NTSB Number: MAR-09/01
NTIS Number: PB2009-916401
Adopted February 18, 2009
On Wednesday, November 7, 2007, about 0830 Pacific standard time, the Hong Kong registered, 901-foot-long containership M/V Cosco Busan allided with the fendering system at the base of the Delta tower of the San Francisco-Oakland Bay Bridge. The ship was outbound from berth 56 in the Port of Oakland, California, and was destined for Busan, South Korea. Contact with the bridge tower created a 212-foot-long by 10-foot-high by 8-foot-deep gash in the forward port side of the ship and breached the Nos. 3 and 4 port fuel tanks and the No. 2 port ballast tank. As a result of the breached fuel tanks, about 53,500 gallons of fuel oil were released into San Francisco Bay. No injuries or fatalities resulted from the accident, but the fuel spill contaminated about 26 miles of shoreline, killed more than 2,500 birds of about 50 species, temporarily closed a fishery on the bay, and delayed the start of the crab-fishing season. Total monetary damages were estimated to be $2.1 million for the ship, $1.5 million for the bridge, and more than $70 million for environmental cleanup.
The National Transportation Safety Board determines that the probable cause of the allision of the Cosco Busan with the San Francisco-Oakland Bay Bridge was the failure to safely navigate the vessel in restricted visibility as a result of (1) the pilot's degraded cognitive performance from his use of impairing prescription medications, (2) the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the accident voyage, and (3) the master's ineffective oversight of the pilot's performance and the vessel's progress. Contributing to the accident was the failure of Fleet Management Ltd. to adequately train the Cosco Busan crewmembers before their initial voyage on the vessel, which included a failure to ensure that the crew understood and complied with the company's safety management system. Also contributing to the accident was the U.S. Coast Guard's failure to provide adequate medical oversight of the pilot in view of the medical and medication information that the pilot had reported to the Coast Guard.
The following safety issues were identified during this accident investigation:
As a result of its investigation of this accident, the Safety Board makes safety recommendations to the U.S. Coast Guard, the American Pilots' Association, and Fleet Management Ltd.
As a result of this accident investigation, the National Transportation Safety Board makes the following safety recommendations:
To the U.S. Coast Guard:
Propose to the International Maritime Organization that it include a segment on cultural and language differences and their possible influence on mariner performance in its bridge resource management curricula. (M-09-1)
Revise your vessel traffic service policies to ensure that vessel traffic service communications identify the vessel, not only the pilot, when vessels operate in pilotage waters. (M-09-2)
Provide Coast Guard-wide guidance to vessel traffic service personnel that clearly defines expectations for the use of existing authority to direct or control vessel movement when such action is justified in the interest of safety. (M-09-3)
Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. (M-09-4) Supersedes M-05-5
Establish a mechanism through which representatives of pilot oversight organizations collect and regularly communicate pilot performance data and information regarding pilot oversight and best practices. (M-09-5)
To Fleet Management Ltd.:
When assigning a new crew to a vessel, ensure that all crewmembers are thoroughly familiar with vessel operations and company safety procedures before the vessel departs the port. (M-09-6)
Provide safety management system manuals that are in the working language of a vessel's crew. (M-09-7)
To the American Pilots' Association:
Inform your members of the circumstances of this accident, remind them that a pilot card is only a supplement to a verbal master/pilot exchange, and encourage your pilots to include vessel masters and/or the officer in charge of the navigational watch in all discussions and decisions regarding vessel navigation in pilotage waters. (M-09-8)
To the U.S. Coast Guard:
Revise regulation 46 CFR 10.709 to require that the results of all physical examinations be reported to the Coast Guard, and provide guidance to mariners, employers, and mariner medical examiners on the specific actions required to comply with these regulations.
Safety Recommendation M-05-4, previously classified "Open—Acceptable Response," is reclassified "Closed—Acceptable Alternate Action" in the "Coast Guard Medical Oversight of Mariners" section of this report.
In formal consultation with experts in the field of occupational medicine, review your medical oversight process and take actions to address, at a minimum, the lack of tracking of performed examinations; the potential for inconsistent interpretations and evaluations between medical practitioners; deficiencies in the system of storing medical data; the absence of requirements for mariners or others to report changes in medical condition between examinations; and the limited ability of the Coast Guard to review medical evaluations made by personal health care providers.
Safety Recommendation M-05-5, previously classified "Open—Acceptable Response," is reclassified "Closed—Acceptable Action—Superseded" in the "Coast Guard Medical Oversight of Mariners" section of this report.