Coast Guard Releases Cosco Busan Report

WASHINGTON — The U.S. Coast Guard released Tuesday the marine casualty investigation report for the Nov. 7, 2007, allision between the motor vessel Cosco Busan and the San Francisco-Oakland Bay Bridge.

The report outlines the causal and contributing factors that led to the accident that resulted in the discharge of more than 53,000 gallons of oil into San Francisco Bay.

The report indicates the main causes of the accident were:

[li] Navigational error by the pilot of the Cosco Busan, John Cota, who navigated the vessel at a high, unsafe speed in near-zero visibility, failed to properly monitor the vessel’s position and progress, and lost situational awareness;[/li][li] Failure of the master of the Cosco Busan to adequately monitor the navigational actions of the pilot and to maintain sufficient situational awareness to question or correct navigational errors made by the pilot;[/li][li] Failure of the pilot and master to effectively communicate relevant navigational information with each other during the course of the voyage leading up to the casualty;[/li][li] Failure of the pilot and master to conduct a proper pilot-master exchange prior to getting underway;[/li][li] Failure of the master to adhere to restricted-visibility procedures in the vessel’s safety management system; and[/li][li] Failure of the pilot and Cosco Busan’s crew to employ proper bridge management team principles.[/li][li] The purpose of the Coast Guard marine casualty investigation is to examine the causes of a marine casualty and to make recommendations to help avoid a similar incident. In addition to the primary causes, investigators in this case discovered practices, policies, and procedures employed by the Coast Guard and other parties involved that can be, and in some cases have already been, addressed to improve overall maritime transportation safety.[/li][/ul]

The marine casualty investigation does not address spill response operations in detail. The oil spill response was extensively investigated when the Coast Guard chartered a multi-agency Incident Specific Preparedness Review panel. The panel issued a detailed report of its findings in Jan. 2008. The panel reported that despite early incorrect spill quantity estimates, spill response personnel acted on a “worst case scenario” basis, resulting in one of the most aggressive and successful responses in recent history, yielding an approximate 40 percent recovery rate of spilled oil.

The U. S. Coast Guard marine casualty investigation of Cosco Busan allision can be found visiting:

The ISPR reports can be found visiting the following sites:

ISPR Phase I report:

ISPR Phase II report: