Preliminary Inquiry No. 2 of 2007

Report of Investigation

into the Collision of the

Hong Kong Registered Container

Carrier COSCO BUSAN with the

Delta Tower of the

SAN FRANCISCO-OAKLAND

BAY BRIDGE

on 7 November 2007

Preliminary Inquiry No. 2 of 2007

In accordance with Section 51 (1) of the Merchant Shipping Ordinance (Chapter

281), on 13 November 2007, the Director of Marine appointed Mr. LI San-tai,

Surveyor of Ships (Nautical) to carry out a Preliminary Inquiry into the

circumstances attending the casualty.

Purpose of Investigation

This incident is investigated, and published in accordance with the IMO Code for the

Investigation of Marine Casualties and Incidents promulgated under IMO Assembly Resolution

A.849(20). The purpose of this investigation conducted by the Marine Accident Investigation

and Shipping Security Policy Branch (MAISSPB) of Marine Department is to determine the

circumstances and the causes of the incident with the aim of improving the safety of life at sea

and avoiding similar incident in future.

The conclusions drawn in this report aim to identify the different factors contributing to the

incident. They are not intended to apportion blame or liability towards any particular

organization or individual except so far as necessary to achieve the said purpose.

The MAISSPB has no involvement in any prosecution or disciplinary action that may be taken

by the Marine Department resulting from this incident.

Table of Contents Page

Glossary of Terms and Abbreviations iii

1 Summary 1

2 Description of the Vessel and the Bridge 2

2.1 COSCO BUSAN 2

2.2 San Francisco-Oakland Bay Bridge 3

3 Sources of evidence 5

4 Outline of Events 6

4.1 Account of COSCO BUSAN 6

4.2 Vessel Traffic Services (VTS) San Francisco 9

5 Analysis of Evidence 11

5.1 Certification and Experience of Personnel 11

5.2 Certification of the vessel 12

5.3 Weather, visibility and tidal stream conditions 12

5.4 Movement of COSCO BUSAN after leaving the Berth 13

5.5 Actions of Bridge Team on COSCO BUSAN 15

5.6 Pilot-Master Exchange 15

5.7 Passage Planning 16

5.8 Damages sustained to COSCO BUSAN, Bay Bridge and the 17

Environment

5.9 Equipment and engine 19

5.10 Communication between the Pilot and the Master 21

5.11 Alcohol and Drug 22

5.12 Fatigue 22

5.13 Medical Condition 23

6 Conclusions 24

7 Recommendations 26

8 Submissions 27

i

List of Figures

Figure 1 COSCO BUSAN 2

Figure 2 Towers “B”, “C”, “D” and “E” of the Bay Bridge looking east 4

Figure 3 Locations of the RACONS and towers on the Bay Bridge 4

Figure 4 AIS Track of COSCO BUSAN after leaving the Berth 14

Figure 5 Inbound and outbound courses shown on the paper chart 16

Figure 6 Damage on the forward port side shell of COSCO BUSAN 17

Figure 7 Damage on the base of Delta Tower of the Bay Bridge 18

Figure 8 Radar image displayed on the radar at 082614 retrieved from SVDR 19

Figure 9 Vessel’s track from the entrance channel to the bridge displayed on 20

electronic chart from COSCO BUSAN

ii

Glossary of Terms and Abbreviations

AIS Automatic Identification System

ARPA Automatic Radar Plotting Aid

GPS Global Positioning System

kW kilowatt

n.m. nautical mile

RACON Radar Beacon

STCW Seafarer’s Training, Certification and Watchkeeping

SVDR Simplified Voyage Data Recorder

VHF Very High Frequency

VTC Vessel Traffic Centre

VTS Vessel Traffic Services

iii

1. Summary

1.1 At about 0830 local time i.e. Pacific Standard Time on 7 November 2007, the Hong

Kong registered container carrier COSCO BUSAN (hereinafter referred as the Vessel)

collided with the fendering system around the Delta Tower i.e. Tower “D” of the San

Francisco-Oakland Bay Bridge (hereinafter referred as the Bay Bridge) in foggy

weather with a visibility of less than 0.25 nautical mile (n.m.). At the time of collision,

the Vessel was transiting from Berth No. 56 in the Oakland Inner Harbour to sea under

the navigational control of a licensed pilot. As a result of the collision, the shell

plating in way of No. 2 cargo hold and two fuel oil tanks on the portside were

punctured. Approximately 53,500 gallons i.e. about 200 tonnes of heavy fuel oil were

discharged from the above fuel oil tanks into San Francisco Bay causing pollution.

The fendering system of the Delta Tower of the San Francisco-Oakland Bay Bridge

was also damaged by the collision.

1.2 The probable causes of the collision were as follows:

Loss of situational awareness by the Pilot in very poor visibility as the Vessel

approached the Oakland Bay Bridge. The Pilot believed the Delta Tower was the

center of the D-E span of the Oakland Bay Bridge. His performance could have been

affected by his medical condition during his assignment on COSCO BUSAN.

Failure of the Bridge Team i.e. the Master and the Third Officer to monitor the movement of the Vessel and the action of the Pilot.

