At about 0800 am on 7 November 2007, the Hong Kong-registered container ship ‘Cosco Busan’ departed its berth at pier 56 in the Port of Oakland heading for Busan, South Korea, with all Chinese crew.
At about 0827, the ship was about 1/3 nautical mile from the San Francisco–Oakland Bay Bridge, when a VTS operator, who was monitoring traffic in the Central Bay Sector, noticed that the vessel deviating from its intended route and was out of position to make an approach to the bridge’s Delta–Echo span. The VTS operator radioed the pilot addressing him by his pilot designator name, “Romeo.” The VTS operator and the pilot referred to VTS as “traffic.”
The VDR showed that when the pilot reported to VTS that he was “steering 280,” the ship’s actual heading was 262°. The VTS operator did not further communicate with the pilot.
At 0829, the bosun used his radio to report, in Mandarin, “The bridge column. The bridge column.” The master replied (in Mandarin), “Oh, I see it. I see it.” The pilot then said, “Yeah, I see it.”
About 10 seconds later, the pilot ordered the rudder (which had been at hard starboard) to mid-ships. After another 5 seconds, the pilot ordered hard port rudder. The forward port side of the vessel struck the corner of the fendering system at the base of the Delta tower at 0830.
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. There were no injuries, but a large oil spill occurred.
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.
As a result of the breached fuel tanks, about 53,500 gallons of fuel oil were released into San Francisco Bay, contaminating about 26 miles of shoreline, killing thousands of birds, temporarily closing fishery on the bay, and delaying the start of the crab-fishing season.
More than 50 public beaches were closed, including Crissy Field, Fort Point, Baker Beach, China Beach and Kirby Cove.
According to an official environmental assessment on the aftermath, the impact was estimated as follows:
- Birds: 6,849 birds were estimated killed, representing 65 different species. The primary species impacted were diving ducks, grebes, cormorants, and murres.
- Fish: An estimated 14-29% of the winter 2007-8 herring spawn was lost due to widespread egg mortality in some areas of the Bay.
- Shoreline Habitats: 3,367 acres of shoreline habitat were impacted.
- Human Uses: 1,079,900 user-days were lost, representing a wide variety of activities (recreational fishing, general beach use, surfing, etc.).
The operating company pleaded guilty to charges of water pollution and falsifying documents and agreed to pay $10 million in fines and penalties. They accepted part of the blame for the accident for failing to provide adequate training to the ship’s new captain and crew. The company also admitted presenting false and forged documents to the USCG about the ship’s voyage plan to obstruct the investigation.
On 10 July 2009, the pilot of the Cosco Busan was sentenced to 10 months imprisonment. On 19 September 2011, federal, state, and local agencies announced a final comprehensive civil settlement for $44.4 million, including:
- $32.2 million for natural resource damages,
- $1.25 million for state penalties, and
- $10.9 million for unpaid government response and assessment costs.
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NTSB identified as key cause of the incident the failure to safely navigate the vessel in restricted visibility as a result of:
- the pilot’s degraded cognitive performance from his use of impairing prescription medications,
- the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the voyage, and
- the master’s ineffective oversight of the pilot’s performance and the vessel’s progress.
Contributing to the accident was:
- the failure of the operator to adequately train the crew members before their initial voyage on the vessel, which included a failure to ensure that the crew understood and complied with the company’s SMS.
- the USCG’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 USCG.
The following ISM related issues revealed during investigation:
- Short or non-SMS familiarization for the key officers onboard;
- The master did not implement several procedures found in the company SMS related to safe vessel operations;
- The company had not successfully instilled in the Cosco Busan master and crew the importance of following all company SMS procedures;
- Most crew members had limited knowledge of English language factor which limited their abilities to read and understand SMS.
Among the key safety issues identified after the incident were issues related to poor training of the crew, as well as issues related to medical oversight of the ‘Cosco Busan’ pilots and mariners in general. The official report also underlined the fact that a passage plan was not prepared in accordance with the SMS procedure for sailing in restricted visibility.
The pilot also made many basic errors that resulted in the accident, such as leaving in extreme fog, failing to notify the Master of the USCG at the time regarding the unreliable radars- which were later found to be fully operational- failing to consult the ship’s official paper navigational chart at any time, confusing the operation of the electronic chart system, and failing to disclose his medical conditions.
Communication problems with an emphasis on language were also stressed.
When crewmembers from different nationalities serve onboard the same vessel, the working language is English. Because the crewmembers on the Cosco Busan were Chinese, the working language was Mandarin, with English being the language used when interacting with non-crewmembers.
Cultural problems also related to poor communication between the master and the pilot. The NTSB report stated that the master did not feel comfortable questioning the pilot because of the pilot’s off-hand manner, which may have been due to the cultural differences. On the other hand, masters have to deal with all nationalities. And good bridge team management should be modelled to overcome this cultural divide.
Explore more in the official investigation report:
Did you know?
- By 14 November 2007, beaches as far south as Pacifica, California had been closed due to the spill.
- In December 2007, the Cosco Busan, having been renamed the Hanjin Venezia, sailed out of San Francisco Bay en route to Busan, South Korea, with a new crew.
- During clean-up operations, oil-soaked birds were put in boxes and driven to the San Francisco Bay Oiled Wildlife Care and Education Center in Fairfield to be rehabilitated, and as of November, some birds returned to the wild.