MULTIPLE FACTORS CITED BY NTSB AS CAUSE OF CONTAINER SHIP ACCIDENT IN SAN FRANCISCO BAY

[NTSB Press Releases <NTSBPressReleases@xxxxxxxx>]

Title: MULTIPLE FACTORS CITED BY NTSB AS CAUSE OF CONTAINER SHIP ACCIDENT IN SAN FRANCISCO BAY

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                      NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: February 18, 2009
SB-09-06

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MULTIPLE FACTORS CITED BY NTSB AS CAUSE OF CONTAINER SHIP
ACCIDENT IN SAN FRANCISCO BAY

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Washington, DC - The National Transportation Safety Board
determined today 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 to
be $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.
 
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Media Contact: Peter Knudson, 202-314-6100
peter.knudson@xxxxxxxx

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