T/V OVERSEAS REYMAR ALLISION WITH THE SAN FRANCISCO

Transcription

Commandant
United States Coast Guard
U.S. Coast Guard STOP 7501
2703 Martin Luther King Jr. Ave. SE
Washington, DC 20593-7501
Staff Symbol: CG-INV
Phone: (202) 372-1029
Fax: (202) 372-1904
16732
8 Jan 2015
T/V OVERSEAS REYMAR ALLISION WITH THE SAN FRANCISCO –
OAKLAND BAY BRIDGE ON JANUARY 7, 2013
ACTION BY THE COMMANDANT
The record and the Report of Investigation for the Informal Investigation convened to explore the
circumstances for the subject casualty have been reviewed. The record and the report, including
the findings of fact, analysis, conclusions, and recommendations are approved subject to the
following comments.
ACTION ON RECOMMENDATIONS
Recommendation 1: Recommend release of a Safety Alert that addresses the latent unsafe
condition regarding the execution of Bridge Resource Management (BRM) between navigation
watch teams and Pilots due to perceived and real cultural and language differences that prevent
the necessary flow of communication.
Action: I concur with the intent of this recommendation. The Coast Guard issued Safety
Alert 09-13, Bridge Resource Management (BRM) in Pilotage Waters, on August 30, 2013,
reminding navigation watch teams of the importance of adhering to BRM Principles and
ensuring proper communications, even when their ship is being directed by a properly
licensed pilot.
Recommendation 2: Recommend the Harbor Safety Committee (HSC) include San Francisco –
Oakland Bay Bridge (SF-OBB), west of Yerba Buena Island, as a Critical Maneuvering Area
(CMA) in the HSC Guidelines and Best Practices publication, and develop appropriate
associated navigation guidelines for this area. The inclusion of the SF-OBB as a CMA will
enhance the safety of the bridge and the vessels that transit under it during periods of restricted
visibility.
Action: I concur with this recommendation. Following the COSCO BUSAN allision on
November 7, 2007, the San Francisco HSC designated nine different areas within the San
Francisco Bay Area as CMAs, including four bridges. However, the SF-OBB was not one of
the designated areas. In the wake of this incident the San Francisco HSC adopted
“Temporary Safety Guidelines for Navigating in Reduced Visibility” on February 13, 2013.
A copy of this investigation will be forwarded to the San Francisco HSC to help inform any
future efforts to permanently designate the SF-OBB as a CMA.
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Recommendation 3: Recommend that Caltrans develop policy and procedures for testing,
inspecting, and monitoring the SF-OBB radar transponder beacons (RACON). The policy and
procedures should contain instructions for notifying the Coast Guard immediately upon
discovering a failed RACON. Implementation of this type of policy/ procedure would better
ensure that critical navigation information is passed to the maritime community in a timely
manner.
Action: I partially concur with this recommendation. A properly working RACON may
have prevented the allision from occurring and the ability to monitor RACONs and provide
immediate notification to the Coast Guard in the event of a failure is necessary. A copy of
this investigation will be provided to Caltrans so they can work with the Sector San
Francisco to review existing Private Aids to Navigation (PATON) reporting procedures. To
address this issue nationwide, a copy of this investigation will be forwarded to all Coast
Guard District Waterways Management Branches. District Commanders are responsible for
ensuring that all duly approved PATON are maintained in accordance with policy and the
standards described in the PATON permit. Paragraph 5.E.2 of the Aids to Navigation
Manual – Administration (COMDTINST M16500.7A) has requirements for additional
information with respect to privately operated RACONs. The District Commander should
ensure that this information is up to date.
Recommendation 4: Require that OSG Ship Management conduct frequent and regularly
scheduled underway evaluations of their navigations watch crews to ensure the proper execution
of the BRM when Pilots are aboard. The evaluation interval should not exceed one year for
master and officer of the watch qualified personnel.
Action: I concur with the intent of this recommendation, but believe that the scope should be
expanded beyond OSG Ship Management. Provisions within the International Safety
Management (ISM) Code require commitment from the highest levels of the organization to
ensure development, implementation, and maintenance of a Safety Management System
(SMS) that define the levels of authority and lines of communication between BRM teams
and pilots. A copy of this report will be forwarded to the International Maritime
Organization to help inform any future efforts to revise existing guidelines for effective BRM
practices.
Recommendation 5: Recommend the Board of Pilot Commissioners (BOPC) develop a
mechanism to evaluate Pilots while underway and piloting on a regularly scheduled basis but not
to exceed one year. If appropriately executed in diverse circumstances, these types of
evaluations will provide an opportunity to identify and correct bad habits developed by Pilots,
and provide critical feedback regarding Bridge Resource Management, navigation, and overall
risk management practices.
Action: I concur with the intent of this recommendation. This casualty demonstrates the
potential benefits of conducting periodic underway Pilot evaluations as the involved Pilot had
developed a habit of consistently using a span of the SF-OBB which could be argued is not
the most appropriate choice, especially in low visibility conditions. A copy of this report will
be forwarded to the American Pilots’ Association (APA) for its consideration of the
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recommended pilot training and evaluation issues. As the national association of the piloting
profession in the United States, the APA is best suited to provide and/or update existing
national "best practices" and guidelines for potential incorporation into local pilot
professional development and training programs.
Recommendation 6: Recommend that the BOPC consider an additional training requirement for
Pilots to participate in low visibility/ restricted waters radar navigation training on an annual
basis.
Action: I partially concur with this recommendation. In this case, there is no clear evidence
suggesting that the involved Pilot lacked proficiency with using RADAR and the Portable
Pilot Unit (PPU), but rather, that the equipment was not utilized to its full potential by the
Pilot to safely transit in a low visibility situation. Use of all available navigation equipment
is essential to maximize safety, especially during periods of low visibility. A copy of this
report will be forwarded to the APA for its consideration of the recommended pilot training
issues. The APA is best suited to explore the use of emerging navigation technology and
bridge resource management (for pilots) principals during times of restricted visibility and to
incorporate any needed updates to existing national "best practices" and guidelines into local
pilot professional development and training programs.
Recommendation 7: Recommend relocating two of the Yerba Buena Island CCTV cameras to a
lower elevation to facilitate better viewing of visibility condition at sea-level thus decreasing the
frequency at which the cameras are obscured by marine layer fog that does not extend to the
surface of the water.
Action: I partially concur with this recommendation. Cameras located at or near sea-level at
the SF-OBB could potentially serve several beneficial functions, such as providing real-time
visibility conditions at the bridge spans and enabling greater utility in situations where the
marine layer does not fully extend to sea level. However, relocating existing cameras could
lead to adverse impacts by potentially reducing the existing macro-view CCTV utility of the
San Francisco Bay. As such, this recommendation is being considered by the Coast Guard’s
Office of Navigation Systems (CG-NAV) for potential incorporation into Vessel Traffic
Service (VTS) national policy.
Recommendation 8: Recommend the Coast Guard and HSC explore the use of AIS-based "eATON" as an additional tool to mark the SF-OBB and/or to mark a low visibility approach
channel for use by vessels transiting the SF-OBB.
Action: I partially concur with this recommendation. The Coast Guard does not distinguish
between low and high visibility approach channels. However, similar e-ATON technologies
have been used on smaller scales with success, including San Francisco Bay to mark
boundaries for the 34th America's Cup race. Beginning in March 2014, the SF-OBB bridge
abutments were marked using AIS ATON at the request of the Coast Guard and San
Francisco Harbor Safety Committee. Virtual AIS-ATON prototypes are currently in the
testing phase. The Coast Guard is seeking public comment to determine if it is better to mark
3
United States Coast Guard
Report of Investigation into the
Circumstances Surrounding the Incident
Involving
T/V OVERSEAS REYMAR Allision with the
San Francisco-Oakland Bay Bridge
On January 7, 2013
MISLE Activity Number: 4512323
Originating Unit: Sector San Francisco
MISLE Case Number: 624316
This document shall not be published or otherwise released outside the Coast Guard without
approval from Commandant (CG-5453).
Subj: T/V OVERSEAS REYMAR SF-OBB ALLISION ON 7 JAN 2012
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The San Francisco Vessel Traffic Service (VTS) Sector Operator who was monitoring the SFOBB area recognized the vessel’s unusual approach to the Delta-Echo span and immediately
called the Pilot to warn him. However, at that point, the vessel’s course was set and the allision
was unavoidable.
The vessel’s hull sustained approximately $150,000 worth of damage; however, the hull was not
breached and no oil was discharged into the water. The bridge’s fender system sustained
approximately $1.4 million in damages. No one was injured as a result of this casualty.
Vessel Data:
Name:
Official Number:
Service:
Year Built
Built By:
Flag State:
Gross Tons:
Length:
Breadth:
Draft:
Propulsion:
Horsepower:
Owner:
Operator:
OVERSEAS REYMAR
9275749
Tank Ship
2004
Daewoo Shipbuilding
Marshall Islands
40,063
752 Feet (748 LOA)
106 Feet
34 Feet 9 Inches (Design Draft)
Low Speed Diesel (MAN-B&W)
13900
Reymar, LTD
OSG Ship Management (UK), LTD
(Photo shows the T/V OVERSEAS REYMAR.)
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Vessel Personnel Data:
Position:
Pilot
Name:
Age:
Sex:
Male
Nationality:
U. S.
License/Rating:
Commissioned San
Francisco Bay Pilot
Master
Master
Male
Philippines
Third Officer
Male
Philippines
Helmsman
Male
Philippines
Officer in Charge of
the Navigational Watch
(2nd Mate)
Able Bodied Seaman
Bow Look-Out
Bosun
Male
Male
Philippines
Philippines
Able Bodied Seaman
Able Bodied Seaman
VTS Personnel Data:
Position:
Watch
Supervisor
Name:
Age:
Bay Sector
Operator
Ocean & Delta
Sector Operator
Sex:
Male
Male
Qualification(s):
Watch
Supervisor &
Operator
Operator
Male
Operator
Bridge Data:
Name:
Bridge Type:
Year Built:
Length (West Bay Crossing Only):
Preferred Navigation Channels:
Alpha-Bravo Span Vertical &
Horizontal Clearance:
Charlie-Delta Span Vertical &
Horizontal Clearance:
Delta-Echo Span Vertical & Horizontal
Clearance:
Navigation Markings:
San Francisco-Oakland Bay Bridge (West
Bay Crossing)
Double-decked Suspension
1936
10, 304 Feet
Three (Alpha-Bravo, Charlie-Delta, & Delta
Echo)
V = 210 Feet (MLLW), H = 2210 Feet
RACONs (only on preferred channel spans),
pier buoys & fog signals
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San Francisco
C Pier
D Pier
E Pier
AB Span
CD Span
DE Span
Yerba Buena
Island
(Photo shows the West Bay Crossing of the San Francisco-Oakland Bay Bridge.)
