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John Lloyd

October 2015

Compendium of Case Studies

Case Study 1
A general cargo vessel was making way in a busy traffic separation scheme
(TSS). A bulk carrier was abaft the vessels starboard beam at a distance of
1.7nm and slowly overtaking.

The OOW of the general cargo saw another vessel forward, 20 degrees off
his starboard bow at 3.9nm and with a CPA of 0.1nm. He did not acquire
the vessel on the ARPA or use the AIS data to determine the vessels name
or status. However, he assessed that the vessel was crossing their bow
from starboard to port so he judged his vessel was the give way vessel.
As it turned out, this was a fishing vessel engaged in fishing, not a crossing
vessel. The fishing vessel began to manoeuvre to port to stay away from the
commercial traffic but the OOW on the general cargo vessel did not immediately
notice this. When he did notice the change of course, he was confused as this did
not match his mental picture of a vessel crossing the traffic lane. His response
was to continue to alter to starboard, putting the fishing vessel about 30 degrees
off his port bow. By now he was becoming unsure of what to do and in the
following two minutes he made several alterations of course to both port
and starboard. He was still unaware that this vessel was a fishing vessel that was
manoeuvring out of his way.

The coast guard TSS services, seeing the movements on radar, became aware

that an ambiguous situation was developing and called the OOW of the general
cargo vessel. A short conversation ensued and the TSS services inquired if the
general cargo vessel was executing a 360 degree turn. Although this was not the
OOWs plan, he replied in the affirmative to TSS services; immediately after this
conversation, the OOW selected hand steering and applied 35 degree starboard
helm. Since the vessel was equipped with a high lift rudder the rate of turn
increased rapidly. He did not realise that the bulk carrier was now about 500m
off his starboard beam.
Meanwhile, the bulk carriers OOW had also been contacted by the TSS services
and after a short conversation this OOW ordered hard port helm. Although he
had been monitoring and was now aware that the general cargo was to do a
360degree turn, he did not think this manoeuvre was already underway. He
assumed that the general cargo would pass ahead before starting the 360 degree
turn. But within seconds he noticed that the cargo vessel was turning quickly
towards him so he immediately ordered hard starboard helm. Nonetheless, soon
afterwards the two vessels collided.

Case Study 2
The weather was fine with light winds, a smooth sea and visibility of about 4nm.
The red vessel [see image] was making way at about 12.5 knots. The pilot on the
red vessel observed a radar target, the green vessel, on a radar bearing two
points on the port bow at a range of 1.8 nm. The green vessel was also visually
observed to be a crossing vessel that the pilot estimated would cross ahead at
0.5nm. He assessed that a close-quarters situation was developing due to the
green crossing vessel and other traffic such as the blue vessel on their starboard
bow. A continuous sound signal was given from the red vessels whistle for about
30 seconds to attract the attention of the crossing vessel. For the time being the
red vessel maintained her course (338T) and speed.
A few minutes later, in order to allow more room for the green vessel and other
traffic in the vicinity, the pilot ordered a speed reduction; first to slow ahead, then
dead slow ahead and stop. A few minutes later the green vessel was observed to
be crossing ahead at a range of four cables. To allow the green vessel to pass
ahead even sooner the pilot ordered the helm ten degrees to port. While the
vessel was swinging to port, the green vessel was observed to alter course to
starboard. In an attempt to avoid collision, the pilot aboard the red vessel
ordered the helm to midship and then hard-to-starboard while the engine was at
dead slow ahead. At about this time the red ship sounded three prolonged blasts
of the vessels whistle. Shortly thereafter the bridge team members felt the vessel
shudder; it was suspected that a collision had occurred with the green vessel.

Meanwhile, on the green vessel, the only person on the bridge responsible for
steering the vessel and keeping a proper lookout was the OOW. As the green
vessel was proceeding at a speed of about five knots, the red vessel was
observed heading north in the fairway. The OOW initially assessed that there was
sufficient room for his vessel to pass clear ahead of the red vessel. Within a few
minutes he realised his assessment was wrong so he altered course to starboard
attempting to give way and pass clear. At this juncture the red vessel was
observed to be altering course to port heading towards his vessel. In order to
avoid collision, the OOW then altered course to port. Despite these actions there
was a collision with the red vessel.
Following the collision the green vessels engine compartment was flooded and
the vessel finally foundered some two hours later. Her six crew boarded the
vessels lifeboat and were rescued. The red vessel sustained paint scratches to
the starboard bow.

Case Study 3
During the early morning hours a tanker was transiting a heavily used waterway
under VTS control at a speed of about 12 knots and using autopilot control. In the
early morning hours there was a handover of OOWs. The new OOW was joined
by the deck cadet who was assigned lookout duties. The intended route had
been prepared using the ships electronic chart display and information system
(ECDIS) and the OOW selected the scale on the ECDIS display that closely
aligned with the 12 nm range scale set on the adjacent radar display.

The safety contour had been left at the factory default value of 30m even though
the vessels draught was only 7.9m. The OOW then sat in the port bridge chair
where he had a direct view of both radar and ECDIS displays (Figure 1). As the
vessel approached the Varne Bank the deck cadet became aware of flashing
white lights ahead but he did not identify the lights or report the sighting to the
OOW. At approximately 0417, the vessel passed close by the Varne Light Float;
15 minutes on the ships speed slowly reduced until the vessel stopped when it
grounded on the Varne Bank two minutes later. At this point, the OOW did not yet
realise that the vessel was aground. Three minutes after grounding an
engineering alarm sounded and the OOW placed both azipod control levers to
zero. He then informed the Master of the alarm and also rang the engine control
room to request they check the engines. Within a few minutes the engineer
telephoned the bridge and informed the OOW that ahead pitch was available on
the starboard azipod. Accordingly, the OOW moved the starboard azipod control
lever to pitch ahead but the ship remained stationary. This led him to assume that
there was still a problem with the ships engines. A few minutes later, after having
been contacted by VTS, the OOW zoomed in on the ECDIS display and realised
that the vessel was aground. He placed the starboard lever back to zero pitch
and called the Master, who came to the bridge.

