Final determination is up to the National Transportation Safety Board, but after reviewing Coast Guard reports and radio records about the accident that spilled 58,000 gallons of heavy fuel oil into San Francisco Bay last Wednesday morning, it appears that the collision was entirely due to pilot error. Also, the slow clean-up response appears to have been caused by the pilot's inattention to important details after the collision took place.

Experts suggest several possible explanations, including pilot error, crew error, and mechanical or instrument failure. But the facts now in, seem to point solely to pilot error.

FIRST, VESSEL TRAFFIC WARNED THAT THE SHIP WAS OFF COURSE:

On Friday, the pilot's attorney said that Vessel Traffic Service (VTS), similar to aviation air traffic controllers, notified the pilot of the Cosco Busan that he was off course shortly before the container ship hit the Bay Bridge tower. Vessel Traffic told the pilot by VHF radio (channel 14) that "Your heading is (compass) bearing 235; what are your intentions?"

CHECKING EVERY INSTRUMENT:

At this point, the pilot faces a critical decision. He has just been handed a 50/50 situation. The Coast Guard's instruments say he is off course, but his instruments say he is not. Obviously, he has only a 50% chance that his instruments are the more accurate. Immediate verification from alternate instruments is now imperative. Standard navigational practice in this situation is to slow down or stop until verification of course can be achieved. But the pilot takes no action and instead radios to tell VTS that he thinks he is on the correct course. Attorney John Meadows also stated that the pilot, Captain John Cota, immediately radioed back that the ship's instruments showed that he was on the correct heading. The pilot told the Vessel Traffic Service dispatcher: "I'm heading directly for the center of the span."

NO INSTRUMENT ERROR:

Since he was off course and hit the bridge, it would seem that his instruments might have been giving the wrong reading. But the facts now in indicate that there was no equipment failure. On Saturday, Coast Guard Admiral Craig Bone, said "Our preliminary investigation shows no indication that there was anything mechanical wrong with the vessel." But, according to Cota, all the navigational electronics he checked were reporting the same correct course, even though, as it turned out, he was on an incorrect course. Unfortunately, with no detectable mechanical failures, "What remains," said Admiral Bone, "is human error."

STANDARD PROCEDURES:

But why didn't the pilot follow standard procedure and check several instruments? For instance, two days earlier, when the commercial vessel I was piloting approached the Golden Gate bridge under similar circumstances (i.e. outbound in dense morning fog), I was also monitoring VTS Channel 14. Although, I had received no call indicating I might be off course, still I followed standard fog navigation procedures, which are taught in radar collision avoidance classes. I carefully checked several instruments simultaneously for confirmation of my ship's course and speed. That morning as we approached the bridge, I watched both the GPS chart plotter and the radar display. In the dense fog, I was unable to visually see the bridge span or the towers, so I carefully checked the radar and the chart plotter for consensus that they both agreed on my location, course and speed. Such checking of all instruments is simply standard "by the book" navigational procedure. Yet, the fact of Cota's radioing back immediately, indicates that he did not check all the available instruments for confirmation.

CONSULTING THE RADAR:

As a licensed UNLIMITED radar observer, I know that navigational radars show the bridge towers as distinctly darker areas than the rest of the span, and the radar also shows exactly where the ship is headed. Simply consulting the ship's radar would have shown the pilot that collision with the bridge tower was imminent. But, apparently, he did not look there to confirm his course and speed.

UNRECOGNIZED URGENCY:

Just the suggestion from Vessel Traffic that you are off course should be taken very seriously. Vessel Traffic does not normally question the course and speed of commercial traffic. Their function is to monitor traffic to avoid collision situations by telling captains when they appear to be in harm's way. If they think you are off course, they will check their calculations again to make sure before calling you. Consequently, when they do call to say you are off course, the automatic assumption should be that they are correct and you are wrong. The proper action then is to back all engines and stop the vessel completely until you can carefully verify that you are not headed for a collision. Especially when the bridge is completely hidden by pea soup fog. Clearly faced with a 50/50 situation, the pilot did not recognize the urgency and instead of prudently stopping and rechecking everything he tosses the dice and strangely decides that the instrument he is looking at is correct, and the instrument Vessel Traffic is looking at is wrong.

THERE WAS NO LANGUAGE PROBLEM:

Finally, the human error might have been caused by the ship's crew and not the pilot. In fact, there is much discussion of possible language problems between the Chinese-speaking helmsman and the English-speaking pilot. Yet, this appears to have no bearing on the case. The fact that the Coast Guard questioned his course in English, and the English-speaking pilot responded, would seem to remove any possible language problems. Indeed, it appears from the records provided that the pilot never gave a helm order to change course, or an engine-stop order, which could have been misinterpreted by the crew.

SLOWNESS TO REPORT LEAK:

The pilot's next error compounded the extent of the damage from the spill. Unfortunately, the language of his verbal accident report to VTS minimized the extent of the damage. According to Meadows, Cota said in his statement to the Coast Guard that, after striking the bridge, he promptly notified the Vessel Traffic Service of what had happened. But he apparently made no comment about an oil spill or the need for skimming equipment. Limiting his report to saying that ship has contacted the fendering system, which is the protective barrier around the base of the bridge tower, with no mention of any oil leaks could be interpreted as, "we bumped the bridge slightly."

Yet, the actual damage is much more severe. The collision actually sheared most of the fendering system off the bridge tower, and cut a gash over 100 feet long in the side of the vessel rupturing one of his fuel tanks which began immediately gushing bunker "C" heavy fuel oil into the bay.

Under standard procedure, his next move should be to ask for a report of the damage from the ship's crew, and to relay an accurate report of such damage to VTS and the Coast Guard so that they can mobilize the proper response. Anytime you sustain a collision, you check all damaged areas for leaks to insure that you are not sinking.

After the collision, the pilot proceeded to a safe anchorage and anchored his vessel. But he made no move to rig an oil containment boom around his vessel even though he has just had a collision. Though he notices an oil sheen on the water, he does not radio for oil clean up services. Apparently, even though it has been some time since the collision, he is still unaware that there is a 100-foot hole in the side of his ship gushing heavy bunker C into the bay. Yet, according to Capt. Peter McIsaac, president of the San Francisco Bar Pilots, who had boarded a pilot boat and headed for the Cosco Busan, coming aboard as she passed Treasure Island, oil was pouring out of a gash in the ship. "I've never seen oil going into the water like that," McIssac said.

According to the pilot's statement, it was only after anchoring that he finally noticed there is an oil slick, "I observed a sheen on the water and instantly reported that to VTS," Cota said, as reported by Meadows, "Prior to my leaving the ship, no response vessels were seen." Cota went on to say that he was relieved by a senior bar pilot who immediately started notifying various agencies that deal with oil spills. Apparently, the idea that as pilot he should have been calling those response vessels had not occurred to Cota.

The Coast Guard log shows that the first notification of the collision arrived at 8:30 a.m., with the VTS contacting the Coast Guard and reporting the incident. A Coast Guard patrol vessel arrives about a half hour later at the scene. The first environmental response team had arrived in the area to begin skimming operations by 9:50 a.m. Finally, at 10:39 a.m., full-scale containment operations finally began more than two hours after the collision. This delay in commencement was compounded by the pilot's delay in reporting the oil spill until after the vessel was anchored.