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NTSB Report on Cosco Busan

In a final analysis of the Cosco Busan oil spill on November 7, 2007, the National Transportation Safety Board determined this week that several factors caused the collision that spilled more than 53,000 gallons of fuel oil into San Francisco Bay and resulted in close to $75 million in damages. The NTSB passed the blame around, citing pilot John Cota’s “degraded cognitive performance due to his use of impairing prescription medication,” an “ineffective master” who was “reluctant to assert authority over the pilot,” the operating company’s failure to properly train its crew, and the Coast Guard’s “inadequate medical oversight” of the pilot’s condition as factors in the accident. “There was a lack of competence in so many areas,” said Acting Chairman Mark V. Rosenker, “that this accident seemed almost inevitable.”

Five of the board’s eight safety recommendations were directed at the Coast Guard, suggesting that they 1) address language and cultural differences; 2) require VTS to identify the vessel, not just the pilot; 3) clarify when VTS has the authority to direct or control a vessel, 4) require mariners to report changes in their health or medications between physicals; and 5) ensure pilot oversight organizations share performance and safety data. The two recommendations aimed at Fleet Management Ltd, the owners of Cosco Busan, were to ensure all new crew members are familiar with the vessel’s operations and safety procedures, and to provide safety manuals in the crew’s “working language.” The final recommendation was to the American Pilots’ Association to encourage pilots to include the master of the ship in the piloting of the vessel.

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