Cosco Busan NTBS Report - Master / Pilot Exchange

Cosco Busan, anchored after striking the Oakland Bay Bridge

Back in February Bob Couttie posted NTSB on Cosco Busan: Unfit, Ineffective, Incompetent.

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.

Bob updated in May when the NTSB released it final report with Communication, Cosco Busan And Sex With A Duck

>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]. . .

Basically the finding are that the pilot was impaired and that the master failed to properly monitor the vessel progress, In other words the pilot conned the ship into the bridge tower while the master and bridge crew stood by and did nothing.


The degree to which the pilot is willing to cooperate with the master varies a great deal. In Japanese ports, for example, the pilots come aboard with a form which includes the intended track of the vessel including the approach, in other ports, some pilots view the master's questions as a nuisance. In the U.S. it could go either way depending upon the port and the individual pilot.

Update: This is what I'm talking about.

From the Site The Pilot Boat example of what I would consider an excellent passage plan.
K.C.

Cosco Busan coverage - One year later

It has been a year since the Cosco Busun struck the Oakland Bay Bridge. There has been some coverage on line regarding the Cosco Busan. The crew is still be held as material witnesses. - Forbes Article here.

A pilot commissioners' board in San Francisco found that pilot error was a factor in the incident - From Mercury News

The mistakes included allowing the ship to sail in heavy fog, failing to resolve concerns with the ship's radar system and an electronic chart system, and proceeding at an unsafe speed.

Another error, the report said, was failing to take into account communication difficulties with the Chinese crew, who had limited English-speaking abilities.

Robin Storm has a good summary of the incident from the SFGate here.

There have been congressional hearings, and several investigations. A report by the National Transportation Safety Board and the Coast Guard into the cause of the accident is due in January.

gcaptain has three interesting regarding the Cosco Busan, two by pilot Capt John Denham and one by Capt. John Konrad.


Deconstructing The Cosco Busan Incident - More On Accidents And Why - by John Denham

John Denham points out the importance of BRM:

"if the BRM is not functional the vessel is not seaworthy”

The Cosco Busan - A Failure in xx"x Resource Management - by Captain John Konrad

John points out both the pilot and the capt made errors but in addition points to the individual who authorized changing the entire crew of the vessel.

John Cota made two crucial errors; a willingness to proceed (even rush) under adverse conditions and refusal to fully utilize resources available to him, namely electronic charting systems. Captain Sun also made two critical mistakes; acceptance of the position and willingness to proceed on the day of the incident. The high level of proficiency and low incident rate of our nations pilots helps to explain Cota’s decision and Captain Sun’s trust of his decision to proceed that morning but does not explain either’s willingness to proceed knowing one important fact; the entire vessel crew was replaced just two weeks prior.

Feedback - A failure in XXX Resource Management - by John Denham

A vessel found undermanned, crewed with unqualified persons or lacking operational proficiency is unseaworthy and local authority, as a matter of public policy, should be responsible to detain it.

It will be interesting to see the NTSB and US Coast Guard report in particular the role of fatigue with regards to the ship's crew


K.C.