Parties in Interest:
Name:
OSG Ship Management, LTD
Role:
Operating Company
Captain
Board of Pilot Commissioners,
San Francisco Bay (BOPC)
San Francisco Bar Pilots
Association (SFBP)
Pilot
Pilot Regulatory/Oversight
Agency
Pilot Association
Representation:
Emard, Danoff, Port,
Tamulski & Paetzold, LLP.
Sterling & Clack
Not represented
Not represented
Findings of Fact:
1. On 7 January 2013, at approximately 1020 hours, the OVERSEAS REYMAR was anchored
in South San Francisco Bay at Anchorage 9. The vessel’s crew had just completed bunkering
operations with a tug and barge and was preparing to receive a San Francisco Bar Pilot. The
vessel was manned in accordance with their Safe Manning Certificate and was in good
mechanical and material condition. The steering and propulsion systems were functioning
properly and were in good working order. The vessel was in-ballast (cargo holds empty) with a
19 foot draft forward, a 23 foot draft amidships, and a 27 foot draft aft.
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Yerba Buena
Island
SF-OBB West
Crossing
Anchorage 9
San Francisco
(Image shows a section of NOAA Chart 18650)
2. The OVERSEAS REYMAR was a Marshall Islands flagged, double-hulled tank vessel
operated by OSG Ship Management, LTD. The vessel was classed by The American Bureau of
Shipping (ABS). ABS issued OSG a Document of Compliance on 26 November 2008, which
certified that the company’s Safety Management System (SMS) for the operation of oil tankers
was in compliance with the International Management Code for the Safe Operation of Ships and
for Pollution Prevention (ISM Code). OSG’s SMS was audited by ABS on 12 November 2008,
with a most recent verification audit performed on 20 December 2012. The vessel was issued a
Safety Management Certificate by ABS on 2 May 2012, which stated that the vessel’s SMS had
been audited on 9 September 2010 and was found to be in compliance with the ISM Code.
3. Transiting the West Bay Crossing of the SF-OBB (henceforth referred to as “the bridge”) was
the first navigation hazard on the OVERSEAS REYMAR’s proposed voyage plan, with Alcatraz
Island and the Golden Gate Bridge being the second and third. The West Bay Crossing of the
bridge is a double-deck suspension bridge built in 1936. The bridge is supported over the water
by five towers, each of which has a “pier” where the tower meets the water. The bridge’s towers
are protected at the waterline by a concrete and wood fender system. The fender system is
designed to limit damage to the tower in the event a vessel allides with it. The West Bay
Crossing of the bridge has six over-water spans, three of which are considered “preferred
channel spans” by the Coast Guard for use by large vessels. The preferred channel spans are the
Alpha-Bravo, Charlie-Delta, and Delta-Echo spans. The U. S. Coast Pilot 7 (45th Ed.)
recommends that vessels use the northeast half of the Alpha-Bravo span for southbound passage,
and that northbound vessels use the southwest half of the Delta-Echo span.
4. The bridge incorporates lights and markings on its structure as required by the bridge lighting
and marking regulations found in 33 Code of Federal Regulations (CFR), Section 118.
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The required lights and markings associated with the West Bay Crossing of the bridge include:
fog signals on the Alpha, Bravo, Charlie, Delta, and Echo Piers; a buoy on the north side of the
Bravo Pier, and buoys on both the north and south side of the Delta Pier. The bridge also
incorporates the use of radar beacons known as RACONs. RACONs are radar transponders that
emit Morse code-type signals that are visible on a ship’s radar. The RACONs are located at the
center of spans Alpha-Bravo, Charlie-Delta, and Delta-Echo; however, these RACONs are
considered “elective” by the Coast Guard, meaning that the RACONs are not required by the
Coast Guard. The California Department of Transportation (Caltrans) made a decision in 1992 to
install the RACONs for the purpose of “…reducing the potential for ships hitting the bridge by
clearly indentifying the center of the navigational channel in all kinds of weather conditions.”
With the exception of the bridge’s buoys, which are maintained by the Coast Guard, all of the
bridge’s lighting and markings are maintained, in accordance with federal regulations, by
Caltrans.
5. The bridge’s three RACONs are mounted at the center of their respective spans on the bottom
of the lower deck. They are labeled as follows: RACON “N” for the Alpha-Bravo span,
RACON “B” for the Charlie-Delta span, and RACON “Y” for the Delta-Echo span.
The RACON transmits a Morse code signal that corresponds with the letter designation of the
RACON itself (e.g. RACON “Y” transmits a dash-dot-dash-dash signal). All of the RACONs
were capable of transmitting in the 9300 to 9500 MHz, and 2900 to 3100 MHz ranges, which
encompass all of the RACON interrogation frequency ranges utilized by modern radars.
The RACONs were installed on the bridge during 1993. They were not included in any of
Caltrans’ regularly scheduled maintenance or inspection procedures or policies; they were
replaced upon failure. Caltrans was notified of RACON failures (via telephone) by the Coast
Guard. The Coast Guard was notified of RACON failures by ship crews that observed that a
particular RACON was not working (mariners are required to report malfunctioning RACONs to
the Coast Guard as per 33 CFR 161.13(d)(4)). Upon notification of a discrepant RACON, Coast
Guard Sector San Francisco would issue a Broadcast Notice to Mariners (BNM) on VHF-FM
marine frequencies to notify mariners of the discrepant RACON. In addition to a BNM,
information about the discrepant RACON would be published in the Eleventh Coast Guard
District’s Local Notice to Mariners (LNM), which is published on a weekly basis and made
available to the public on the internet.
(Continued on next page)
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RACON N
Location
RACON B
Location
RACON Y
Location
AB Span
CD Span
DE Span
(Photo above shows RACON locations on the West Bay Crossing of the SF-OBB. The inset
picture is an example of a RACON, similar to the type mounted on the SF-OBB.)
DE Span
RACON Y
Signal
Yerba Buena
Island
West Bay Crossing
SF-OBB
T/V OVERSEAS
REYMAR
San Francisco
(Image shows how RACON “Y” appeared on the OVERSEAS REYMAR’s S-band radar, which
was being used by the Pilot. RACON “N” did not activate at the same time as RACON “Y”, and
RACON “B” did not show because it was inoperative.)
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6. Prior to the OVERSEAS REYMAR’s allision with the Echo Pier, there were no reports to the
Coast Guard or Caltrans that any of the RACONs or other Aids to Navigation (AToN) on the
bridge were malfunctioning or off-station. A Caltrans work-boat conducted a routine visual
inspection of the equipment on the bridge’s piers on 18 December 2012, and again on 2 January
2013. The boat crew did not (and was not required to) utilize the vessel’s radar to verify that the
RACONs were working. Prior to the OVERSEAS REYMAR’s allision with the Echo Pier on 7
January 2013, neither the Coast Guard nor Caltrans had reason to believe, or were otherwise
aware, that any of the bridge’s RACONs were not fully functional.
7. Ship traffic in the waterways of the greater San Francisco Bay area, including the
Sacramento and San Joaquin Rivers, and the ocean waters within a 38 nautical mile radius of
Mount Tamalpais is managed, as per regulatory authority under 33 CFR 161.50, by Vessel
Traffic Service (VTS) San Francisco. This service is provided via the Vessel Traffic Center
(VTC), which is located on Yerba Buena Island. The VTC is staffed with operators who provide
information related to the safe navigation of the waterway with the purpose of enhancing
navigation, vessel safety, and marine environmental protection and promoting safe vessel
movement by reducing the potential for collisions, allisions, and groundings. VTS San Francisco
currently operates using the Coast Guard Vessel Traffic System (CGVTS) software as its Traffic
Management System (TMS). CGVTS integrates radar and Automatic Identification System
(AIS) information for display on charts which are optimized to scale for each geographic area.
VTC operators utilize several desk-top and wall-mounted monitors that display CGVTS and
closed circuit television cameras (CCTV) feeds to observe and monitor vessel movements within
the VTS area of responsibility. They also utilize designated VHF-FM frequencies to
communicate with vessels. VTC operators rely on mariners, and sometimes CCTVs, to provide
them with real-time maritime weather, sea state, and visibility information. Under certain
circumstances, a VTC operator may issue directions to control the movement of vessels in order
to minimize the risk of collision between vessels or damage to property or the environment.
When issuing such a direction, the VTC operator will direct a desired outcome, rather than
ordering a specific course or speed change due to the inherent limitations of the Vessel
Movement Reporting System (VMRS). Mandated use of the VRMS is limited to power driven
vessels 40 meters in length or greater, towing vessels eight meters in length or greater and
vessels certificated to carry 50 or more passengers, while engaged in trade.
8. During core hours, which are defined by the Sector San Francisco VTS Internal Operating
Procedures (IOP) Manual as the hours between 0600 and 2200 hours, the VTC is required to be
staffed with five people, four of whom are on active watch at any one time during normal
operations with one person on break. The watch bill consists of one Watch Supervisor, one
Ocean and Delta Sector Operator, one Bay Sector Operator, one Watch Assistant, and one
Auxiliary Operator to provide mandated breaks to each Sector Operator. On 7 January 2013,
the scheduled VTC watch consisted of: Watch Supervisor,
and Sector Operators
and Petty Officer (PO) First Class
Operator trainee, PO Second Class
was also on the VTC schedule
but was not performing any operator-type duties. PO
schedule was amended and he
was not actually in the VTC that day; he was attending an all-hands meeting on Coast Guard
Island in Alameda. Due to PO
schedule change, the 7 January 2013 day-watch
consisted of four personnel, rather than the mandated five personnel.
