Officials cite poor information sharing in 2007 ship crash

Thursday, February 19, 2009

WASHINGTON -- A medically unfit pilot, an ineffective captain and poor communication between the two were the cause of a November 2007 accident leading a ship to spill thousands of gallons of fuel oil into San Francisco Bay, officials said Wednesday.

In reviewing the accident, the National Transportation Safety Board said prescription medications impaired the performance of the pilot trying to guide the 901-foot-long Cosco Busan under the San Francisco-Oakland Bay Bridge. The ship sideswiped one of the bridge's support towers.

The board also stressed the captain failed to oversee the pilot's performance. The board said the two poorly communicated what efforts should be undertaken to guide the ship through dense fog.

The board found other contributing factors. It said the ship's operator, Fleet Management Ltd., didn't properly train and prepare crew members before the accident, and the U.S. Coast Guard failed to provide adequate medical oversight of the pilot.

"How a man who was taking a half-dozen impairing prescription medications got to stand on the bridge of a 68,000-ton ship and give directions to guide the vessel through a foggy bay and under a busy highway bridge, is very troubling, and raises a great many questions about the adequacy of the medical oversight system for mariners," said Mark V. Rosenker, the NTSB's acting chairman.

The crash ruptured two fuel tanks, spilling more than 53,000 gallons of fuel oil into the bay. Cleanup efforts cost more than $70 million. No one was injured in the crash, but the spill contaminated 26 miles of shoreline. It also killed more than 2,500 birds of about 50 species and delayed the start of the crab-fishing season.

Investigators told the board that the pilot, John Cota, committed several errors during the trip, including failure to interpret radar images and effectively communicate with officials when questions arose about the ship's course. Yet, the captain, Mao Cai Sun, didn't step in and take control despite troubling signals.

The captain's lack of experience with the bay made him more dependent upon the pilot to guide the ship, investigators said. Language differences also contributed to their lack of communication, and perhaps cultural differences did as well, with the captain less willing to question the authority of somebody with superior knowledge of local waters, investigators said.

Investigators also said medical records for the ship's pilot showed he had taken numerous prescription medications in the months leading up to the accident and that some of the medications are shown to have an adverse effect on cognitive performance.

"There was a lack of competence in so many areas that this accident seemed almost inevitable," Rosenker said.

Cota, and the ship's Hong Kong-based operator, Fleet Management Ltd. have been charged with crimes connected to the spill. Cota's lawyer Jeff Bornstein alleged that his client is a "scapegoat" for an accident caused by many factors, including a poorly trained crew that spoke little English.

"That ship was unseaworthy because the crew was so improperly trained," Bornstein said.

Cota has pleaded not guilty to two felonies alleging he failed to disclose prescription drugs he was taking on two annual medical reports required by the Coast Guard. Fleet Management is charged with ordering at least one Chinese crew member to alter documents after the accident. Both are also charged with environmental crimes.

Some NTSB members said they saw an even more fundamental problem that contributed to the accident.

"This accident started when they left the dock," said board member Debbie Hersman. "They should have never left the dock in those conditions."

But investigator Rob Jones told the board that he believed a competent crew could pass under the bridge despite the poor visibility.

"Ships do depart in fog," Jones said. "Ships did depart in fog before the Cosco Busan."

The board also made eight recommendations designed to improve safety, including asking the International Maritime Organization to address cultural and language differences in its bridge resource management curricula. It also wants to require mariners to report any substantive changes in their health or medication use between required medical evaluations.


Associated Press writer Paul Elias contributed to this report from San Francisco.


On the Net:

National Transportation Safety Board: http://www.ntsb.gov

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