Marine Accident Report MAR-09-01

161 Pages·2009·2.08 MB·English

Allision of Hong Kong‐Registered Containership M/V Cosco Busan 
with the Delta Tower of the San Francisco–Oakland Bay Bridge 
San Francisco, California 
November 7, 2007 

Accident Report
NTSB/MAR-09/01
PB2009-916401
National

Transportation

Safety Board

Notation 7976B/C
Adopted February 18, 2009

Marine Accident Report
Allision of Hong Kong-Registered Containership M/V Cosco Busan
with the Delta Tower of the San Francisco–Oakland Bay Bridge
San Francisco, California
November 7, 2007

National
Transportation
Safety Board
490 L’Enfant Plaza, SW

Washington, DC 20594
National Transportation Safety Board. 2009. Allision of Hong Kong-Registered Containership M/V
Cosco Busan with the Delta Tower of the San Francisco–Oakland Bay Bridge, San Francisco,
California, November 7, 2007. Marine Accident Report NTSB/MAR-09/01. Washington, DC.

Abstract: On November 7, 2007, 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. 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 safety issues identified during this accident investigation include medical oversight of the Cosco
Busan pilot, medical oversight of mariners in general, guidance for vessel traffic service operators in
exercising authority to manage traffic, procedures for improving the assessment of oil spills in
California waters; and training and oversight of the Cosco Busan crew. 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.

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railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is
mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation
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safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The
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matter mentioned in the report.
NTSB Marine Accident Report
Contents
Figures..........................................................................................................................................vii
Acronyms and Abbreviations...................................................................................................viii
Executive Summary.....................................................................................................................xi
Factual Information.......................................................................................................................1
Accident Synopsis............................................................................................................................1
Accident Narrative...........................................................................................................................1
Postaccident Interview with the Pilot..............................................................................................8
Postaccident Interviews with the Master and Other Ship’s Officers...............................................9
Master.......................................................................................................................................9
Other Ship’s Officers..............................................................................................................11
Postaccident Activities...................................................................................................................11
Organizations/Agencies Involved in the Spill Response...............................................................12
U.S. Coast Guard....................................................................................................................13
California Office of Emergency Services...............................................................................13
California Department of Fish and Game–Office of Spill Prevention and Response............13
Fleet Management Ltd............................................................................................................13
The O’Brien’s Group/Qualified Individual............................................................................14
Oil Spill Response Organizations...........................................................................................14
Incident Response and Spill Estimate............................................................................................14
Communication Within the Unified Command.............................................................................19
Notification of Local Jurisdictions.................................................................................................20
Oil Recovery Response..................................................................................................................21
Meteorological Information...........................................................................................................23
Damage..........................................................................................................................................23
Cosco Busan...........................................................................................................................23
Bay Bridge..............................................................................................................................24
Environmental Impact............................................................................................................26
Vessel Information.........................................................................................................................27
Ownership...............................................................................................................................27
Operations–Fleet Management Ltd........................................................................................27
Vessel Description..................................................................................................................32
Fuel and Fuel Storage.............................................................................................................33
Navigation Equipment and Charts..........................................................................................34
Waterway Information...................................................................................................................38
Bay Bridge Information.................................................................................................................39
General....................................................................................................................................39
Bridge Tower Fendering System............................................................................................39
Accident History.....................................................................................................................41
Risk Assessment.....................................................................................................................42
Personnel Information....................................................................................................................42
San Francisco Bar Pilot..........................................................................................................42
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NTSB Marine Accident Report
Master.....................................................................................................................................46
Chief Officer...........................................................................................................................46
Second Officer........................................................................................................................46
Third Officer...........................................................................................................................46
Helmsman...............................................................................................................................47
Bosun.....................................................................................................................................47
Medical and Toxicological Information........................................................................................47
Postaccident Drug and Alcohol Testing of Mariners.............................................................47
Drug and Alcohol Testing of the Cosco Busan Pilot..............................................................48
Drug and Alcohol Testing of the Cosco Busan Crew.............................................................48
Drug and Alcohol Testing of VTS San Francisco Watchstanders.........................................50
Medical Requirements for Merchant Mariners.......................................................................51
Review of Pilot’s Coast Guard Medical Reporting Forms.....................................................52
Centralization of Mariner Medical Review............................................................................55
Oversight of San Francisco Bar Pilots...........................................................................................56
San Francisco Bar Pilots Association.....................................................................................56
Board of Pilot Commissioners................................................................................................59
Pilot’s Incident Record...........................................................................................................62
Cosco Busan Safety Management System and Navigation Safety................................................64
Passage Planning....................................................................................................................65
Pilot Oversight........................................................................................................................66
Safe Speed in Restricted Visibility.........................................................................................66
Master/Pilot Information Exchange...............................................................................................66
VTS San Francisco........................................................................................................................68
Tests and Research.........................................................................................................................72
Propulsion and Steering System Evaluations.........................................................................72
Radar Functionality and Testing.............................................................................................72
Tests of the Electronic Chart System......................................................................................73
Review and Evaluation of Radar Images................................................................................74
Chart Symbols........................................................................................................................76
Other Information..........................................................................................................................77
Postaccident Actions Involving the Board of Pilot Commissioners.......................................77
Postaccident Actions Involving VTS......................................................................................77
Harbor Safety Committee of the San Francisco Bay Region.................................................79
National Contingency Plan.....................................................................................................80
Regional Contingency Plans...................................................................................................80
Area Contingency Plans.........................................................................................................81
National Preparedness for Response Exercise........................................................................82
California Local Jurisdiction Response Plans........................................................................83
Postaccident Actions of California DFG–OSPR....................................................................83
Postaccident Actions of U.S. Coast Guard and Department of Homeland Security..............84
Nontank Vessel Response Plans.............................................................................................86
IMO Initiatives Regarding Bunker Fuels...............................................................................87
Previous Safety Board Action Regarding Mariner Medical Review......................................89