1

2.1 COSCO BUSAN

2.1.1 Particulars

Port of Registry : Hong Kong

IMO No. : 9231743

Call sign : VRD16

Type : Container Vessel

Year Built : 2001

Gross Tonnage : 65,131

Net Tonnage : 34,078

Length Overall : 274.67 metres

Maximum Breadth : 40.00 metres

Summer Draft : 14.020 metres

Summer Deadweight : 68,086.5 tonnes

Main Engine : DIESEL Hyu B&W 10K98MC-C

Engine Power : 57,100 kW

Number of cargo holds : 7

Speed : 25.6 knots

Class : Germanischer Lloyd (GL)

2. Description of the Vessel and the Bridge

Figure 1- COSCO BUSAN

2

2.1.2 COSCO BUSAN (hereinafter referred as the Vessel) is a container ship classed with

Germanischer Lloyd. It has 7 cargo holds with a total container carrying capacity of

5,447 Twenty-foot Equivalent Units (TEU). The accommodation and the main

machinery space are situated aft. The navigational equipment consists of two sets of

radar with Automatic Radar Plotting Aids (ARPA), three sets of Very High Frequency

(VHF) radiotelephone, a receiver for Global Positioning System (GPS) Navigator, a

gyro compass, a magnetic compass, a course recorder, an echo sounder, a speed log, an

Automatic Identification System (AIS) and a simplified voyage data recorder (SVDR).

2.1.3 The vessel was manned by a Master, three deck officers, four engineers, one deck cadet

and fifteen ratings. All crew members were Chinese nationals.

2.2 San Francisco-Oakland Bay Bridge (Figure 2)

2.1 San Francisco-Oakland Bay Bridge (hereinafter referred as the Bay Bridge) consists of

two major spans i.e. eastern and western spans connecting Oakland and San Francisco

with Yerba Buena Island located at mid-bay. The wood and plastic fender system was

designed to prevent sparks in the event of a collision and it was replaced in 2006.

2.2 RACONs on the bridge mark the centerlines of the main navigable channels under the

primary bridge spans. RACON (N) marks the centerline of the A-B span, RACON (B)

marks the centerline of the C-D span while RACON (Y) marks the centerline of the D-E

span (Figure 3). The recommended passage for southbound i.e. inbound traffic is to pass

beneath the A-B span and the recommended passage for northbound i.e. outbound traffic

is to pass beneath the D-E span. The D-E span has a horizontal clearance of 674 metres

and a vertical clearance of 62 metres at mid-span.

2.3 Post casualty operational tests of the RACONS found them all to be on station and

working properly. RACON signals were displayed on the radar images captured by the

SVDR on board COSCO BUSAN.

3

Tower “D” (Delta Tower)

Tower “B”

Tower “C” Tower “E”

Figure 2 – Towers “B”, “C”, “D” and “E” of the Bay Bridge looking east

Figure 3 – Locations of the RACONS and towers on the Bay Bridge

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3. Sources of Evidence

3.1 Statements from the Pilot, Master and crew members of COSCO BUSAN;

3.2 National Transportation Safety Board (NTSB) of United States of America;

3.3 United States Coast Guard (USCG);

3.4 Office of Spill Prevention and Response, California, U.S.A.

3.5 Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun;

3.6 American Pilots’Association;

3.7 Northrop Grumman Sperry Marine i.e. Repair and maintenance provider for radar and

ECDIS on board COSCO BUSAN; and

3.8 Fleet Management Limited i.e. technical manager of COSCO BUSAN .

5

4. Outline of Events

4.1 Account of COSCO BUSAN

4.1.1 COSCO BUSAN arrived at Port of Oakland on 6 November 2007 for loading and

unloading of containers. At about 0620 local time on 7 November 2007, a San

Francisco Bar Pilot boarded COSCO BUSAN at Port of Oakland Berth 56 to take the

Vessel to sea. Although the Vessel was scheduled to depart at 0630 upon completion

of cargo work, the Pilot and Master of COSCO BUSAN agreed to postpone sailing due

to dense fog and waited for the visibility to improve. At 0630, the engine was ordered

to be put on stand-by. In order to tune the two radars properly and to acquire, track

and plot a target on the automatic radar plotting aid (ARPA) successfully, the Pilot,

Master and Third Officer took 45 to 60 minutes in performing the above tasks. After

tuning the radars and acquiring targets on ARPA, the Pilot examined the electronic

chart. Since the Pilot was not familiar with the symbols on the electronic chart and did

not see any track lines appearing on it, nor did he consult the paper chart on the bridge,

he asked the Master to point out the center of the D-E span of the Bay Bridge to him.

In response, the Master somehow pointed to the buoys marking Delta Tower i.e.

Tower “D” which was about midway between the prominently marked RACONS

(Radar Beacons) on C-D and D-E spans.

4.1.2 At 0645 the tug REVOLUTION was directed by the Pilot to put up a headline to be

made fast on the Vessel’s port quarter. The Pilot visually observed the tug SOLANA

and two barges proceeding up the estuary and the range of SOLANA was 0.25 n.m..

