Situation Report: Diagnosing the Cosco Busan Debacle

You may well be wondering why Telstar Logistics has been so uncharacteristically silent about the events surrounding the Cosco Busan incident, in which a large container ship struck the San Francisco Bay Bridge and created a massive oil slick that has done great harm to the Bay Area's marine ecosystem.  Truth is, since we initially reported on the accident, there's not much Telstar Logistics could say that our Maritime Correspondent John Konrad over at gCaptain hasn't already said faster and smarter.

If you haven't been following along at home, here's the briefing: Last Tuesday, November 7, a large container ship called the Cosco Busan went astray in heavy fog while under the control of a seasoned local pilot. The Cosco Busan hit the base of a Bay Bridge tower, carving a large gash in the ship's hull.

Cosco Busan photo by Scary Cow.

The Coast Guard intially reported that 140 gallons of fuel oil were spilled in the accident, but after reports of oil slicks and foul smells began streaming in from all across the San Francisco waterfront, the Coast Guard revised the size of the spill upward to 58,000 gallons. The delay meant that environmental incident responders got a late jump on the crisis, and with many Bay Area beaches fouled and still closed a week later, two big questions have been front page news in San Francisco ever since: How did the accident happen, and why wasn't it immediately contained?

Suffice to say, "communications breakdowns" effectively answers both questions. But when it comes to diagnosing why the Cosco Busan hit the bridge, gCaptain's Konrad has been way ahead of most analysts -- and journalists. That makes sense: He's a Master Mariner, after all, so he does this stuff for a living.

So here's the summary: Konrad pointed out that the accident was, formally speaking, an allision, NOT a collision. He then posed a series of questions intended to clarify the circumstances that prompted the Cosco Busan to hit the bridge. Most of these questions focused on issues of communication and interaction between the local pilot, the ship's captain, and the rest of her crew. Along the way we learned about the concept of Bridge Team Management, which are essentially a set of management communications procedures designed for use on big ships, and inspired by similar initiatives that have proven effective in the field of aviation safety. On November 12th, Konrad wrote:

Investigators should shy away from providing quick answers, despite media protests, and avoid singling out an individual in this incident. An incident might occur because the helmsmen failed to take a required training course a year back or due to a improperly installed antenna 6 years back or a policy decision 15 years previous. Most likely it was caused by all of the above and 100 additional errors that combine to form what marine incident investigators call an error chain. Remove one error in the chain and the allision would not have occurred.

This was prescient, as subsequent stories in the mainstream media and an initial assessment by the Coast Guard suggest that the cause of the accident will ultimately be traced to human factors, rather than technological failures. On Wednesday November 14, the San Francisco Chronicle reported:

[Representing the local pilot, Attorney John Meadows] said problems also cropped up in "bridge management," the communication between the pilot, who had years of experience on the bay, and the ship's officers, who had never navigated the bay in the Cosco Busan. All were supposed to work together and exchange information on how to successfully navigate the harbor.

"While some information was exchanged, perhaps it could be said it wasn't a full transfer of information. It was enough for the pilot to work with the master and get the ship ready for sea," Meadows said.

That's where things stand now. To track where these developments will go in the days and weeks ahead, we advise you to monitor gCaptain for the most insightful updates. We'll be doing the same.

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Ooops! Container Ship Collides with SF Bay Bridge

Blogging on the High Seas with gCaptain

Comments

[Dorris Gagnier]

What happened to "The Rule in Fog" that says a ship shall procede no faster than to be able to stop in half the distance it can see. Didd radar replace this rule?

[john]

Well I'm not sure about smarter but speedy is my middle name ( not really ;)

Dorris,
That's more of a geographical (and political?) rule of thumb. In Texas they close the Houston Ship Channel in nearly all fog conditions but It's fairly safe to navigate in SF fog IF you have reliable equipment and an experienced bridge team.

The actual rule states you must transit at a "Safe speed" taking into consideration (among other things) "The manageability of the vessel with special reference to stopping distance and turning ability in the prevailing conditions;" Which translates to "The Captain can go as fast as he want as long as he doesn't hit anything or can prove in a court of law he was acting responsible."

I suspect shipping continues in SF fog for two reasons... the bay is wide open and relatively easy to navigate and the high number of foggy days. Closing the port each time the visibility lowered would put a considerable strain on shipping traffic and result in the shipping companies moving operations elsewhere (maybe portland, tacoma or vancouver?). A result local politicians (rightfully) want to avoid.

Or maybe it's just because Houston pilots are scared of doing the Texas Chicken blind ;)

[Dawn]

Moments later, while the ship was going 11 knots, the Chinese lookout in the ship's bow shouted in Chinese and rang a warning bell, reporting that he could see the bridge tower dead ahead.

The pilot had the helm turn hard to the right, Meadows said, and "that saved the ship from going head-on into the tower."

SFGate

This is my favorite bit. The ship is loaded with state of the art navigation electronics and the thing that saves them from maybe knocking down the Bay Bridge is a good old-fashioned lookout in the bow of the ship who rang a bell. Nice use of thousand year old technology.