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Press Release from NTSB Board Meeting on Cosco Busan
Sunday 22 Feb 2009, 02:48
Filed under: harbor

gCaptain:Press Release from NTSB Board Meeting.

“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 Acting Chairman Mark V. Rosenker.

In its determination of probable cause, the Safety Board cited three factors: 1) the pilot’s degraded cognitive performance due to his use of impairing prescription medications; 2) the lack of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the short voyage; and 3) the master’s ineffective oversight of the pilot’s performance and the vessel’s progress.

Contributing to the cause of the accident, the Board cited 1) the ship’s operator, Fleet Management, Ltd., for failing to properly train and prepare crew members prior to the accident voyage, and for failing to adequately ensure that the crew understood and complied with the company’s safety management system; and 2) the U.S. Coast Guard for failing to provide adequate medical oversight of the pilot.

“Given the pilot’s medical condition, the Coast Guard should have revoked his license, but they didn’t; the pilot should have made the effort to provide a meaningful pre-departure briefing to the master, but he didn’t; and the master should have taken a more active role in ensuring the safety of his ship, but he didn’t,” said Rosenker. “There was a lack of competence in so many areas that this accident seemed almost inevitable.”

As a result of its investigation, the Safety Board made a total of eight safety recommendations. In its five to the U.S. Coast Guard, the Board recommended that it 1) ask the International Maritime Organization to address cultural and language differences in its bridge resource management curricula; 2) revise policies to ensure that, in its radio communications, the Vessel Traffic Service (VTS) identifies the vessel, not only the pilot; 3) provide guidance to VTS personnel that defines expectations for when their authority to direct or control vessel movement should be exercised; 4) require mariners to report any substantive changes in their health or medication use that occur between required medical evaluations; and 5) ensure that pilot oversight organizations share relevant performance and safety data with each other, including best practices.

The Board recommended that Fleet Management Limited 1) ensure that all new crew members are thoroughly familiar with vessel operations and company safety procedures; and 2) provide safety management system manuals in the working language of the crew.

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