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The short staffing of the 7 January 2013 day-watch was due to schedule shifting to accommodate
an operational need on an adjacent night watch. Mr.
noted the discrepancy in the watch
manning, but decided not to call in additional personnel since another sector operator was
scheduled to arrive at 1200 for the swing watch (1200-0000).
9. At 1118 on 7 January 2013, the watch was manned as follows: Watch Supervisor
Ocean and Delta Sector Operator
Bay Sector Operator
Watch Assistant, vacant. Mr.
was on a regularly scheduled, mandated break (as per the
requirements outlined in national-level VTS policy) and was not in the VTC at the time of the
casualty. PO
was also not in the VTC at the time of the casualty; he was out getting
food for the rest of the watch standers. Since POs
and
and Mr.
were
not in the VTC at relevant times leading up to, and during the casualty, their experience, training
and human factors were considered irrelevant and were not investigated.
10. Watch Supervisor
was an experienced watch supervisor having worked in this
position for approximately 15 years. He was responsible for ensuring that all of the operators on
watch were performing their duties in accordance with established standards, procedures, and
policies. He was also responsible for maintaining an accurate and complete knowledge of vessel
traffic within the VTS area. Prior to qualifying as a watch supervisor,
worked as a VTS
sector operator for approximately 15 years. His qualification for the watch supervisor position
was current at the time of the casualty, and was in accordance with Coast Guard standards.
He was recertified for this position in 2010, which was in accordance with Coast Guard
standards that require revalidation of certification once every five years.
11. Mr.
awoke at 0310 on the morning of 7 January 2013 in order to make it to work by
0530. He had gone to bed at 2030 the night before. Prior to assuming the 0530 to 1730 watch
on 7 January 2013, Mr.
kept a two day on, two day off work schedule from 1800 to 0600
for the previous three months. His last day of work prior to Monday, 7 January 2013 was
Thursday, 3 January 2013. He stated that he did not feel fatigued and that he was well rested
prior to assuming his duties on 7 January 2013. Mr.
did not have any medical conditions or
take any medications that would have interfered with his ability to do his job properly.
He indicated that he was not distracted by, or otherwise pre-occupied with, professional or
personal issues. His employment record revealed that he did not have any performance issues
throughout his VTS career. Mr.
post-casualty drug and alcohol test results were
12. Sector Operator
was an experienced operator having worked in this
position for approximately ten years, eight of which were in San Francisco, and two of which
were in New Orleans. Operators are the primary interface with vessels that communicate with
the VTS. They are responsible for maintaining an accurate and complete knowledge of vessel
traffic within their sector at all times and are empowered to ask the watch supervisor for
assistance, if needed. Mr.
maintained a qualification as a sector operator and had
previously held a watch supervisor qualification. Since he had not stood watch as a watch
supervisor in over a year, his watch supervisor qualification was not current. His qualification
for the sector operator position was current with his most recent recertification being in 2009,
which was in accordance with Coast Guard standards.
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13. Like Mr.
Mr.
had worked the two day on, two day off 1800 to 0600 shift for
the previous three months. Also like Mr.
7 January 2013 was the first day of his new shift
schedule which started at 0600 and ended at 1800. His last day of work prior to Monday, 7
January 2013 was Thursday, 3 January 2013. He stated that he did not feel fatigued and that he
was well rested prior to assuming his duties on 7 January 2013. Mr.
did not have any
medical conditions or take any medications that would have interfered with his ability to do his
job properly. He did not indicate that he was distracted by, or otherwise pre-occupied with,
professional or personal issues. His employment record revealed that he did not have any
performance issues throughout his VTS career. Mr.
post-casualty drug and alcohol test
results were
14. Sector Operator
was also an experienced VTS sector operator having worked
in this position for approximately four years. He maintained a qualification as a sector operator,
which he attained in 2008. His qualification for the sector operator position was current and in
accordance with Coast Guard standards. Mr.
had worked the two day on, two day off, 0600
to 1800 shift consistently for the previous three years. He maintained a consistent sleep schedule
of 2100 to 0415. He stated that he did not feel fatigued and he was well rested prior to assuming
his duties on 7 January 2013. Mr.
did not have any medical conditions or take any
medications that would have interfered with his ability to do his job properly. He indicated he
was not distracted by, or otherwise pre-occupied with, professional or personal issues. His
employment record revealed he did not have any performance issues throughout his VTS career.
Mr.
post-casualty drug and alcohol test results were
.
15. The VTS watch supervisor is tasked with “Analyzing the weather, realized or forecasted that
may contribute to an increased difficulty for safe navigation…” as per the VTS IOP. At 0540 on
the morning of 7 January 2013, the on-coming Watch Supervisor
obtained weather
reports that stated the visibility in the San Francisco Bay area was 10 miles. The reports did not
suggest that visibility would decrease later on that morning or at any other point during the day.
16. On 7 January at 0818, a mariner reported to the VTS that the fog at Anchorage 9 (south of
the SF-OBB) was extremely dense, limiting visibility to one-tenth of a mile. Another mariner
reported visibility in the central San Francisco Bay (north of the SF-OBB) as one mile.
During the mid to late morning hours, the fog in South San Francisco Bay was intermittently
present with variable density. At 0940, Captain
the pilot scheduled to take the
OVERSEAS REYMAR from Anchorage 9 to sea, was looking east from the SFBP Office, which
was located on San Francisco’s Pier 9, and observed one to two mile visibility. At 1014, a
mariner reported the visibility at the West Bay Crossing of the SF-OBB as one-half of a mile,
and at 1015, Captain
observed four to five mile visibility looking towards the south while
riding the pilot boat from Pier 9 to the OVERSEAS REYMAR. When Captain
arrived
aboard the ship, and up to the time of departure, the visibility looking north from the ship
towards the SF-OBB was variable from one-half to two miles.
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17. Following the 7 November 2007 T/V COSCO BUSAN casualty, whereby the vessel struck
the SF-OBB Delta Pier, then California Governor Schwarzenegger indirectly tasked the Harbor
Safety Committee (HSC) to “analyze the navigational safety-related issues…and make
appropriate recommendations regarding the prevention aspects of the incident.” As a result of
this tasking, the HSC developed two sets of reduced visibility guidelines, one for “large vessels”
which are defined as vessels of 1600 gross tons (GT) or greater, tugs with tows 1600 GT or
greater, and all tugs towing petroleum barges navigating in the greater San Francisco Bay area;
and one for vessels and tugs with tows less than 1600 GT. The guidelines included the creation
of Critical Maneuvering Areas (CMAs) which were implemented on 9 February 2009. A CMA
is defined as “an area within the bay where additional standards of care are required due to the
restrictive nature of the channel, proximity of hazards, or the prevalence of adverse currents.”
CMAs are in effect for large vessels when visibility is less than one-half of a nautical mile at the
location of the CMA, and for vessels less than 1600 GT when visibility is less than one-quarter
nautical mile at the location of the CMA. For the remainder of this report, CMA’s will be
referred to only as they apply to “large vessels” as those are the guidelines pertinent to this
investigation. The HSC Guidelines for Navigating in Reduced Visibility in-place at the time of
the incident stated that large vessels should not transit through CMAs when visibility is less than
one-half of a nautical mile. The 40,000 GT OVERSEAS REYMAR clearly falls within the
parameters of a large vessel.
18. At the time of the OVERSEAS REYMAR casualty, there were nine designated CMAs in the
San Francisco Bay area, four of which were bridges; however, the SF-OBB was not one of them.
The list of CMAs included:
a. Redwood Creek
b. San Mateo-Hayward Bridge
c. Islais Creek Channel
d. Oakland Bar Channel
e. Richmond Inner Harbor
f. Richmond-San Rafael Bridge (East Span)
g. Union Pacific Bridge
h. New York Slough (up-bound only)
i. Rio Vista Lift Bridge
19. The HSC Navigation Working Group considered recommending the SF-OBB be designated
as a CMA, but ultimately did not for two reasons: 1) If a CMA were imposed on the bridge
during periods of reduced visibility, large ships inbound from sea would not have access to
Anchorage 9 or berths in Oakland or the South Bay. If these ships had already cleared the
Golden Gate Bridge, they would be forced to either turn around in the Central Bay and return to
sea, or seek temporary anchorage at Anchorage 7, which has very limited capacity. Turning a
large ship around in the Bay in reduced visibility conditions was seen as a poor option because of
the relative small size of the Bay, the numerous shallow water areas within the Bay, the high
density of other vessel traffic, and the presence of Alcatraz Island.
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Further, eliminating access to a vital anchorage was also deemed to present undesirable systemic
impacts, such as potential increased risk of collision due to congestion. 2) The SF-OBB was not
seen as a particularly challenging navigation hazard by the local pilots. SFBP representatives
felt that because of the ample horizontal clearance between the bridge’s towers and the ability to
set the ship on a straight-line approach to the bridge well before reaching it, a pilot could easily
guide a ship through the bridge in a low-visibility situation using installed navigation equipment
and the pilot’s Portable Pilot Unit (PPU). Thus the overall system-wide impacts of eliminating
access to Anchorage 9 for inbound vessels were deemed too significant to justify implementation
of a SF-OBB CMA. Indeed the Oakland Bar Channel was deemed the more hazardous/critical
area for establishing a CMA due to its strong cross currents and dynamic navigation demands.
20. Implementation of CMA guidelines is monitored by the VTS. Vessels transiting in CMAs
are required to notify the VTS when visibility is less than one-half nautical mile. Upon
notification that visibility in a CMA area is less than one-half nautical mile, the VTS watch
supervisor declares that the CMA area is “enforced” and informs all vessels 1600 gross tons and
over, and tugs with petroleum barges, that the CMA guidelines for an area are in effect.