SOLANA had just entered the estuary after passing Port of Oakland berth 38. Due to

improved visibility, the Pilot and Master agreed to sail. SOLANA was informed by the

Pilot that COSCO BUSAN would remain at the berth until SOLANA and the barges

were past and clear. At 0714 lines were singled up aft i.e. only a single stern line, a

breast line and a spring line were still ashore aft. At 0745 lines were singled up

forward and all lines were ordered to be let go. The last line was let go at 0748. There

were four people on the bridge i.e. the Master, Third Officer, Pilot and the Helmsman.

The Bosun was posted forward on the forecastle deck as lookout as the visibility was

very poor. At 0755 when SOLANA and the barges were past and clear and all lines

were clear, REVOLUTION was directed to pull COSCO BUSAN off the berth and by

using the bow thruster, the Vessel moved off the berth to mid-channel. At 0800

REVOLUTION was directed to let go and make fast her headline to the center chock

on the stern of COSCO BUSAN. REVOLUTION was instructed to follow COSCO

BUSAN and to keep the headline slack. The Pilot advised that REVOLUTION would

be kept there until COSCO BUSAN was clear of the Oakland Bar Channel.

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4.1.3 At 0808 engine was ordered to be put on slow ahead and when COSCO BUSAN began

to move out of the estuary, the Pilot observed visually Lights ‘7’ and ‘8’ as well as

Lights ‘5’ and ‘6’ at the edge of the channel. Due to flood current, the Pilot purposely

held the Vessel to the right side of the channel. The speed was ordered by the Pilot to

be increased to half ahead when the Light Buoys ‘1’ and ‘2’ were in the vicinity at

0820. The Pilot did not visually observe the Light Buoys ‘1’ and ‘2’ as he was

concentrating on the radar picture. After clearing the Oakland Bar Channel, the Pilot

had forgotten about the presence of REVOLUTION and did not release the tug.

4.1.4 The Pilot planned to set the radar’s variable range marker (VRM) to 0.33 n.m. and to

maintain that distance from Yerba Buena Island (YBI) as COSCO BUSAN approached

the Bay Bridge. This is a normal practice of other pilots in navigating vessels under

the D-E span of the Bay Bridge in reduced visibility. The Pilot set the VRM and

manoeuvred the Vessel to 0.33 n.m. south of the tip of YBI and commenced to make

alteration of course to starboard as planned. After commencing the turn, the Pilot

asked the Master about the red triangles shown on the electronic chart and the Master

replied that they were lights on the bridge. Failing to recognize that the Master was in

fact pointing to the buoys between that marked the Delta Tower, the Pilot took the

point as the center of the D-E span and thought that the Vessel would be turning short

of that point. He then steadied the Vessel briefly, checking the turn and deviating from

his plan of turning 0.33 n.m. off the shoreline of YBI.

4.1.5 The Pilot stated that when the Vessel was commencing to turn to starboard, the radar

pictures on both radars began to deteriorate. Neither the RACON on the D-E span of

the Bay Bridge, nor the towers or the buoys near the Delta Tower were displayed on

the radar. The image of the Bay Bridge became a thick green ribbon on the radar

screens. The Pilot lost confidence in the accuracy of the radar and did not trust the

radar image and the VRM. At this juncture, the fog became thicker and visibility was

further reduced. The Pilot resumed the turn to starboard and received a radio call from

United States Coast Guard (USCG) Vessel Traffic Services (VTS) who were

monitoring harbour traffic. VTS informed the Pilot that automatic identification

system (AIS) indicated that COSCO BUSAN was on a heading of 235˚T and made

inquiry about his intentions. The Pilot observed from the radar that the heading

marker showed 280˚T and the ship’s head was still swinging to starboard. The Pilot

replied to VTS that the Vessel was coming around and was steering 280˚T at that

moment. VTS acknowledged his reply and asked the Pilot whether or not the Vessel

was still intending to use the D-E span. An affirmative answer was given by the Pilot.

7

4.1.6 As the Pilot had lost confidence in the radars, he moved to the electronic chart and

asked the Master to point out the center of D-E span. The Master pointed to the Delta

Tower instead of the center of D-E span and the Pilot failed to recognize this. At 0827

the Pilot gave an engine order of full ahead and at 0828 he gave a helm order of hard

to starboard in order to bring the Vessel closer to Echo Tower i.e. Tower “E”. The

increased speed and propeller wash caused the towline to the tug REVOLUTION to

tighten. In order to avoid tripping the tug, the tug released the winch brake to let the

towline run to maintain a slack line. At about 0829, the Bosun who was on stand-by

on the forecastle deck called the Master by walkie-talkie that he saw the Delta Tower

which was very close to the Vessel and the Pilot observed Delta Tower looming out of

the fog close on the port bow. The Pilot saw that the Vessel’s port side was going to

contact the tower’s fendering system and he gave a helm order of hard to port to lift

the stern away. At 0830 the Vessel contacted the fendering system on the

east-south-east corner of the Delta Tower. At 0830.5 the Pilot gave an engine order of

dead slow ahead. At 0832 the Bosun on the forecastle deck reported to the bridge that

there was oil leakage and the Pilot informed the USCG accordingly. At 0834 the

engine was stopped.

