-
Website
http://gcaptain.com/maritime/blog/ -
Original page
http://gcaptain.com/maritime/blog/cosco-busan-google-earth-tracking/ -
Subscribe
All Comments -
Community
-
-
Top Commenters
-
Popular Threads
All Comments
Next chart you produce, how showing the currents as well? :)
"Yes but in stepped a gCaptain reader who we can’t thank enough. He transposed the timestamps from regional AIS beacons and helped us create a shipplotter version (Disclaimer here and shipplotter results here) of the events."
You PC drivers may temporarily have to do a right click: Save Target As.. to get the animation to download. QuickTime is a sure viewer. Others work. Time Tags are the hook.
I found this post about "Free Earth" on Kurt's weblog... I'll be sure to pass it on to the guys at Jakota:
http://schwehr.org/blog/archives/2007-12.html#e...
http://gcaptain.com/maritime/blog/may-9-1980-ta...
The Incident Review Committee of the Board of Pilot Commissioners for the Bays of San
Francisco, San Pablo and Suisun has accused the Pilot of misconduct. Detail of that accusation include:
"During the period ... the visibility in the approach to the bridge was reduced to about 0.1 nm, the ship’s radar pictures deteriorated to the point that (the Pilot) lost confidence in them, and he lost situational awareness to accurately assess the vessel's position, although he had the means to do so."
" Under the circumstances, prudence and compliance with Inland Navigation Rules 6, 7 and 19 would have dictated that (the pilot) reduce speed and/or proceed to Anchorage 9 rather than
continue to attempt to transit under the bridge between the Delta and Echo towers, which he could
not see on radar and which were not visible due to the dense fog."
"(The Pilot) failedt o make full use of all available resources, including the tug REVOLUTION, which remained tethered to the stern and thus useless to him, of the Coast Guard Vessel Traffic Service, which could have provided more information as to his position and heading if he had requested it, and of his ship's lookout, who could have provided information on the bridge's fog signals and lights if the lookout had been properly instructed."
I read this to indicate that the Board holds that determining the location of mid-span and guiding the ship under it is the proper role of the Pilot.
Most of all publications concerning this accident found out that the pilot (Mr. John Cota) of the ship is responsible for that occurence.
Everybody ascertains the so called „human error“ very quickly.
But what is the background for human errors ? In any cases of accidents at sea one can find a very complex construction of different factors causing at last the “result” : the error, the mistake.
I investigated a lot of papers in the last few month’s, published in Internet.
I can’t agree all official ascertainments and personal opinions or judgements.
In my report I am able to prove that Mr. Cota is only limited responsible for the accident.
A very important part plays the voyage plan of the Captain. In my opinion he was not informed where the center of the span is. His track leads to an accident directly. Please look at waypoint 3.
But the most important meaning one can find in the radar. An exact analysis of the visibility of racon signals, the change of signals and the different quality of displayed information dependent on the range leads to a lack of situation awareness in a moment of necessary concentration. Further more the pilot was distracted by VTS- call.
I am ready to offer the results of my research to Mr.Cota’s lawyer or the attorney of the Government of the State of California or the NTSB.
Dear Paul, you wrote in
“Oakland Tribune” , Nov 13, 2007 :
“UPDATE: Ship transponder data shows Cosco Busan changed course and ...”
"The $100 million question is why did he choose to turn when he did?” (said Michael Slater )
I am able to answer that question . Please keep an eye on your money ! It would very well if you are able to make a contact to Mr. Cota or to start a helpful discussion between maritime experts.
My name is Dr.Ing.habil. Diethard Kersandt, Lecturer of a Maritime Academy in Germany for 21 years,
Master Mariner, researcher in the field of “human errors”, accident investigation, expert systems for risk assessment in navigation, 65 years, retired.
More information : http://www.competence-site.de/1779/mitglieder.n...
With kindly regards
Diethard Kersandt
One must always, however, err on the side of caution. The ship's passage plan itself is in question with Fleet Management having been charged with falifying it after the incident. This is the result of poorly trained USCG investigators in the first instance who failed to secure documents on the bridge, thus there is a question regarding their evidence trail.
Unfortunately, given the enthusiasm for throwing cluster-bombs of criminal charges around, it is unlikely that the depth of information will come to light to contribute to navigational safety.
Let me make it clear that in what follows that I intend to make no assumption of liability on behalf of the pilot or the master. I am merely considering how Dr. Kerstandt's views might play.
If Dr. Kersandt will permit me a moment of being a hypothetical prosecutor. I accept, hypotheically,his comments on the visibility of the racon, the change of signal and the quality of the display and the potential interference of the VTS. All this would have been apparent to the pilot. The question for me would be whether the pilot took appropriate action, was the vessel's speed appropriate to the conditions, which include his uncertainty?