According to the CMA guidelines that were in effect during this casualty “large vessels at a dock
within the Bay should not commence a movement if visibility is less than one-half of a nautical
mile at the dock; and large vessels proceeding to a dock should anchor if visibility at the dock is
known to be less than one-half of a nautical mile, unless, under all circumstances, proceeding to
the dock is the safest option.” On 7 January 2013, the Richmond Inner Harbor CMA was in
effect briefly during the early morning hours. No other CMA was in effect that day.
21. In addition to the development of CMAs, the HSC also recommended the use of AISenabled laptops equipped with navigation chart-overlay software for use by pilots (PPU).
An evaluation of the feasibility and potential effectiveness of PPUs was conducted by the Board
of Pilot Commissioners (BOPC) and the SFBP Association. The HSC recommended a
requirement for pilots to be equipped with PPUs, which was in-turn adopted and implemented by
the BOPC in July 2009. As per California Code of Regulations, Title 7, Section 219 (4), pilots
are not required to utilize a PPU. As per the Code, the use of a PPU is “left to the discretion of
the pilot.”
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(Image shows a screen-capture of the Pilot’s PPU approximately one minute before the vessel
allided with the SF-OBB Echo Pier.)
22. The Pilot, Captain
was an experienced mariner and pilot. He began his
maritime career as a student at the U. S. Merchant Marine Academy at Kings Point, New York.
Upon graduating from the academy in 1976, through 1991, he sailed on numerous ships and held
various positions aboard them to include third mate, third engineer, second mate, chief mate, and
master. From 1991 to 2003 he worked as a docking pilot for the Louisiana Offshore Oil Port
(LOOP) where he made approximately 15,000 moorings and un-moorings without incident.
He was admitted to the SFBP training program in October 2003 and successfully completed the
training in October 2005. The SFBP training included numerous voyages whereby Captain
observed, and was observed by, other qualified SFBP pilots. He served continuously as a
SFBP since 2005 having made approximately 1,160 trips prior to this voyage. In addition to his
San Francisco, San Pablo, and Suisan Bay commission, he also held commissions as a “river
pilot” for the Ports of Stockton and Sacramento since 2009. His most recent Bridge Resource
Management (BRM) refresher class was 17 September 2010.
23. The BOPC requires pilots to participate in a Continuing Professional Development Program.
The Program includes a five-year perpetual training cycle for BRM, which includes simulator
evaluations, and a separate five-year perpetual training cycle that includes a one-week ship
handling course.
24. Captain
was involved in three incidents prior to the OVERSEAS REYMAR allision;
two of which were groundings and one of which was an allision with a dock structure. For the
allision incident, Captain
was taking a vessel to a dock in Stockton and misjudged the
effect the current was having on the vessel. He allowed the vessel to allide with the dock harder
than he had intended. The resultant damage was minor, but the BOPC found pilot error.
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The other two incidents were grounding incidents that did not result in any damage, and no pilot
error was found during the subsequent BOPC investigations.
25. As a California state-commissioned pilot and U. S. merchant marine first class pilot, Captain
was required to be evaluated by a physician on a regular basis. His medical status was
evaluated by a BOPC-contracted physician on 14 January 2011 and by a National Maritime
Center (NMC) physician on 10 February 2012. Both the BOPC and NMC physicians were made
aware of his
, whereby during 2010 he underwent
He took
to control the
disease. The NMC physician noted that his physical exam and EKG were normal and cleared
him for full, unrestricted duty, and the BOPC physician found him “fit for duty.” In addition to
his
e, he was also near-sighted (correctable to 20/20). He was provided a
waiver by the NMC requiring him to wear corrective lenses at all times during the performance
of his duties. At all times during this casualty, Captain
was wearing his prescription
glasses.
26. Captain
maintained a relatively consistent sleep schedule during the 96 hour period
prior to the allision. His typical sleep time started at 2000 and lasted until 0600. He stated
during interviews that he was a sound sleeper and did not experience sleep interruptions. He also
stated that he had never been diagnosed with a sleep disorder. He indicated he maintained a
consistent workout routine and maintained a healthy diet.
27. On the morning of 7 January 2013, Captain
awoke at 0530. He immediately called
the SFBP dispatch office and learned that he would be piloting the OVERSEAS REYMAR from
Anchorage 9 outbound to sea. He prepared a trip sheet for the voyage, as he routinely did for
each voyage, which contained distances, running times, speeds and estimated times of arrival for
points along the intended route. He checked the LNM and the BNM for pertinent information
(of which there was none). He also assessed what the expected currents would be at various
locations and examined under-keel and air draft clearance information. He noted that he would
encounter a strong ebb current along the west side of Yerba Buena Island (YBI) with an expected
three knot current.
28. Captain
arrived at the SFBP office at 0940. He determined that the visibility, looking
east towards Oakland from the office, was one to two miles. He obtained a listing of current and
expected vessel traffic for his route from the dispatcher and proceeded to board the pilot boat
GOLDEN GATE at 1015. During the voyage from the SFBP office to the OVERSEAS
REYMAR, which was moored at Anchorage 9, he observed that the visibility had improved from
when he first arrived at the office. As the pilot boat passed under the SF-OBB, Captain
stated that he could see the Oakland docks and vessels in Anchorage 9. He estimated visibility in
the area to be four to five miles.
29. The GOLDEN GATE arrived at the OVERSEAS REYMARs position at 1032. Captain
boarded the ship and observed that the visibility had decreased and was approximately
one to two miles looking towards the north, south and west.
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30.
(henceforth referred to as “the Pilot”) arrived on the OVERSEAS
REYMAR’s bridge at 1035 (henceforth referred to as the wheelhouse in order to alleviate any
potential confusion regarding the SF-OBB and the OVERSEAS REYMAR’s navigation bridge).
He introduced himself to the Master and ascertained that the Master spoke very good English.
The Pilot inquired about the length of the anchor chain and immediately asked the Master to
direct his crew to commence retrieving the anchor, knowing that this process would take
approximately 25 minutes to complete. The pair then conducted a master-pilot exchange which
included a review of the Pilot Card, and a Master-Pilot Exchange Form used by the OVERSEAS
REYMAR’s operating company. The Pilot informed the Master of the intended route and his
intention to use the Charlie-Delta span of the SF-OBB, which had become over time, the Pilot’s
preferred span to use. During interviews with the Pilot, he stated that he was comfortable using
the Charlie-Delta span because he had used it so often – he was familiar with it. He also
mentioned to the Master the fact that there would be an ebb current and that there was no
expectation of other vessel traffic along the intended route. Upon clearing the SF-OBB, the Pilot
intended to guide the vessel into the central part of San Francisco Bay, underneath the Golden
Gate Bridge, and out to sea. The Master agreed with the proposed navigation plan. The Pilot
and the Master did not make any alternate or backup passage plans for passing under the SFOBB.
(Image shows a representation of the OVERSEAS REYMAR’s intended and actual routes.
Graphic courtesy of the Bay Area News Group.)
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31. The master,
was an experienced mariner. He had been sailing aboard
ships since graduating from the Philippine Merchant Mariner Academy in 1992. He held third
officer, second officer and chief mate positions for approximately 19 years prior to being
promoted to master in 2011. He had been a master for approximately 14 months prior to this
casualty; all of which time was aboard the OVERSEAS REYMAR. The date of his most recent
BRM refresher class was 29 January 2010. He was tested for illicit drug use and intoxication
following the casualty and the results of those tests were
32. The Master’s normal rest schedule was disrupted during the 72 hour period prior to the
casualty. He typically worked from 0700 to 1700 each day, with a rest period from 1700 to
0700. On 5 January 2013, his rest schedule was disrupted by the vessel’s arrival to Martinez,
California, where it moored and discharged its cargo of oil ashore. During this period, he
worked from 0030 to 0800, rested from 0800 to 1230, and worked again from 1230 to 1700.
His rest schedule was again disrupted on 6 and 7 January 2013, whereby he worked from 2100
on 6 January 2013 to 0300 on 7 January 2013 during the vessel’s departure and transit from
Martinez to Anchorage 9. His schedule indicates that he rested from 0300 to 0900 on the
morning of 7 January 2013.
33. Prior to the voyage on the morning of 7 January 2013, the Master set bridge watch condition
“B”, which is required by the company’s Safety Management System (SMS) policy for vessels
leaving port in restricted visibility conditions. Bridge watch condition B required two deck
watch officers, a helmsman, and a look-out. Having two licensed deck officers for the
navigation watch is also required by U. S. regulations for foreign tank vessels over 1600 gross
tons. The company’s policy emphasized that a pilot shall not be considered part of the vessel’s
navigation watch complement and shall not assume any of the bridge watch organizational
positions.
34. The OVERSEAS REYMAR’s operating company, OSG Ship Management, had overarching
and redundant policies and procedures in-place regarding the conduct of the navigation watch
with a pilot aboard. The following document was posted on the back side (forward facing) part
of the helm station. It is a good example and summary of the company’s philosophy and
expectations regarding BRM and pilots:
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(Red arrows indicate items that were particularly relevant to this casualty with regard to BRM.)
35. The navigation watch team members were sufficiently licensed, experienced, and qualified
for their respective positions. Each of the members (master, third officer, helmsman, and lookout) had at some point in their careers, been trained, and were familiar with the concepts of
BRM.
36. In preparation for getting underway, the Pilot positioned himself at the S-band (10cm) radar,
which was to the right of the longitudinal centerline of the wheelhouse. He positioned his PPU
in front of him on a ledge beneath the forward wheelhouse windows. The Master positioned
himself at the X-band (3cm) radar, which was just to the left of the longitudinal centerline of the
wheelhouse. The Helmsman was positioned at the helm station, which was forward in the center
of the wheelhouse, and the Look-Out was positioned on the bow.
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The Bosun was also on the bow with the Look-Out, but was not assigned to perform look-out
duties; he was there to act as the anchor watch.
Radar that Pilot
was Using
SAT Phone
Location
(Photo shows the starboard side of the OVERSEAS REYMAR’s wheelhouse.)