4.1.7 At 0836 an engine order of slow ahead was given by the Pilot who then informed VTS

by VHF that the Vessel had contacted the fendering system on Delta Tower and was

proceeding to Anchorage 7 off Treasure Island (TI). At 0855 COSCO BUSAN was

anchored 0.5 n.m. off the northwest corner of TI in Anchorage 7. At 0858 the tug

REVOLUTION was let go. Another San Francisco Bar pilot boarded the Vessel at

about 0900 to relieve the Pilot who was taken to the pilot office ashore at 0945 for

drug screening test and alcohol test. COSCO BUSAN heaved anchor at 1105 and

shifted to Anchorage 9.

8

4.2 Vessel Traffic Service (VTS) San Francisco

4.2.1 The VTS San Francisco, which operates from the vessel traffic center (VTC) on Yerba

Buena Island, is under the management of the U.S. Coast Guard Sector San Francisco.

Its mission is to coordinate the safe and efficient transit of vessels in San Francisco

Bay and its tributaries and approaches in an effort to prevent accidents and the

associated loss of life and damage to property and the environment. Due to the large

area covered by the VTS, the area is divided into offshore or ocean/delta sector and

the inshore or central bay sector which are managed by two operators separately. VTS

San Francisco monitored and controlled marine traffic using Coast Guard Vessel

Traffic System (CGVTS) equipment and a partial deployment of the Marine Traffic

Management (MTM-200) system developed by Lockheed Martin Corporation. These

two systems comprise a variety of sensors and communication devices such as radar,

closed-circuit television, VHF radio and AIS data to provide VTS operators with a

visual representation of vessel traffic within their areas of responsibility. In addition to

using sensors, equipment and software, VTS San Francisco uses a regulatory Vessel

Movement Reporting System (VMRS) to monitor and track vessel movements. A

sailing plan, position report and a final report are required to be provided to the VTS

by vessels using the VTS waterway. Under the VMRS, VTS will provide the vessels

with advisories, marine event information, potential hazards or other hindrances to

vessel’s safe transit. During periods of restricted visibility, VTS also provides the

vessels with all radar targets that may affect the vessel’s transit. VTS San Francisco is

manned by both civilian and military personnel and the watch sections are normally

operated by three VTS controllers and a VTS watch supervisor.

4.2.2 In traffic control, four levels of control over vessel movements i.e. monitor, inform,

recommend and direct will be exerted by the VTS operators. Detailed explanation of

the four levels of control can be found in Chapter IV (Vessel Traffic Administration)

of the VTS Operational Policies Manual. In the VTS Operational Policies Manual,

controllers are instructed to use the highest level of vessel control i.e. direct to address

perceived incidents that have potential to drastically affect the transit of one or more

vessels, cause damage to property and the environment or cause injury or loss of life.

4.2.3 The VTS controller responsible for vessel traffic in the central bay sector at the time

of collision i.e. 0830 on 7 November 2007 said that at about 0828 the heading of 235˚

T and position of COSCO BUSAN in relation to Delta-Echo span of the Bay Bridge

had caused his concern. He contacted COSCO BUSAN by VHF requesting

confirmation of the vessel’s intention to use the Delta-Echo span. The Pilot responded

that he was

9

bringing the ship around and steering 280˚T and he still intended to use the Delta-Echo

span. There was no further communication between VTS and the Vessel before the

vessel’s collision with the Delta Tower. At 0830, the Pilot informed VTS that COSCO

BUSAN had touched the Delta Tower and the Vessel would proceed to the anchorage.

4.2.4 At 0900, the relief pilot reported to VTS via VHF that he was on board COSCO

BUSAN and would remain there for the duration of the incident. At 0901, VTS began

broadcasting Sector San Francisco’s first safety-related radio transmission to alert

vessels to keep well clear from a designated area within Anchorage 7 where COSCO

BUSAN was at anchor. Throughout the morning hours and into the early afternoon,

VTS received multiple VHF radio communications and telephone calls regarding oil

sightings and the locations of oil accumulation along various portions of the

waterway.

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5. Analysis of Evidence

5.1 Certification and Experience of Personnel

5.1.1 The Master was a holder of a valid Certificate of Competency as Master issued by the

Liaoning Maritime Safety Administration of the People’s Republic of China for

vessels of or over 3000 gross tons on 21 June 2005 and a Hong Kong Class 1

Foreign-going Deck Officer Licence issued on 11 December 2007. He has been

serving as Master since 1998 and he joined COSCO BUSAN in Busan on 24 October

2007. Previously he had sailed on at least three ships with a size larger than COSCO

BUSAN and this was his first trip into San Francisco Bay.

5.1.2 The Chief Officer was a holder of a valid Certificate of Competency as Chief Mate

issued by the Shanghai Maritime Safety Administration of the People’s Republic of

China for vessels of or over 3000 gross tons on 27 April 2005 and a Hong Kong Class

2 Foreign-going Deck Officer Licence issued on 30 June 2006. He joined COSCO

BUSAN in Busan on 24 October 2007. He had sailed on another vessel with a similar

size to COSCO BUSAN and had previous experience on board a vessel at anchor in

San Francisco Bay in 1999.

