Multiple Factors Cited in Cosco Busan Incident

The National Transportation Safety Board cited "a medically unfit pilot, an ineffective master, and poor communications between the two" yesterday as the cause of the Nov. 7, 2007, Cosco Busan container ship's striking a tower of the San Francisco-Oakland Bay Bridge, causing a spill of more than 53,000 gallons of fuel oil into San Francisco Bay. The ship was being piloted out of the bay by the pilot in heavy fog, and he told investigators the ship's instruments were showing conflicting information. The board said the incident ultimately killed more than 2,500 birds and caused at least $73.5 million in damage, with $70 million attributed to the environmental cleanup. The ship sustained $2 million in damage, and the bridge sustained $1.5 million in damage.

"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 NTSB Chairman Mark Rosenker. The board cited three factors: the pilot's performance degraded by "his use of impairing prescription medications," lack of a comprehensive pre-departure master/pilot exchange and ineffective communication between the pilot and the master, and the master's "ineffective oversight of the pilot's performance and the vessel's progress."

The board also said the ship's operator, Fleet Management, Ltd., failed to train crew members properly before the voyage and failed to ensure they understood and complied with the company's safety management system. It said, too, that the U.S. Coast Guard failed 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," Rosenker said Wednesday. "There was a lack of competence in so many areas that this accident seemed almost inevitable."

The board made eight safety recommendations in its report to the Coast Guard and recommended that Fleet Management Limited "ensure that all new crewmembers are thoroughly familiar with vessel operations and company safety procedures and provide safety management system manuals in the working language of the crew." The crew members spoke Chinese.

A synopsis of the report is available at http://ntsb.gov/events/Boardmeeting.htm.

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