37. The Navigation Watch Officer, Third Officer
was positioned at the chart
table, which was aft and to the left of the wheelhouse centerline. He was required for the
navigation watch as per federal regulations and company policy. His primary responsibility, as
outlined by company policy, was to plot the OVERSEAS REYMAR’s navigational progress and
to pay particular attention to possible position deviations from the planned track.
used
Admiralty Chart 588, edition seven, which was published by the United Kingdom’s
Hydrographic Office on 8 November 2012. Course lines and parallel index lines that appear on
the chart were placed there by the Second Officer and used for reference by
He used
the vessels Global Positioning System (GPS) equipment to fix the vessel’s position.
38. At 1044, the Pilot reported to VTS that the OVERSEAS REYMAR was preparing to get
underway from Anchorage 9 and was bound for sea. He indicated that the vessel’s draft was 27
feet 3 inches and that he would be guiding it through the Charlie-Delta span of the SF-OBB via
the Deep Water Traffic Lane. He also indicated that no tug escort was required and that the
vessel would proceed westbound upon clearing the Golden Gate Bridge. The VTS Operator
acknowledged and informed the Pilot of a tug and barge proceeding to sea from Richmond and
that there was no in-bound traffic. Neither the Pilot nor the VTS Operator spoke of visibility
during this communication.
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39. At 1058, the Pilot reported to the VTS that the OVERSEAS REYMAR was underway.
The VTS Operator inquired about the visibility and the Pilot reported it as “less than one-half
mile right now but it’s been up and down.” While at anchor, the vessel had been facing south
against the ebb tide. The Pilot gave the Helmsman a series of starboard rudder commands to turn
the vessel towards the west from a southerly heading to a northerly heading. As the vessel
turned and steadied on its northerly heading, the Pilot gradually took the engine from dead slow
ahead to half ahead.
40. At 1107, the OVERSEAS REYMAR (henceforth referred to as “the vessel”) was due west
of the “SC” buoy (LLNR 4620) and was heading north. The Pilot noted that visibility looking
north towards the SF-OBB was variable between one-half and one mile. The Pilot asked the
Master to turn on the automatic fog signal and the Master did so. When the vessel was steadied
up on its northerly heading, the Pilot began using the S-band radar to try to identify the RACON
for the Charlie-Delta span of the SF-OBB (RACON “B”). He tried various ranges, gain
adjustments, and sea/rain adjustments for the next several minutes, but was unable to see the
RACON “B” Morse code signal. At this point in the voyage, the vessel was approximately one
and a half miles from the Charlie-Delta span with a speed over ground (SOG) of approximately
seven and a half knots (henceforth all distances, speeds, and headings are assumed approximate;
all degrees are true).
(Image shows a screen-capture from the vessel’s S-band radar. The time is approximately 1107.
*Note – This is the radar that was used by the Pilot.)
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41. At an unknown point in time, RACON “B” (LLNR 4446), which was positioned in the
center of the Charlie-Delta span, stopped working.
42. At 1110, the vessel was one mile from the Charlie-Delta span with a SOG of 9.5 knots.
Visibility was still one-half to one mile. The Pilot realized that, for reasons unknown to him,
Charlie-Delta’s RACON “B” was not showing up on his radar. The Pilot wanted to transit a
span with a working RACON due to the low visibility conditions, so he changed his passage plan
from using the Charlie-Delta span to the Delta-Echo span. He could see the Delta-Echo span’s
RACON “Y” on his radar screen. He considered aborting the bridge transit, but decided against
it because he felt that there was enough navigation aids available to transit the span safely.
The Pilot radioed the VTS and informed them that he would be using the Delta-Echo vice the
Charlie-Delta span; however, he did not mention the apparent malfunctioning of RACON “B”,
nor did he mention the decreasing visibility conditions. The VTS Operator acknowledged.
The Pilot discussed the RACON “B” problem with the Master and informed him of the span
change. The Master nodded in approval. The Pilot issued the Helmsman a series of commands
to steer the vessel on a northeasterly course parallel to the bridge.
43. At 11:11:35, the Master answered a call on the vessel’s Inmarsat satellite (SAT) telephone.
The SAT phone was located on the wheelhouses’ aft starboard console. The call was from a
representative for the vessel’s chartering company. The Master conversed with the
representative about the vessel’s fuel consumption particulars. The call lasted 25 seconds before
the connection was unexpectedly lost.
44. OSG company policy specifically addressed cell phones, iPods, and TVs as distractions;
however, it did not specifically address the SAT phone as a distraction nor did it forbid the
navigation watch team from using it during periods of restricted visibility.
45. At 11:11:45, the Pilot ordered full ahead from half ahead. The Third Officer, who was
responsible for manipulating the engine controls, complied with the order.
46. At 1113, the Pilot ordered the Helmsman to steer a course of 020 degrees. The Helmsman
complied with the order. At this point in the voyage, the vessel was one-half of a mile from the
SF-OBB Charlie Tower Pier heading 015 degrees with a course over ground (COG) of 007
degrees; SOG was 10.8 knots. The ebb current, which was flowing at three knots in the direction
of 316 degrees, was setting the vessel to the north towards the bridge.
47. At 1114, the visibility was one-half mile and the vessel was one-quarter mile from the bridge
with a SOG of 11.9 knots, heading 020 degrees with a COG of 11 degrees. The Pilot lost visual
contact with the SF-OBB Delta Tower and could not see the buoy in front of the Delta Tower
Pier on his radar screen. The Pilot did not begin his turn to port at this point because of how he
perceived the ebb current to be setting the vessel towards the bridge. He felt that turning at this
point would result in the vessel getting set into the Delta Pier.
48. During the next few minutes, the visibility decreased from one-half mile to less than onetenth of a mile. The Pilot stated that he could not see the deck of the ship from the wheelhouse
and could not see any of the bridge’s features.
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This assessment of visibility is consistent with the Bow Look-Out’s statements whereby he
stated that he could not see the wheelhouse while looking back from the bow. The Pilot stated
that the images on his radar had significantly deteriorated due to the radar’s proximity to the
bridge, and that RACON “Y’s” signal had deteriorated to a “broad smear” that provided only a
vague reference point.
49. At this point in the voyage (between 1114 and 1116), the Pilot contemplated the feasibility
of continuing the voyage as planned. He considered two alternatives as opposed to going under
the bridge. Alternative number one: He considered turning to starboard and returning to
Anchorage 9. He decided against this option because he believed the vessel might not clear the
shoals to the south of YBI and run aground. Complicating this option was the presence of a
dredge and dredge tender positioned in the Oakland Bar Channel, for which he believed a
collision might occur. Alternative number two: He considered dropping the anchor but did not
think that it would hold. Complicating this option was the proximity of the vessel to the Bay
Area Rapid Transit (BART) tunnel, which is buried near the bridge. He feared that the anchor
might land on top of the tunnel and damage it.
50. At 11:15:30 the Master received another SAT phone call. He spoke with the caller (the
same person from the first call) for three and a half minutes. He was on the SAT phone talking
with the caller as the vessel turned towards, and passed under the bridge.
(Image shows a screen-capture from the vessel’s S-band radar. The time is approximately 1115.
This is the approximate point in the voyage where the Pilot considered alternatives to going
under the bridge.)
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51. At 11:15:40, the Pilot initiated the vessel’s turn towards the bridge by ordering the
Helmsman to turn the rudder 20 degrees to port. The vessel was heading 020 degrees with a
COG of 12 degrees; SOG was 12.4 knots. The vessel was one-tenth of a mile from the Delta
Pier; visibility was an estimated 200 to 300 feet. Five seconds later, the Pilot ordered the
Helmsman to turn the rudder hard to port. The Helmsman complied.
52. At 11:17:10 the VTS Operator contacted the Pilot to advise him that his (the VTS
Operator’s) AIS display showed the OVERSEAS REYMAR “going directly at the Echo Tower”
and that he “wanted to confirm that everything was ok.” The Pilot acknowledged by saying,
“We’re going under the bridge right now.” At this time the vessel’s heading was 318 degrees
with a COG of 352 degrees; SOG was 11.6 knots. The VTS Operator attempted to use the VTS
Closed Circuit Television camera (CCTV) positioned at Point Blunt to visually observe the
OVERSEAS REYMAR; however, the entire West Crossing of the SF-OBB was obscured by
heavy fog and the Operator could not see the vessel.
53. At 11:17:33, the Pilot visually observed the underside of the bridge and the Echo Tower and
realized that the vessel might allide with the Echo Pier. He ordered the Helmsman to put the
rudder amidships. Five seconds later, he ordered the Helmsman to turn hard to port, but
immediately corrected himself and repeated the command as hard to starboard. By ordering the
rudder hard to starboard, he was attempting to perform a maneuver that would lift the stern away
from the Pier.
(Image shows a screen-capture from an AIS-chart display software program at 1117, which is the
time that the VTS Operator called the Pilot).
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54. At 11:17:45, the Pilot left the wheelhouse and moved onto the starboard bridge wing to
observe the vessel’s proximity to the Echo Pier. At this point, the Master sensed that something
was wrong and abruptly ended his SAT phone call.
55. At 11:17:50, the vessel's starboard aft quarter allided with the southwest corner of the SFOBB Echo Pier. The starboard aft section of the vessel's hull and internal structural members
sustained damage as a result of the allision. The Helmsman verbalized that the rudder was hard
to starboard. The Master reaffirmed the Pilots order and instructed the Helmsman to keep the
rudder hard to starboard. Approximately five seconds later the Pilot returned to the wheelhouse
and ordered the engine to full stop and the rudder amidships.
(Image above shows a screen-capture from the vessel’s S-band radar. The time is approximately
1118. This is the approximate point in the voyage where the vessel allided with the Echo Pier.)
56. At 11:18:10, the Pilot radioed the VTS and informed the VTS Operator that the vessel had
allided with the SF-OBB and that the vessel was proceeding to Anchorage 7, which is adjacent to
the northwest side of YBI.
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(Photo above shows damage to the southwest corner of the Echo Pier’s fender system as a result
of the T/V OVERSEAS REYMAR alliding with it.)
(Photo above shows damage to the starboard aft quarter of the T/V OVERSEAS REYMAR’s
hull as a result of the vessels allision with the SF-OBB Echo Pier.)