5.1.3 The Second Officer was a holder of a Certificate of Competency as Third Mate issued

by the Tianjin Maritime Safety Administration of the People’s Republic of China for

vessels of or over 3000 gross tons on 18 November 2004 and a Hong Kong Class 3

Foreign-going Deck Officer Licence issued on 29 June 2006. He joined COSCO

BUSAN in Busan on 24 October 2007. He had not sailed on a ship with a similar size

to COSCO BUSAN and he had never been to Oakland before. This was his first trip as

a Second Officer and he had never used the electronic chart before.

5.1.4 The Third Officer was a holder of a Certificate of Competency as Second Mate issued

by the Tianjin Maritime Safety Administration of the People’s Republic of China for

vessels of or over 3000 gross tons on 11 May 2007 and a Hong Kong Class 3

Foreign-going Deck Officer Licence issued on 11 December 2007. He has been

serving as Third Officer for about fourteen months and he joined COSCO BUSAN in

Busan on 24 October 2007. He had not sailed on a ship with a similar size to COSCO

BUSAN and he had never been to Oakland before.

5.1.5 The Pilot of COSCO BUSAN was issued a Third Officer’s license i.e. Officer in

charge of a navigational watch for ocean-going vessels of any gross tonnage under the

STCW Convention by the USCG in 1972. He started working as a pilot trainee in San

Francisco in 1977 and became a member of the San Francisco Bar Pilots Association

11

on 1 February 1981. At the time of accident, he was a First Class Pilot qualified to

pilot any vessels for the Bays of San Francisco, San Pablo and Suisun. He stated that

he had made thousands of trips under the Bay Bridge and it was not uncommon to

pilot vessels in fog. Every pilot is required to attend electronic simulator training

every three years and manned model ship handling training every five years. In this

connection, the Pilot of COSCO BUSAN had most recently completed a 7-day

simulator training course at the Maritime Institute of Technology & Graduate Studies

near Baltimore in Maryland in June 2005 and a ship handling training course at Port

Revel in France in August 2003. During his 26-year piloting career, the Pilot was

involved in 13 pilot-related incidents and 4 incidents occurred within the last 10 years.

5.2 Certification of the vessel

5.2.1 The statutory trading certificates of COSCO BUSAN were all valid and in order.

5.3 Weather, visibility and tidal stream conditions

5.3.1 The weather was reported to be dense fog with a visibility of 0.25 n.m. or less from

Oakland out to the Golden Gate Bridge and the wind was calm. At the time of

collision, the tidal stream was flooding and setting in a direction of 168˚T with a rate

of about 1.25 knots. In view of the fact that the Bosun who was on stand-by on the

forecastle deck only called the Master when the Delta Tower was very close to the

Vessel, the very poor visibility is considered to have a bearing on the occurrence of

the accident.

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5.4 Movement of COSCO BUSAN after leaving the Berth (Figure 4)

5.4.1 At about 0810 COSCO BUSAN commenced sailing from Berth 56 in the Port of

Oakland on a heading of about 288˚T towards the estuary of the Inner Harbour

Entrance Channel. At about 0815 COSCO BUSAN arrived at the estuary between

Light Buoys 7 & 8 on a heading of about 290˚T at a speed of 5.7 knots. At about

0823 the Pilot gave a helm order of port ten intending to alter course to the southwest.

The vessel was on a heading of about 282˚T at a speed of about 10 knots.

5.4.2 At about 0825 the Pilot gave a helm order of midships when the vessel was on a

heading of about 253˚T, then he requested for steering on courses 250˚T followed by

245˚T. At about 0826 when the vessel was on a heading of about 241˚T, she was

almost parallel to the bridge and her course over ground was about 255˚T. Helm

orders of starboard ten followed by starboard twenty were given by the Pilot.

Despite the use of starboard rudder and the ship’s heading began to move to

starboard, the course of the ship over ground continued to move to port. At about

0827, the ship’s heading was 247˚T and 236˚T over ground. The heading had

increased to 261˚T but the course over ground was 235˚T after a few seconds. The

speed was about 10 knots since 0823.

5.4.3 At 0828 a series of helm orders were given by the pilot as follows:

Time Helm order

082802 Starboard 20

082813 Hard starboard

082842 Midships

082851 Starboard 20

After giving a helm order of hard starboard at 0829, the Pilot saw the Delta Tower of

the Bay Bridge. In an attempt to move the stern of the Vessel away from the tower, a

helm order of hard to port was ordered by the Pilot. At about 0830, the forward port

side of COSCO BUSAN struck the corner of the fendering system at the base of the

Delta Tower. A helm order of midships and engine order of dead slow ahead were

given by the Pilot after collision.

13

14

5.5 Actions of Bridge Team on COSCO BUSAN

5.5.1 It is stipulated in Section A-VIII/2 of Seafarer’s Training, Certification and

Watchkeeping (STCW) Code that despite the duties and obligations of pilots, their

presence on board does not relieve the master or officer in charge of navigational

watch from their duties and obligations for the safety of the ship. The master and/or

the officer shall co-operate closely with the pilot and maintain an accurate check on

the ship’s position and movement.