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NTSB Marine Accident Report
Analysis.........................................................................................................................................91
The Accident..................................................................................................................................91
Exclusions......................................................................................................................................93
Bay Bridge Damage and Response................................................................................................94
Responsibilities of the Master and the Pilot..................................................................................95
Performance of the San Francisco Bar Pilot..................................................................................96
Potential Influences on the Pilot’s Performance............................................................................99
Fatigue....................................................................................................................................99
Medical Conditions...............................................................................................................100
Medications and Medication Side Effects............................................................................100
Performance of the Cosco Busan Master.....................................................................................105
Before Getting Under Way...................................................................................................105
The Master’s Role During the Accident Voyage.................................................................107
The Master’s Implementation of the Safety Management System (SMS)...........................108
Potential Influences on the Master’s Performance......................................................................110
Experience Navigating in the Bay Area...............................................................................110
Cultural Differences..............................................................................................................111
Postaccident Drug Testing of Master and Bridge Crew..............................................................112
Performance of VTS San Francisco.............................................................................................112
Potential Influences on the Performance of VTS San Francisco.................................................115
Medical Oversight of the Cosco Busan Pilot...............................................................................116
Personal Physician................................................................................................................116
Examining Physician............................................................................................................117
Pilot’s Knowledge of His Medication Use...........................................................................118
Board of Pilot Commissioners..............................................................................................119
Coast Guard..........................................................................................................................119
Coast Guard Medical Oversight of Mariners...............................................................................121
Role of Fleet Management...........................................................................................................123
Environmental Response.............................................................................................................126
Actions Taken to Quantify the Amount of Oil Released......................................................126
FOSC Evaluation of Response.............................................................................................128
Notification of Local Jurisdictions.......................................................................................128
Actions of the Vessel Crew and Qualified Individual..........................................................129
Timeliness and Effectiveness of Oil Spill Response Organizations’ Efforts.......................129
Nontank Vessel Response Plans...........................................................................................130
Local Planning......................................................................................................................131
Communications Among Pilot Oversight Organizations............................................................131
Prevention of Fuel Oil Spills........................................................................................................132
Conclusions.................................................................................................................................133
Findings........................................................................................................................................133
Probable Cause.............................................................................................................................135
Recommendations......................................................................................................................137
New Recommendations...............................................................................................................137