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(Photo above shows damage to the starboard aft quarter of the T/V OVERSEAS REYMAR’s
hull as a result of the vessel’s allision with the SF-OBB Echo Pier.)
(Photo above shows damage to the T/V OVERSEAS REYMAR’s internal structural members as
a result of the vessel’s allision with the SF-OBB Echo Pier.)
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Analysis:
1. The OVERSEAS REYMAR was properly manned, and there were no mechanical or material
issues or problems that would have precluded it from being operated in a normal, safe, and
predictable manner.
2. The unloaded condition of the vessel (in ballast) resulted in the ship being directionally stable
as opposed to a loaded vessel, which in most cases is less directionally stable. During the vessels
voyage from Anchorage 9, the three knot northwesterly ebb current was a following current,
meaning that it was essentially pushing the vessel along in a northwesterly direction.
A following current impedes a ship’s ability to turn as quickly as it would in a slack tide or headon current. This condition was particularly apparent when the vessel was turned to port at
11:15:40 from a northeasterly heading. During this turn, the vessel’s starboard quarter had to lift
into the following current, which further slowed the rate of turn.
3. The navigation sections of the vessel’s SMS were in compliance with applicable regulations
and marine best practices at the time of the casualty. There were no apparent failures in
oversight by the Flag State or the Classification Society that contributed to this casualty.
4. The SF-OBB utilized lighting, markings, and Aids to Navigation (AToN) in accordance with
applicable bridge regulation requirements. The use of RACONs on the bridge, while not
required by federal regulations, appears to be an important component of the bridge’s overall
anti-strike scheme because some mariners have come to rely on them in low-visibility
conditions. The failure of the bridge’s RACON “B” was a factor in this casualty; however, there
is no evidence to suggest that additional lights, markings or ATON would have prevented this
casualty from occurring.
5. Caltrans was unable to actively monitor the status of the SF-OBB’s RACONs. As a result,
Caltrans bridge management personnel were unable to detect the failure of RACON “B” in a
timely manner.
6. There were no apparent inadequacies with VTS San Francisco policies or procedures.
The equipment utilized by the VTS appears appropriate with the exception of the placement of
the three CCTVs positioned on top of YBI. The view from these CCTVs can be (and often is)
obscured by fog that does not extend to the water level.
7. The VTS watchstanders that were manning the VTC at the time of the casualty were
sufficiently qualified, experienced, and proficient in their respective positions. The Watch
Supervisor and Bay Sector Operator may have suffered from short-term fatigue, given the fact
that both had recently (within a four day period) switched from a night time to a day time work
schedule; however, neither displayed poor or degraded performance during the casualty that is
typically present when fatigue is a factor. The Ocean and Delta Sector Operators were not
fatigued. None of the watchstanders suffered from performance-degrading medical conditions,
or were under the influence of medications that negatively affected their performance. None of
the watchstanders were under the influence of alcohol or illicit drugs at the time of the casualty.
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8. The actions of VTS watchstanders, including the Watch Supervisor, were appropriate and
substantially in accordance with Coast Guard policy and procedure. An analysis of
communications between the VTS watchstanders and the Pilot revealed some minor deviations
from prescribed language; however, these deviations were insignificant and not considered as
contributory to this casualty.
9. VTS watchstanders rely on external, publicly available sources for weather information.
10. The visibility and fog patterns in the South San Francisco Bay area were highly variable
during the morning hours of 7 January 2013.
11. It is difficult to speculate whether designation of the SF-OBB as a CMA would have
prevented this casualty. If the bridge had been designated as a CMA, it is conceivable that the
Pilot would have given greater thought and consideration to initiating the transit, or perhaps
decided to turn back into South San Francisco Bay when visibility dropped below one-half mile
as he approached the bridge. It is also conceivable that when the visibility dropped below onehalf mile, the Pilot may have felt committed to passing under the bridge, regardless of whether or
not a CMA was in effect.
12. The Pilot was equipped with a PPU during the voyage; however, despite the presence of the
PPU, he failed to navigate the OVERSEAS REYMAR to avoid the SF-OBB’s Echo Pier.
13. The Pilot was sufficiently trained, qualified, and experienced; however, his proficiency is
held in-question. He was not suffering from fatigue, poor physical or mental condition,
14. The Pilot developed a routine, and a mental rule-of-thumb, for passing under the SF-OBB
that was not appropriate for certain situations. He chose to use the Charlie-Delta span for almost
every outbound transit from Anchorage 9 because he felt that by using just one span consistently,
he would become more familiar with it as opposed to using different spans inconsistently.
It could be argued that selecting the Charlie-Delta span for outbound voyages in questionable
fog/visibility conditions is not a wise choice; however, there are no rules or regulations that
forbid it. The U. S. Coast Pilot 7 (45th Ed.) recommends the use of the Delta-Echo span for all
outbound voyages and warns of the hazardous ebb tide rip currents near the piers. The Pilot
stated that he did not like to use the Delta-Echo span as a matter of avoiding other vessels
transiting into or out of the Oakland Bar Channel; however, in this instance, there were no
vessels transiting into or out of the channel. It should also be noted that the Delta-Echo span
horizontal clearance is approximately 1,131 feet wider than the Charlie-Delta span, or nearly
double the width.
15. The Pilot’s navigation and BRM proficiency on an actual ship’s bridge, and during an actual
voyage, had not been evaluated during his previous seven years as a pilot. He was however,
evaluated in situ extensively during the SFBP training program.
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16. The Pilot’s three prior casualty incidents that were investigated by the BOPC, and his
performance as it pertained to those casualties, is not necessarily indicative of a history of poor
performance or suitability for his position. The three incidents were relatively minor in nature.
17. The Pilot prepared for the OVERSEAS REYMAR voyage by obtaining route, traffic,
weather, tide, and vessel particulars information. He did not formulate any contingency plans
pertaining to unexpected reduced visibility, nor did he consider contingencies for passing under
the SF-OBB.
18. The Master and crew were sufficiently experienced and qualified for their respective
positions. The Master ensured the navigation watch was staffed in accordance with U. S.
regulations and company policy. The Master may have suffered from the effects of short-term
fatigue. The Third Officer, Helmsman, and Look-out were not likely suffering from fatigue.
no one, except the Master was doing anything to distract them from their
navigation watch duties.
19. The Master and Pilot agreed on using the Charlie-Delta span during their exchange and
brief; however, it is unknown whether or not the Third Officer plotted a course from Anchorage
9 to the center of the Charlie-Delta span; the chart did not show any evidence that a line was
drawn, and then erased. The chart did show that a line had been drawn from Anchorage 9 to the
center of the Delta-Echo span; however, it is believed that this line was drawn at some point after
the vessel allided with the bridge. It could not possibly have been drawn during the Master-Pilot
exchange or at any point prior to the vessel getting underway because a course towards the center
of the Delta-Echo span was not the original intended course. The line drawn from Anchorage 9
to the Delta-Echo span included parallel indexing lines on both sides. The right-side parallel
index line was drawn at a 0.13 nautical mile range, and the left side line was drawn at 0.15
nautical miles. The use of parallel index lines is indicative of good seamanship; however, in
order for them to be useful, the lines must fall upon an object that can be easily detected and is
visible on the vessels radar. The parallel index lines in this instance were drawn to use the Delta
and Echo piers as points of reference. The piers were difficult, but not impossible, to discern on
the X-band radar, and likely would have been difficult to discern on the S-band radar.
20. The first position fix taken by the Third Officer was at 1100, followed by a fix at 1102 that
showed the vessel nearly abeam, and to the west of buoy “SC”. The next three fixes taken at
1104, 1110, and 1114 are consistent with what would be expected for an approach to the center
of the Charlie-Delta span. The next fix taken at 1116, when the vessel was approximately onehalf of a mile from the center of the Charlie-Delta span, is consistent with the Pilot’s intention to
switch from the Charlie-Delta span to the Delta-Echo span; however the fix is well to the right of
the track-line drawn from Anchorage 9 to the center of the Delta-Echo span, which further
supports a belief that the track-line from Anchorage 9 to the center of the Delta-Echo span was
drawn after the allision occurred. Beginning with the 1116 fix, the Third Officer began taking
fixes every 60 seconds, with one at 1117, and another at 1118. This increased-frequency time
interval was required by the SMS which stated that “As risks of danger increase, the frequency
of position fixing shall increase correspondingly.” This is consistent with the decreasing
visibility and the vessel’s ever decreasing distance from the bridge.
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There is no indication on the vessel’s Voyage Data Recorder (VDR) playback, or any other
evidence, to suggest that the Third Officer had any concerns, or voiced any concerns about the
vessels course, speed, heading, or passage plan. In fact, there was no verbal communication
between the Third Officer and the Master or the Pilot with respect to the ship’s position for the
duration of the transit.
21. The “Navigation in Restricted Visibility” and “Navigation in Pilotage Waters” sections of
the vessel’s SMS were comprehensive, clear, and robust. The Restricted Visibility section
clearly communicated a need for extra vigilance during low visibility, in addition to additional
crew and equipment considerations (e.g. speed reductions, fog signals, additional look-outs, etc.).
The Pilotage Waters section clearly communicated the company’s philosophy that the master is
the final authority for matters involving the navigation plan, and that the pilot is an “advisor”
who can and should be overridden when concerns for the safe navigation of the vessel arise.
22. The vessel's SMS included a section that addressed BRM. This section of the SMS
adequately addressed the concept and intended execution of BRM theories and best-practices.
Specifically, in section 3.3.5.1.4, it addressed the need for the navigation team to ensure the
appropriate level of communication in order to avoid a "one man error" type incident.
OSG also had a program in-place for auditing their master’s BRM performance. The Master and
crew did not utilize or employ BRM concepts or techniques while the Pilot was aboard.
Mermarion had not been through a BRM audit process since becoming a master for OSG.
23. The visibility and fog density in the South San Francisco Bay, south of the SF-OBB,
between the times of 0940 and 1118 were highly variable ranging between five miles and onetenth of a mile. For this casualty, the fog developed along the eastern shore of the San Francisco
Peninsula, south of the SF-OBB, and moved north and east. This type of formation of fog in this
area is rare and difficult to predict. This explains why the fog was not detected by the VTS
CCTV positioned at Point Blunt until it had already reached the SF-OBB.