5.5.2 Section 1.5.8 of the company’s Bridge Procedures Manual also reminds the masters

that even though pilotage may be compulsory, a pilot acts only as an adviser and the

master being responsible for the ship’s safe navigation. Should the master consider the

pilot to be endangering the ship or contravening any law, rule or regulation, he shall

reject the pilot’s advice or relieve him of his duties and assume control of the ship

himself. The responsibilities of the ship’s navigating officers do not transfer to the

pilot, and the duties of the Officer of the Watch remain with that officer.

5.5.3 The master of a vessel remains to be in overall command even with the assistance of

the pilot and he has the ultimate responsibility to the safety of the vessel at all times.

The Master of COSCO BUSAN appeared to have delegated the navigation completely

to the Pilot on board the Vessel. In the incident there was no indication that the

Master had taken any initiatives or intervention to ensure the safety of his vessel.

Although at 0820 the Third Officer had plotted the first position on the paper chart

using the GPS receiver and found that the fix was about 183 metres to the left of the

intended course, he did not report to the Master or the Pilot. The bridge team just

totally relied on the Pilot to navigate the Vessel.

5.6 Pilot-Master Exchange

5.6.1 Section A-VIII/2 of Seafarer’s Training, Certification and Watchkeeping (STCW)

Code stipulates that with a pilot on board, the master and pilot shall exchange

information regarding navigation procedures, local conditions and the ship’s

characteristics. Section 1.5.8 of the company’s Bridge Procedures Manual also

requires masters to consult the pilots on the passage plan to be followed. In this case,

although the Pilot had discussed with the bridge team on his dissatisfaction with the

radar images and tracking of targets, the Master had not consulted with the Pilot and

the Pilot had not informed the Master of his intended plans for the passage.

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5.7 Passage Planning

5.7.1 Section 1.3.1 of the company’s Bridge Procedures Manual states that the masters

should ensure that a plan for the intended voyage is prepared before sailing. This plan

should be prepared from “berth to berth” and not “pilot-station to pilot-station” as is

traditionally being followed. However, it was discovered that the original passage plan

prepared by the Second Officer before sailing was not from berth-to-berth but was

from pilot-station to pilot-station. The berth-to-berth plan that had been provided to

the NTSB investigators was actually prepared by the Second Officer after the

collision.

5.7.2 Although the passage plan was from pilot-station to pilot-station, a single course

indicating the planned route through the Delta-Echo span of the Bay Bridge to and

from the berth 56 was laid down on the paper chart British Admiralty Chart No. 588

by the ship’s crew prior to entering San Francisco Bay (Figure 5).

Figure 5 – Inbound and outbound courses shown on the paper chart

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Damage

5.8 Damages sustained to COSCO BUSAN, Bay Bridge and the Environment

5.8.1 COSCO BUSAN

According to the damage report of the vessel’s classification society Germanischer Lloyds, as a result of collision COSCO BUSAN sustained damage to the forward port side shell and the adjoining frames, panel stringers and longitudinal stiffeners extending from approximately frame 128 to frame 150 over a height of 3 metres between 14 and 17 metres above baseline. The torn and deformed side shell and structure were pushed inboard from approximately 1 to almost 2 metres along the 67-metre damaged area. The hull was breached in way of No.2 port water ballast tank, No. 3 and No. 4 port fuel oil tanks (Figure 6).

Figure 6 - Damage on the forward port side shell of COSCO BUSAN

17

5.8.2 Bay Bridge

As a result of the collision, the Bay Bridge sustained damage to the wood and plastic fendering system and concrete tower support at the base of the Delta Tower (Figure 7).

Figure 7 - Damage on the base of Delta Tower of the Bay Bridge

5.8.3 Environment

The oil spill resulting from the collision spread quickly with the tide and contaminated more than 26 n.m. of salt marshes, rocky coastline and sandy beaches. More than 1,500 birds and six mammals died.

18

5.9 Equipment and engine

5.9.1 Radar

COSCO BUSAN was installed with 2 sets of radar with ARPA facilities. One radar

operates on the X-band i.e. with a wavelength of 3 centimetres while the other

operates on the S-band i.e. with a wavelength of 10 centimetres. The SVDR captured

and stored radar images from the 3-centimetre antenna at 15-second intervals. After

boarding COSCO BUSAN, the Pilot was not satisfied with the radar images and

tracking of targets and spent 45 to 60 minutes in adjusting the radars. The Pilot also

stated that after the vessel had entered the Bay, the radar picture deteriorated and was

not showing the RACONS or bridge piers after the vessel had altered course to

maintain 0.33 n.m. off Yerba Buena Island. However, review of the radar images

captured by the SVDR showed a clear radar image of the bridge and Yerba Buena

Island and RACON marking the mid-point of the Delta-Echo span also appeared on

the radar screen at regular intervals during the voyage (Figure 8). Moreover, after the

collision a radar service engineer was arranged to conduct various tests on the radar

systems and found that all the test results were normal and the radars were operating

correctly at the time of testing.