Did he do his due diligence and adhere to Rule 6 of Colregs?
Dr. Kerstandt will need to demonstrate that the pilots decisions were appropriate to the situation.
One of the functions of good bridge team management is to mitigate an individual's loss or lack of situational awareness – did the pilot, or the master, use the good bridge team management principles?
Let me return to the issue which Dr. Kerstandt begins with – the passage plan. When a pilot boards a vessel ut is good practice for the pilot and the master to discuss the passage plan and for the pilot to explain what his intentions are, where he intends to make his turns and so forth, so that at least the master knows what he's up to and, in a best case scenario, the rest of the bridge team know what to expect.
If that was done, then the pilot would be in a position to confirm or deny the allegations against the ship manager, Fleet Managemnt, that the ship's passage plan was not in accordance with US law. If he was aware, and said nothing, then he is complicit in an illegal act, if he wasn't aware because he had not followed good practice, again he's in trouble. If he saw the plan and it was in accordance with US Law then Fleet Management is off the hook on at least one if its indictments.
As I suspect any pilot might tell you, ship's passage plans are often inadequate within an area of compulsory pilotage, especially when the person responsible is inexperienced in that particular port. It is the pilot's job to make sure the necessary adjustments are made. Indeed, Pilot's usually have their own passage plan for the area of their responsibility, or a simulacrum thereof.
In brief, it is not the ship's passage plan which informs the pilot but the pilot who informs the ship's passage plan in the area of his responsibility.
What changes to the ship's passage plan did the pilot make? Did he communicate those to the bridge team? Did they fully understand his intentions?
Pilots do not meekly follow the ship's passage plan, nor does the wise master meekly follow the pilot's advice.
While a pilot may only be an 'adviser', I would say that he has what is in effect a fiduciary duty towards the safety of the vessel. Did he carry out that duty?
I would reiterate, my intention is not to discuss liability but to demonstrate the complexities of the issues involved. Recently, the US courts have decided that a government official cannot be indicted on criminal charges for making poor decisions because the legal situation is 'too complex'. I leave you to comment upon that.
What are the consequences of such a statement ? We are able to put our finger at a guilty person. And the court of justice has the basis to find a judgement accordingly as well as the insurance companies can work as usually.
But now let me put my question : does that deliver any new knowledge for avoiding future errors and accidents ?
I think that the “case Cota” sticks fast on this stage exactly.
Therefore I am interested in that “case”. My starting point is the cognitive process of information processing by that person, which is responsible for decision finding and action plan. I try to find out what information was available, what information was needed, what kind of information has caused what kind of behaviour. During the analysis of the last 15 minutes up to the allision I found out, what the basis for Cota’s decisions was. And I found a lot of failures and lacks located in the technical equipment, in sea charts, in administration and at last in voyage planning by the captain.
This and only this findings are suitable to recognize possibilities for preventive measures.
And that could be the source for arguments of Cota’s lawyer.
Many thanks for commenting my comment. I hope the very interesting initiative “Prevention Through People”, started by U.S. Coast Guard, will find the needed attention by mariners.
The influence of the human element is long recognised. That is precisely what bridge team management is intended to address. It is also what Colregs are about, to mitigate the effects of false cognition.
(I've very aware of cognitive psychology/neurology. You might consult a book called "Forbidden Knowledge", by Lutterworth Press)
Did Cota, or the master, act appropriately under the conditions?
Knowing that the radar is faulty, do you then continue to proceed at full manouvering speed in fog?
Frankly, it sounds to me you've got Cota bang to rights!
1. I’m able to prove that the navigation by Cota were certain and reliable up to 4 minutes before allision.
2. The most important signal acting as a stimulus on Cota appeared only for abaout 15 seconds. He recognized this situation and ordered a course changing manoeuvre towards to the middle of the span as usually.
3. After the beginning of this manoeuvre the signal disappeared. Cota changed his information source and went to the ECS.
4. The ECS contained a bad planed wrong track . The captain confused the centre of the span with the middle of the RACON-signals “B” and “Y”.
5. In this moment of getting situation knowledge by the pilot the VTS called. The pilot was distracted.
6. Supported by an unforeseeable changing of RACON-signal from “Y” to “B” the pilot
attained the impression of an exact position regarding “centre”.
That were some of my findings and could be able to explain the background for Cota’s mental model.
As you can see I didn’t waste any word on blame. But somebody is able to deduce prevention measures.
Dear Bob, we should finish our conversation now. If you or anybody is interested on my report please don’t hesitate to contact me. (report : 100 pages (pdf-datei); 3 presentations of about 200 slides (in power point); in the moment in German language.