24. The Pilot relied heavily on the radar signal from the Charlie-Delta span’s RACON “B” to
guide him through the span in low visibility conditions; he did not formulate any low visibility
contingency plans for passing through the SF-OBB prior to getting underway.
25. The Master violated company policy by conversing on the SAT phone (twice) while the
Pilot was maneuvering the vessel in a low visibility, high risk situation. The vessel’s SMS
clearly stated that no one from the navigation watch should engage in any type of distracting
activity while on watch, and particularly in challenging navigation situations.
26. An analysis of the Pilots decision regarding his two alternative options, as opposed to
turning to port and passing under the SF-OBB, revealed the following: Alternative option
number one, which was to turn to starboard, was a valid option. This scenario was recreated in a
simulator using vessel and tide characteristics, and speeds and headings reflective of this
casualty. While simulations can never replicate actual events with 100% accuracy, it is fair to
say that the simulations conducted showed that turning to starboard at anytime between 1114 and
1116 would have most likely resulted in the vessel safely returning to South San Francisco Bay.
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In fairness to the Pilot it should be noted that a dredge vessel, which presented a risk of collision
to the OVERSEAS REYMAR, was positioned near the entrance to the Oakland Bar Channel,
which made the decision to turn to starboard less attractive, as did the possibility of grounding
the ship on Yerba Buena Island. Alternative option number two, which was to drop anchor, was
indeed a poor option as the Pilot correctly determined. Given the vessel’s heading, speed, and
the tidal current, it is highly unlikely that dropping the anchors would have stopped the vessel
from grounding or alliding with the bridge. The Pilot’s concern for the anchors potentially
landing on the BART Tunnel was also valid.
27. The Look-Out did not communicate with the Pilot or any other member of the navigation
watch during the vessel’s voyage from Anchorage 9 to the SF-OBB. The Helmsman
communicated with the Pilot, but only to repeat helm commands. The Third Officer
communicated with the Pilot, but again, only to repeat engine speed commands. The Master
communicated with the Pilot, but only at the onset of the voyage. Once the vessel left
Anchorage 9, the Master’s communications with the Pilot were minimal and not related to the
safe navigation of the vessel. Beyond explaining the vessel’s intended transit route through the
Charlie-Delta span and the unplanned change to the Delta-Echo span, the Pilot neither actively
engaged in substantive navigation-related discussions with the navigation watch team, nor
solicited for substantive navigation-related information or recommendations. The Pilot gave no
indication to the master or other members of the navigation watch that he had any significant
concerns regarding the vessel’s position or track at any point before they struck the Echo Pier.
Conclusions:
1. In accordance with reference (c), the initiating event (or first unwanted outcome) for this
casualty was the Pilot’s decision to turn the OVERSEAS REYMAR to port too late in an attempt
to pass underneath the SF-OBB. While there are several causal factors that contributed to this
casualty, the most prominent group of causal factors were the Pilots numerous lapses in
judgment and prudent seamanship at critical points during the voyage. He simply failed to
properly plan for, and adapt to, challenging and dynamic environmental conditions, and thus
created a situation where the limited navigation options he had left were all less than desirable.
2. A contributing causal factor was the Pilot’s mis-calculation of the effect that the ebb current
would have on the OVERSEAS REYMAR’s turn to port. The difference between the vessel’s
heading and its course over ground when it was parallel to the SF-OBB was approximately eight
degrees. This difference was noted by the Pilot and caused him to consider the effect of the
current on the vessel’s course. He assumed that the current would set the vessel into the Delta
Pier if he turned to port too soon. In making this assumption, he delayed the vessels turn to port
to compensate. Unfortunately, he delayed the turn too long which resulted in the vessel tracking
on a course that caused it to allide with the Echo Pier. If the Pilot would not have mis-judged the
effect of the ebb current on the vessel, and would have initiated the turn to port sooner, the vessel
would likely not have allided with the Echo Pier.
3. A contributing causal factor was the Pilot’s over-reliance on the bridge’s RACONs and his
failure to formulate a contingency passage plan, prior to getting underway, for guiding the
OVERSEAS REYMAR underneath the SF-OBB.
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The Pilot chose to use the Charlie-Delta span in highly variable and restricted visibility
conditions, without adequately preparing for the possibility of having to use another span.
Ultimately, he did formulate an alternate passage plan but not until after the vessel reached a
point in the voyage where the alternate plan had to be made in haste and proved to be a
significant deviation from the Pilot’s normal route through the SF-OBB.
4. A contributing causal factor was the Pilot’s failure to engage in industry-standard BRM /BTM
best practices. The Pilot did not engage with the navigation watch team, other than to issue helm
and engine commands, once the vessel left Anchorage 9. There was no communication between
the Pilot and the navigation watch team to indicate any concern or discomfort with the transit
until after the ship struck the bridge.
5. A contributing causal factor was the Master’s failure to ensure that the ship’s entire
navigation watch team, including himself, the Third Officer, the Helmsman, and the Lookout,
engaged in effective and efficient Bridge Resource/Team Management.
6. The unexpected development of a dense fog bank at the SF-OBB was a significant
contributing factor for this casualty. The fog was not predicted and its rapid development and
transition from south to north was unusual.
7. The failure of RACON “B” was a contributing causal factor in this casualty. Caltrans lacked
any organic capability to detect the failure, and the failure was not detected or reported by a
mariner on a passing ship. If the failure had been detected, reported, and ultimately
communicated to the Pilot, he may have changed his passage plan, or at least contemplated an
alternate passage plan, upon his arrival to the OVERSEAS REYMAR.
8. A contributing causal factor was the Master being distracted from his navigation duties.
According to the ship’s SMS, and given the staffing of the wheelhouse at the time of the
casualty, the Master was assuming the responsibilities of the Officer of the Watch (OOW).
The vessel’s SMS stated that the Master was responsible for evaluating the decisions and actions
of the pilot, and that if he did not believe the pilot’s decisions or actions were appropriate, he
should override the pilot. Unfortunately, the Master was engaged in a conversation (official
ship’s business-type conversation, but not related to navigation) on the Inmarsat telephone
during a time period when the ship was approaching the bridge in restricted visibility, and as the
ship passed under the bridge in highly restricted visibility. His engagement in this telephone
conversation, which was a deviation from policy as outlined in the ship’s SMS, prevented him
from focusing his entire attention on the safe navigation of the ship. If the Master had focused
his full attention on the safe navigation of the ship, he may have realized the precarious situation
and taken the “conn” from the Pilot and directed another course of action to include: initiating a
turn to port sooner, or turning the ship to starboard and going back into South San Francisco
Bay.
9. The Third Officer’s failure to fully engage as a member of the navigation watch team
contributed to this casualty. The Third Officer’s presence in the wheelhouse was required as per
federal regulations and company policy due to the restricted waters and low-visibility conditions.
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The point of these regulations and policy is to ensure that the decisions and actions of the OOW
(or master) and pilot are checked and verified to be sound and prudent by another competent
mariner. In this casualty, the Third Officer failed to provide any input to the navigation watch
team and Pilot regarding the safe navigation of the vessel.
10. The ineffective utilization of the Bow Look-Out, and the poor execution of duties by the
Bow-Look Out, contributed to this casualty. The Bow Look-Out did not report, nor was he
asked to report to the wheelhouse navigation team, the visibility conditions or the vessels
position relative to the SF-OBB. Similar to the Third Officer, the Bow-Look Out failed to
provide any input to the navigation watch team and Pilot regarding the safe navigation of the
vessel.
11. A contributing causal factor was the Master’s fatigue. The Master’s work-rest schedule for
the 96 hours prior to the casualty shows two instances where his circadian rhythm was
significantly disrupted. Credible scientific research has shown that circadian rhythm disruptions
significantly degrade cognitive abilities and reduce a person’s level of concern for complex or
dangerous evolutions. While it is impossible to prove, it is conceivable that the Master’s level of
concern with regard to the Pilots navigation decisions may have been degraded in-part because
of his fatigue.
12. A contributing causal factor was the lack of a periodic in situ evaluation of the Pilot’s skills,
proficiency, and BRM execution. The Pilot was evaluated in a simulator on a periodic basis;
however, the simulator evaluations did not provide evaluators with an accurate picture of the
Pilot’s real-world behavior. In particular, the simulator evaluations did not provide the
evaluators with an accurate representation of the Pilots ability to effectively interact with a
foreign vessel’s navigation watch team. The simulator evaluations also failed to provide the
evaluators with insight to the “norms” and potentially bad habits of the Pilot. In this casualty the
Pilot’s norms are represented by his rigid belief that the Charlie-Delta span is the best span to use
in almost any piloting situation while departing Anchorage 9, and his unwillingness to consider
alternate passage plans.
13. With the exception of the failure of RACON “B”, there is no evidence to suggest that
additional lighting, markings or AToN on the SF-OBB would have aided the Pilot in making
decisions about the navigation of the vessel. Therefore, it is concluded that the bridge’s
associated lighting, markings and AToN, or lack thereof, did not contribute to this casualty.
Due to its somewhat experimental nature in the United States, it is unknown whether the use of
electronic “virtual” AToN could have helped prevent this incident.
14. The policies and procedures of the VTS, and the actions of the watchstanders at the time of
the casualty were adequate, appropriate, and prudent. There is no evidence to suggest the VTS
or the watchstanders did anything to contribute to this casualty.
15. It is impossible to determine if the placement of the three VTS CCTVs atop YBI contributed
to this casualty; however, if they were placed in a different (lower) location, the VTS
watchstanders possibly could have utilized them to identify the low-visibility conditions at the
SF-OBB sooner.
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This information could have been communicated to the Pilot which in-turn may have influenced
his decision to continue on towards the bridge. The current location of the cameras is not
optimal for fog/ low-visibility conditions.