Figure 8 – Radar image displayed on the radar at 082614 retrieved from SVDR

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5.9.2 Electronic Chart System (ECS)

Although the ECS on COSCO BUSAN was capable of performing as an electronic

chart display and information system (ECDIS), due to its configuration and the type of

electronic charts that were being used aboard the vessel, it was an ECS rather than a

ECDIS certified under International Maritime Organization (IMO) regulations. The

ECS aboard COSCO BUSAN was type-approved and the symbols displayed were

consistent with IHO Standards 57. ECS was permitted to be used as a navigation aid

only and paper charts were required for primary navigation. Figure 9 illustrates the

vessel’s track from the entrance channel to the bridge shown on the electronic chart of

COSCO BUSAN.

Figure 9 – Vessel’s track from the entrance channel to the bridge shown by electronic

chart from COSCO BUSAN

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5.9.3 The following equipment and navigational aids were tested after the collision:

(a) Gyro compass, ARPAs and ECDIS were tested by a manufacturer’s representative

and found in order; and

(b) RACON “Y” for the center of the Delta-Echo Span was inspected and found

operating normally.

5.9.4 Engine

The engine room automation alarm printout did not reveal any alarm conditions

related to the main engine, electrical system and steering gear.

5.9.5 There was no evidence to indicate that there was any malfunctioning of equipment and

engine in relation to the incident.

5.10 Communication between the Pilot and the Master

5.10.1 The official language of the crew was Chinese. The Master had a reasonable command

of English and conversed with the Pilot in English while the Third Officer and

Helmsman understood the Pilot’s commands. All commands were properly executed

in a timely manner. After the collision, USCG investigating officers interviewed the

Master and found that he had the best grasp of English but an interpreter for detailed

questions was still needed.

5.10.2 According to the conversation recorded on the SVDR, the Pilot asked at about 0828

the following question: “this is the center of the bridge, right ?” and an unidentified

crewmember answered “yeah” to the Pilot. The Pilot actually referred to the center of

the span i.e. D-E Span. However, the crewmember misunderstood that the Pilot was

referring to the geographic center of the Bridge i.e. Bay Bridge. This

mis-understanding was verified by audio recording on the SVDR that at about 0833,

the Master remarked that “this is the center of the bridge not the center of the

channel”.

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5.11 Alcohol and Drug

5.11.1 After the collision, a breath test for alcohol was administered to the Pilot, Master,

Chief Engineer, Third Officer and the Helmsman and the results were negative. Test

for dangerous drugs was also taken by the Pilot, Master, Chief Officer, Third Officer,

Helmsman, Chief Engineer, Second Engineer and Boatswain and the results were

negative.

5.12 Fatigue

5.12.1 The duty roster of the Pilot of COSCO BUSAN was one week on and one week off. He

reported for duty at 0300 on 2 November 2007 and 1600 on 3 November 2007. He

was off on 4 November 2007. He then reported for duty at 0330 on 5 November 2007,

0630 on 6 November 2007 and 0500 on 7 November 2007 respectively. The collision

occurred on 7 November 2007 which was the last day of his one-week duty. The Pilot

stated that he tried to get at least seven hours of sleep before reporting duty. He often

had naps in midday due to his erratic work schedule and took medication to assist with

falling asleep at least two or three times a week. After taking dinner on 6 November

2007, he slept for seven hours and woke up at 0415 to get ready to report for duty on

board COSCO BUSAN at 0600. Based upon the above information on the job

assignments of the Pilot, it appears that he had not suffered from fatigue.

5.12.2 Section A-VIII/2 of Seafarer’s Training, Certification and Watchkeeping (STCW)

Code concerns with fitness for duty for watchkeeping officers or ratings and it

stipulates the requirement for minimum rest hours for watchkeeping crew members

under normal or abnormal e.g. emergency or drill or other overriding operational

conditions. According to the records of working hours/overtime hours/rest hours of the

Master, Third Officer and the Helmsman of COSCO BUSAN, the requirement for

minimum rest hours had been complied with.

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5.13 Medical Condition

5.13.1 According to the medical examination reports submitted by the Pilot to the USCG

under existing US federal regulations, the Pilot had disclosed medications that had

been prescribed by his physicians for several conditions. The Pilot had been found “fit

for duty” by the licensed occupational health physician who examined him under the

requirements of the Board of Pilot Commissioners for the Bays of San Francisco, San

Pablo and Suisun and USCG.. In addition, the USCG had granted the Pilot medical

waivers for the disclosed conditions and medications. However, USCG determined

after the collision that the previously disclosed information about prescription

medication should have disqualified the Pilot under the federal medical standards.

USCG requested and the Pilot agreed to deposit his federal license with the USCG..

Medical history of the Pilot reveals that he has significant health problems and takes

medications that could medically disqualify him. In this connection, it was possible

that the Pilot’s performance had been affected by his medical condition during his

assignment on the COSCO BUSAN.

5.13.2 Prior to joining COSCO BUSAN, all the crew members on board the vessel had been

medically examined and were issued with valid medical certificates.