Previously Issued Recommendations Reclassified in This Report..............................................138
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NTSB Marine Accident Report
Board Member Statement.........................................................................................................139
Appendixes..................................................................................................................................146
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NTSB Marine Accident Report
Figures
Figure 1. The Hanjin Cairo, which would later (in November 2006) be renamed Cosco Busan..2
Figure 2. An enlarged section of the electronic chart on board the Cosco Busan. Two conical
buoys, positioned on either side of the Delta tower, are displayed as red triangles on the
electronic chart.................................................................................................................................4
Figure 3. Navigation chart of the accident area with the approximate intended course of the
Cosco Busan shown by the black dotted line...................................................................................6
Figure 4. Damage to the forward port side of the Cosco Busan after the allision with the bridge
tower..............................................................................................................................................24
Figure 5. Damaged fendering system at the base of the Bay Bridge Delta tower........................25
Figure 6. Close-up view of the fendering system at the base of the Delta tower showing the
likely point of impact and a portion of the 100-foot-long damage area........................................26
Figure 7. The bridge of the Cosco Busan showing primary navigation displays.........................35
Figure 8. The Bay Bridge as displayed on the electronic chart on board the Cosco Busan. The
chart display is from 0821:51, the approximate time the pilot questioned the ship’s master about
the meaning of the red triangles at the bridge................................................................................36
Figure 9. Electronic chart from the Cosco Busan showing the vessel’s track from the entrance
channel to the bridge during the accident voyage. The ship’s position was marked on the chart at
5-minute intervals..........................................................................................................................37
Figure 10. A portion of the paper chart that was on the chart table on the bridge of the Cosco
Busan at the time of the allision. The course line, with in- and outbound headings, had been
plotted and added to the chart by the ship’s crew..........................................................................38
Figure 11. The western crossing of the San Francisco–Oakland Bay Bridge looking east..........40
Figure 12. Graphical display of the Cosco Busan pilot’s prescription history and duty schedule
for the year preceding the allision. Each diamond denotes the filling of a prescription for the
medication indicated......................................................................................................................44
Figure 13. (Top) Radar image displayed on the bridge of the Cosco Busan at 0822:44, just
before the vessel turned to port, and (bottom) the radar image at 0826:14, just after the vessel
made the turn to port. In the bottom image, note the identifier for the RACON at the center of the
Delta–Echo span of the bridge.......................................................................................................75
Figure 14. Radar image on board the Cosco Busan at 0827:14. According to investigators,
0827:14 was the time at which the upper portion of the bridge appeared the most enlarged on the
radar image before returning to normal.........................................................................................76
Figure 15. The International Hydrographic Organization (IHO) symbol used to represent conical
buoys on paper charts (left) and the simplified symbol for the same buoys as represented, in red,
on IHO S-57 electronic navigation charts (right)..........................................................................77

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NTSB Marine Accident Report
Acronyms and Abbreviations
AASHO American Association of State Highway Officials (predecessor to
AASHTO)
AASHTO American Association of State Highway and Transportation Officials
(successor to AASHO)
ACP area contingency plan
AIS automatic identification system
ALCOAST All Coast Guard (message)
ARPA automatic radar plotting aid
Bay Bridge San Francisco–Oakland Bay Bridge
Caltrans California Department of Transportation
CFR Code of Federal Regulations
CGMTA Coast Guard and Maritime Transportation Act
CGVTS Coast Guard Vessel Traffic System
CPAP continuous positive airway pressure
DAPI Coast Guard Drug and Alcohol Program Inspector
DFG–OSPR California Department of Fish and Game–Office of Spill Prevention and
Response
ECDIS electronic chart display and information system
ECS electronic chart system
FHWA Federal Highway Administration
Fleet Management Fleet Management Ltd.
FOSC Federal on-scene coordinator
FOSC-R Federal on-scene coordinator representative
GPS global positioning system
HSC Harbor Safety Committee of the San Francisco Bay region
HSP Harbor Safety Plan
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