16. The visibility conditions at the SF-OBB during the times leading up to this casualty were
highly variable, changing from one-tenth of a mile at 0818 to one-half of a mile at 1014, and then
dropping to less than 500 feet at 1100. Given the variable nature of the fog at the bridge that
morning and the timing of the formation of the dense fog, and the limited capabilities of the VTS
to detect and evaluate fog in the vicinity of the SF-OBB, it is unlikely that a CMA enforcement
status would have been imposed by the VTS at the bridge prior to the start of, or during the
ship’s voyage. As such, the SF-OBB’s lack of designation as a CMA cannot be definitively
considered a contributing causal factor for this casualty.
17. The mechanical and material condition of the vessel did not contribute to this casualty.
The vessel’s steering and propulsion systems and loading and trim conditions were such that the
vessel could be operated and navigated safely.
Safety Recommendations:
1. Even though the SF-OBB’s lack of designation as a CMA was not considered a factor in this
casualty, this lack of designation is a latent unsafe condition that may, in the future, set the stage
for another allision-incident to occur with this bridge. Nine areas within the San Francisco Bay
Area, including four bridges, were designated as CMAs following the T/V COSCO BUSAN
casualty that occurred on 7 November 2007. A review of the HSC meeting minutes and notes
did not reveal any definitive reason(s) why the HSC chose not to designate the SF-OBB as a
CMA. However, interviews of persons involved in the decision making process revealed they
felt that it was inappropriate to designate it as a CMA given the relatively large width of the
bridge’s spans and the potential system-wide impacts to risk associated with restricting inbound
transits during period of reduced visibility. Clearly a case can be made for allowing vessels to
transit southbound through the SF-OBB during periods of restricted visibility, as allowing ships
safe access to anchorage is critical to maintaining overall system safety. That said, the systemwide safety case may not be as compelling for northbound transits. Given that almost all
practicable anchorage grounds for deep-draft vessels are located south of the SF-OBB, it is
critical that the issue of SF-OBB transits in restricted visibility be overtly addressed by
appropriate stakeholders. Accordingly, the Coast Guard recommends that the HSC include the
SF-OBB (West of Yerba Buena Island) as a CMA in the HSC Guidelines and Best Practices
publication, and develop appropriate associated navigation guidelines for this unique area.
The inclusion of the SF-OBB as a CMA will enhance the safety of the bridge and the vessels that
transit under it during periods of low-visibility.
On 13 February 2013, the HSC adopted “Temporary Safety Guidelines for Navigating in
Reduced Visibility” in the wake of the OVERSEAS REYMAR allision. These guidelines were
intended to mitigate the risks associated with transiting the SF-OBB (West of Yerba Buena
Island) during periods of restricted visibility while investigation of the casualty proceeded.
The guidelines implement the following temporary safety measures for all vessels 1600 GT or
greater, tugs with tows 1600 GT or greater, and all tugs with tows in petroleum service:
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1. Vessels should make visibility reports as part of their sailing plan report to the VTS and
at any point in their transit when visibility conditions change substantially and navigation
safety allows the report to be made.
2. Vessels transiting the San Francisco-Oakland Bay Bridge (West of Yerba Buena Island)
in any condition of reduced visibility should generally do so via the A-B or D-E span
unless vessel traffic, environmental or other safety factors dictate otherwise.
3. Outbound/northbound vessels should not transit the San-Francisco Oakland Bay Bridge
(West of Yerba Buena Island) when visibility is less than one-half nautical mile.
4. Inbound vessels transiting the San Francisco-Oakland Bay Bridge in restricted visibility
are advised to exercise extreme caution during their transit.
These guidelines should serve as a starting point for developing an appropriate long-term CMA
arrangement for the SF-OBB. It is also recommended that the HSC complete a comprehensive
review of all CMAs to validate their selection, designation, geographic boundaries, and
procedures after over four years of implementation.
2. The failure of RACON “B” played a significant role in this casualty. If the failure had been
detected and reported immediately, the Pilot may have planned for the ship to pass through a
different span from the outset of his voyage. The Coast Guard recommends that Caltrans
develop policy and procedures for testing, inspecting, and monitoring the SF-OBB RACONs.
The policy and/ or procedures should contain instructions for notifying the Coast Guard
immediately upon discovering a failed RACON. Implementation of this type of policy/
procedure would better ensure that critical navigation information is passed to the maritime
community in a timely manner.
3. The ship’s navigation team performed ineffectively with a pilot aboard, with respect to BRM
execution, from the onset of the voyage from Anchorage 9, and up until the point where the ship
allided with the SF-OBB. It is not unrealistic to suggest that if one of the navigation team
members had verbalized concern(s) about the worsening visibility, and the Pilot’s actions in
response to it, the Pilot might have made different decisions and the allision may have been
avoided. OSG Ship Management had a BRM auditing program in-place prior to, and at the time
of this casualty; however, the audit was focused on the performance of the crew without a pilot
aboard. The Coast Guard recommends that OSG Ship Management conduct frequent and
regularly scheduled underway evaluations of their navigation watch crews to ensure the proper
execution of BRM when pilots are aboard. The evaluation interval should not exceed one year
for masters and officer of the watch qualified personnel.
4. The Pilot planned the ship’s voyage based on his experience as a SFBP and the prevailing
environmental and ship traffic conditions. His decision to use the Charlie-Delta span of the SFOBB was not necessarily an incorrect choice; however, it could be argued that the Charlie-Delta
span was not the best choice for the prevailing conditions. Many pilots use the Alpha-Bravo
and/ or Delta-Echo spans during periods of low visibility because they are significantly wider
than the Charlie-Delta span (1131 feet wider or approximately twice as wide).
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The Pilot rationalized his decision to use the Charlie-Delta span because he had used it
successfully many times in the past, and the 1079 foot horizontal clearance was more than
adequate to safely accommodate the OVERSEAS REYMAR. This “habit” the Pilot developed
for using the Charlie-Delta span, even during periods of low visibility, was never questioned or
challenged by another pilot or pilot-evaluator throughout his seven year career, as no such formal
performance feedback mechanism exists beyond the Incident Review process. The Coast Guard
recommends the BOPC develop a mechanism to evaluate Pilots while underway and piloting on
a regularly scheduled basis but not to exceed one year. If appropriately executed in diverse
circumstances, these types of evaluations will provide an opportunity to identify and correct bad
habits developed by Pilots, and provide critical feedback regarding Bridge Resource
Management, navigation, and overall risk management practices.
5. In this casualty, the Pilot was unable to utilize the ship’s radar and his PPU to successfully
navigate the ship through the SF-OBB. It is possible that he lacked proficiency at using radar in
low-visibility/restricted waters conditions. As such, the Coast Guard recommends that the
BOPC consider an additional training requirement for pilots to participate in low-visibility/
restricted waters radar navigation training on an annual basis.
6. The Pilot, Master, and navigation watch crew’s failure to use BRM to prevent this casualty
from occurring cannot be overstated. This was neither the first, nor will it be the last BRM
failure in pilotage waters. As such, Coast Guard Sector San Francisco recommends that Coast
Guard Headquarters issue a Safety Alert encouraging the international maritime community, to
include ship owners and operators and Pilots associations/commissions, to critically evaluate the
appropriateness, effectiveness, and execution of their BRM training programs, policies, and
procedures, with special emphasis on conduct in pilotage waters. In doing so, the Coast Guard
will ensure that lessons learned from this casualty are effectively shared with the international
maritime community.
7. The three CCTV cameras located on top of YBI were obscured by fog making them
ineffective in helping VTS watch standers evaluate the actual sea-level environmental conditions
as this casualty played out. It is unclear whether or not the watchstanders could have utilized the
cameras to prevent this casualty had the cameras been un-obscured; however, it is safe to say that
moving them to a location that increases their usefulness in low-visibility conditions could
enhance safety. It is recommended that USCG Sector San Francisco VTS relocate two of the
YBI CCTV cameras to a lower elevation to facilitate better viewing of visibility conditions at
sea-level. Positioning the CCTVs at a near sea-level location would decrease the frequency at
which the cameras are obscured by marine layer fog that does not extend to the surface of the
water. CCTV cameras would likely offer only limited utility with respect to definitively
determining visibility conditions, particularly in a highly variable visibility environment like San
Francisco Bay. However, even marginally increasing the utility and effectiveness of the cameras
will no doubt enhance safety in the long run.
8. Recommend the Coast Guard and HSC explore the use of AIS-based "e-ATON" as an
additional tool to mark the SF-OBB and/or to mark a low visibility approach channel for use by
vessels transiting the SF-OBB. While this nascent technology has yet to be deployed on a large
scale within the marine transportation system, the Coast Guard has prototyped "e-ATON" in a
limited capacity and continues to evaluate its efficacy and potential future applications.
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9. While there is no evidence to suggest that a lack of visibility (fog) sensors on the SF-OBB
contributed to this casualty, the Coast Guard recommends that Caltrans install visibility sensors
on the bridge as an additional navigation and decision making tool that mariners can utilize for
planning safe voyages through the SF-OBB.
Enforcement Actions:
1. The Coast Guard does not have jurisdiction over the Republic of the Marshall Islands
Merchant Mariner Certificates and/or Credentials held by the crew of the OVERSEAS
REYMAR and, as such, cannot pursue suspension and revocation action against them.
2. The Pilot was not acting under the authority of his U. S. Coast Guard issued Merchant
Mariner’s License and/ or Credential at the time of this casualty, but instead was working under
the authority of his California State issued Pilot’s License. Suspension and revocation action
against the Pilot’s California State issued Pilot’s License is exclusively within the purview of the
BOPC.
3. The Pilot failed to notify the Coast Guard that the SF-OBB’s RACON “B” was inoperative as
he was required to do as per 33 Code of Federal Regulations, Section 161.13(d)(4). Due to the
circumstances of this casualty, in particular the extremis navigation situation that the Pilot was
dealing with upon concluding that RACON “B” was not operating, enforcement action against
the Pilot for failing to report the RACON’s failure is not recommended.
Administrative Recommendations:
1. Recommend this investigation be closed.
#
36

T/V OVERSEAS REYMAR ALLISION WITH THE SAN FRANCISCO

Transcription

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