode, The Case Of The Confused Pilot is a timely reminder of the issues at stake.

Check out the podcast.home page at www.maritimeaccident.org for the audio podcast, the illustrated transcript is under construction and will be available by the weekend.

Nov 222007

In one of those cosmic coincidences, at around the moment the Cosco Busan kissed the San Francisco-Oakland bridge while under pilotage the finishing touches were being put on a three-episode DVD for the American Club called, what else, Stranger On The Bridge.

AP&I says:“Stranger on the Bridge focuses on the responsibilities of deck crew, and the limitations of over-reliance on marine pilotage, in preventing accidents. It comprises three case studies which highlight the challenges in ensuring proper command and communication between pilot and crew. ”

The DVD was developed in cooperation with the International Development and Environmental Shipping School Interactive Technologies, Inc. (IDESS IT, Inc.) in Subic Bay, Philippines.

In fairness, I have to declare an interest: I wrote and directed the videos so I won’t comment on the DVD itself but I will say that IDESS IT has a great creative team of young people and a real commitment to maritime safety.

If you want to know more about Stranger On The Bridge click here.

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.

Nov 122007

The Cosco Busan after the allision (Source, USCG)

Conspiracy theorists might suggest that last Wednesday’s fog-bound collision,properly called an allision, between the San Francisco-Oakland Bay Bridge and the containership Cosco Busan with one of 60 San Francisco Bay Area pilots aboard was a publicity stunt for the curiously well-timed release of the American P&I Club’s DVD, Stranger On The Bridge, scheduled this week. All that is certain is that the bridge is probably the only participant whose career will not be blighted, but the bridge declines to comment on the advice of its lawyers.

In fact, while the DVD was in production last year the International Group of P&I Clubs, which represents 13 of the major shipowner protection and indemnity organisations published the results of a study into incidents involving vessels under the conduct of a pilot. In a period when maritime accidents generally declined, those involving pilots seem to be intractable.

Over a five year period there were 262 claims from incidents that occurred when there was a pilot on board at an average cost of around $850,00. There were 68 collisons at a hefty average of $800,000 apiece which pales against the two collisions a year costing almost $8m each. Pollution incidents, at around two a year, toted up $1.8 per incident.

Incidents involving fixed and floating objects like that of the Cosco Busan, logged a whopping average of 37 a year at a hit of $400,000 each, around $100,000 less, by the way than the annual salary of a Bay Area pilot.

Two cases, one a collision and the other the collapse of a shore crane, involved seafarer and shoreworker fatalities. Pilots didn’t escape the grisly toll, either; in 2005 alone, according to the International Pilots Association, six lost their lives boarding or disembarking vessels.

There are many direct causes for these incidents: pilot fatigue, poor bridge resource management, miscommunications, loss of situational awareness, bad decisions but all dance to same piper – the relationship between the pilot and the bridge team.

One must certainly wonder how a ship 44 metres wide should come to grief in a channel 737 metres wide, tearing a hole 33 metres long by 4 metres wide in its side but would be inappropriate to pass judgment until all the information is in. Even then it is likely to be controversial. The US National Transportation Safety Board’s investigation will itself be under close scrutiny following recent criticisms of its performance by a former senior executive. Another investigation by the US Coast Guard may be seen to be tainted by the need to answer allegations of a tardy response to the resultant 58,000 gallon spill of bunker oil. Reports by the shipowner’s P&I club will probably not be made publicly available in detail, the flag state investigation will take longer. The there will be the Bay Area VTS and the Board of Pilot Commissioners.


Hovering like a dark cloud over the proceedings will be the issue of the possible criminal liability of those on the bridge, predominantly Chinese nationals, the pilot and the ship’s bridge team. Insurance will cover the cost of damages but ship’s officers, the master especially, may well be looking at imprisonment, not a great career move and, of course, a disincentive to becoming an officer in the first place.

Strictly speaking, the pilot is only an advisor and the master, who is responsible for the safe navigation of the vessel, can choose to accept or reject that advice. In reality, few deep sea masters have extensive ship-handling experience and depend on the pilot, who usually has far more knowledge.

Jockeying for innocence has already started. Part of a three-page statement by the pilot, Captain John Cota, to the USCG has been released to the press by his lawyer who blames the bridge team. Says the lawyer: “There was a big difference between what he ordered and the heading that the ship took.”

At the same time, documents from the Board of Pilot Commissioners show that although Captain Cota had an excellent reputation as a ship handler he had been involved in four previous incidents, one involving the grounding of a bulker 2006, and one involving an aircraft carrier in 2003, and had been counselled on several occasions.

So far there have been no suggestions of electrical or mechanical failure which strongly indicates a fault in bridge resource management.

Under the microscope will be whether the pilot gave the correct commands, whether the bridge officers correctly received those commands, whether the orders passed on to the helmsman were those of the pilot and whether the helmsman correctly understood those commands and responded appropriately to them.

There is, in fact, nothing special about the Cosco Busan incident, it just happened to occur in a rich state of a rich country with well-heeled lawyers and a, rightly, vociferous, media. There will be a liability witch hunt fuelled by inflated damage claims, there can be no doubt, lawyers want to feather their nests as much as anyone else.

Right now the greatest danger doesn’t come from the 58,000 gallons of spilled bunker along the California coast, but from the danger that the witch hunt to find one man to take the blame will obscure the real problem of the apparently intractable number of incidents involving ships under pilotage. Resolving that issue will take more than hot air and regulation, it will require paying attention to how decisions are made within the curious environment of the master/pilot relationship and social engineering to make that relationship work.