The US Coast Guard has released the marine casualty investigation report for the allision between 'Cosco Busan' and the San Francisco-Oakland Bay Bridge on November 7, 2007.
The report outlines the causal and contributing factors that led to the accident that resulted in the discharge of more than 200,000 litres of oil into San Francisco Bay. The allision caused a gash measuring approximately 45 metres long by 3.5 metres high on the port side of the ship, puncturing two of the ship's fuel tanks and damaging the fendering system on the Delta tower of the bridge, and resulting in a significant environmental cleanup.
The report indicates the main causes of the accident were: navigational error by the pilot of the 'Cosco Busan', who navigated the vessel at a high, unsafe speed in near-zero visibility.
The report concluded that the pilot failed to properly monitor the vessel's position and progress, and lost situational awareness. The report also said that the failure of the master of the 'Cosco Busan' to adequately monitor the navigational actions of the pilot and to maintain sufficient situational awareness of navigational errors made by the pilot was another factor.
There was also the failure of the pilot and master to communicate effectively on relevant navigational information with each other during the course of the voyage leading up to the casualty. The pilot and master did not conduct a proper pilot-master exchange prior to getting underway; the master did not adhere to restricted-visibility procedures in the vessel's safety management system; and the pilot and 'Cosco Busan's' crew failed to employ proper bridge management team principles.