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6. Conclusions

6.1 At about 0830 local time i.e. Pacific Standard Time on 7 November 2007, the Hong

Kong registered container carrier COSCO BUSAN collided with the fendering system

around the Delta Tower of the San Francisco-Oakland Bay Bridge.

6.2 At the time of the accident, the weather was reported to be dense fog with a visibility

of 0.25 n.m. or less and the wind was calm. The tidal stream was flooding and

setting in a direction of 168˚T with a rate of about 1.25 knots. The very poor

visibility is considered to have a bearing on the occurrence of the accident.

6.3 As a result of the collision, the shell plating in way of No. 2 cargo hold and two fuel

oil tanks on the portside of COSCO BUSAN were punctured. Approximately 53,500

gallons i.e. about 200 tonnes of heavy fuel oil were discharged from the above fuel oil

tanks into San Francisco Bay causing oil pollution.

6.4 The fendering system of the Delta Tower of the San Francisco-Oakland Bay Bridge

was also damaged by the collision.

6.5 The investigation revealed the following probable causes of the collision:

Due to loss of situational awareness by the Pilot in very poor visibility as the

Vessel approached the Oakland Bay Bridge, the Pilot believed the Delta Tower

was the center of the D-E span of the Oakland Bay Bridge. His performance

could have been affected by his medical condition during his assignment on

COSCO BUSAN.

Failure of the Bridge Team i.e. the Master and the Third Officer to monitor the movement of the Vessel and the action of the Pilot.

6.6 The investigation also revealed the following contributory factors leading to the

collision:

The Pilot and Master elected to get underway when visibility was less than 0.5

n.m. after having problems in tuning and acquiring targets on the ship’s radar.

Misunderstanding existed in the communication between the Pilot and the Master.

The Pilot referred “the center of the bridge” as the center of the D-E span while

the Master took it as the geographic center of the Bay Bridge.

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A pilot-master exchange was not conducted properly between the Master and the

Pilot. The Master had not consulted the Pilot and the Pilot did not inform the

Master about his intended plans for the passage.

Non-existence of a berth-to-berth passage plan had caused the absence of some

important navigational information which potentially could have prevented the

collision.

6.7 There was no evidence to suggest that the Pilot or crew members had been affected by

alcohol or illicit drugs.

6.8 As there was no evidence to indicate that there was malfunctioning of navigational

equipment and machinery, they were not considered as contributory causes of the

accident.

6.9 According to the duty rosters of the Pilot and the crew members, there was no

evidence to suggest that the Pilot or crew members had been affected by fatigue.

6.10 The Pilot’s history of prescription medications and medical conditions would have

potentially disqualified him under federal standards, it was possible that he was

medically unfit to perform his duties during his assignment on board COSCO BUSAN.

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7. Recommendations

7.1 A copy of the report should be sent to the National Transportation Safety Board

(NTSB) of United States of America advising them of the findings of the

investigation.

7.2 A copy of the report should be sent to the operator of COSCO BUSAN who should

issue a notice to draw the attention of their masters and officers to the findings of this

report. They should be reminded to follow the Company’s Bridge Procedures Manual

in the following aspects:

(a) The presence of pilot on board does not relieve the duties and obligations of the

master or officer in charge of the navigational watch for the safety of the vessel;

(b) a berth-to-berth instead of pilot-station to pilot-station passage plan should be

prepared before sailing from port; and

(c) a proper pilot-master exchange should be conducted between the Master and the

Pilot when arriving or leaving port.

7.3 A copy of the report should be sent to the Board of Pilot Commissioners for the Bays

of San Francisco, San Pablo and Suisun, American Pilot’s Association and United

States Coast Guard (USCG). They should be advised of the findings of the

investigation and should consider to conduct the following reviews:

The Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and

Suisun and the American Pilot’s Association should consider to review their

training requirements for their pilots and the possibility of providing appropriate

enhanced and periodic training in electronic navigation equipment expected to be

found on vessels entering US. They should also draw the attention of their pilots

to the risks associated with navigation in restricted visibility and the importance

of observing regulations and port policies on navigation in adverse weather

conditions e.g. poor visibility, etc.

The Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and

Suisun and the USCG should consider to review their existing medical

requirements and examination procedures for their pilots to ensure that the pilots

are medically fit whenever they are engaged in pilotage duties.

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7.4 A Merchant Shipping Information Note (MSIN) should be issued to draw the

attention of all concerned parties to the importance of conducting a proper

pilot-master exchange between the Master and the Pilot.

8. Submissions

8.1 In the event that the conduct of any person or organization is commented in an

accident investigation report, it is the policy of the Marine Department to send a copy

of the draft report to that person or organization for their comments.

8.2 The final draft of the report were sent to the following parties:

Master, Third Officer, Pilot, operator of COSCO BUSAN

Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun

American Pilot’s Association

National Transportation Safety Board (NTSB) of United States of America

United States Coast Guard (USCG)

8.3 Submission had been received from the Pilot of COSCO BUSAN and the draft

investigation report was amended as appropriate according to his submission.

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