During this period the general alarm was not sounded and the crew were not
mustered, although ballast tanks were checked for internal leaks and a visual
search was made around the ship for pollution. The vessel was refloated on the
next rising tide and subsequently berthed at a nearby port to enable the hull to be
inspected by divers.

Case Study 4
A self-unloading bulk carrier sailed in the morning after loading a cargo of
aggregates. The pilot disembarked soon after unberthing, and the vessel
proceeded at Full Ahead (about 12 knots) with the Master, 3/O and a helmsman
manning the bridge. Visibility was good with a moderate breeze. Besides the two
radars, the bridge team was using an ECDIS, on which, a safety contour of 10
metres (inappropriate, considering a sailing draught of 10.63 metres), a crosstrack deviation limit of 0.2 mile and an anti-grounding warning zone that covered
a narrow arc ahead to a range of about ten minutes steaming had been set.
About an hour after departure, the vessel entered a narrow strait, where the
Master instructed the helmsman to engage the autopilot on a heading of 290 and
handed over the con to the 3/O. He then proceeded to the communications desk
on the after port side of the bridge, increased the volume of a portable music
system and busied himself with sending routine departure messages. A few
minutes later, the vessel was approaching a planned waypoint requiring an
alteration of 24 to starboard to 314. At this time, the 3/O visually sighted an
inbound sailing vessel about 3 NM on the starboard bow. After coming on to the
new course on the autopilot, he decided to pass the sailing vessel to port and
adjusted the course to 321. Simultaneously, he observed another small vessel
about a mile away, right ahead and coming head on, and altered more to
starboard to 324. The ECDIS anti-grounding warning zone alarm then activated
on the display, but no audible alarm sounded, a deficiency not known at the time.
As a result, the 3/O, who was monitoring the situation from the forward console,
did not realise that the vessel was heading towards shoal ground. He also
sounded two long blasts on the ships whistle to alert the nearest vessel, which
soon passed clear to port. Thereafter, the 3/O focussed his attention on the
sailing vessel ahead, which was now about a mile away. Two minutes later, the
vessel ran onto a charted shoal at full speed. The severe vibrations lasted
several seconds. The Master ran to the ECDIS display and, recognising that his
vessel had run aground, instructed the helmsman to switch to manual steering
and ordered the wheel to hard-a-port. The sailing vessel also altered course to
port and the vessels narrowly avoided colliding. After he steadied the vessel on a
heading to return her to the planned track, the Master discovered that there was
water ingress in No 3(P) ballast deep tank. Further checks revealed no other
damage, and a preliminary report was sent to the office. Proceeding at reduced
speed, tank soundings confirmed that the ships pumps were able to cope with
water ingress. Nevertheless, the Master ordered the breached compartment to be
opened at sea and for a party consisting of the C/O, C/E and a seaman to
internally inspect the damage. After they identified a 3-metre longitudinal fracture
in the hull bottom plating, the inspection team safely vacated the tank and re-

secured its access. With companys and class approval, the vessel continued on
its short passage towards the discharge port, where, after unloading, she entered
drydock to effect permanent repairs

Case Study 5

Marine Inquiry 11-204: Container ship MV Rena grounding on Astrolabe Reef, 5 October
2011
The Liberian-registered container ship Rena had left the New Zealand port of Napier at 1020
on 4 October 2011 and was bound for the New Zealand port of Tauranga. The master had
given an estimated time of arrival at the Tauranga pilot station of 0300 the next day. The
master calculated the estimated time of arrival by dividing the distance to go by the Rena's
normal service speed. The calculation did not account for the unfavourable currents that
normally prevailed down that stretch of coastline.
After departure from Napier the master learned from notes on the chart of the unfavourable
currents. He then authorised the watchkeepers to deviate from the planned course lines on
the chart to shorten the distance, and to search for the least unfavourable currents.
The Rena's second mate took over the watch shortly after midnight on 4 October. He
calculated that the Rena would arrive at the port of Tauranga pilot station at 0300 at the
ships then current speed. Times for ships entering and leaving Tauranga Harbour are limited
by the depth of water and the strength of the tidal currents in the entrance channel.
Tauranga Harbour Control informed the second mate that the latest time the Rena could
take the harbour pilot on board was 0300.
The planned course to the Tauranga pilot station was to pass two nautical miles north of
Astrolabe Reef before making the final adjustment in course to the pilot station. The second
mate decided to reduce the two miles to one mile in order to save time. The second mate
then made a series of small course adjustments towards Astrolabe Reef to make the
shortcut. In doing so he altered the course 5 degrees past the required track and did not
make an allowance for any compass error or sideways "drift", and as a consequence the
Rena was making a ground track directly for Astrolabe Reef. Meanwhile the master had
been woken and arrived on the bridge to prepare for arrival at the port.
The master and second mate discussed preparations for arrival at the pilot station. The
master then assumed control of the ship, having received virtually no information on where
the ship was, where it was heading, and what immediate dangers to navigation he needed
to consider.
During this period of handover no-one was monitoring the position of the ship. At 0214 the
Rena ran aground at full speed on Astrolabe Reef. The ship remained stuck fast on the reef
and in the ensuing months it broke in two. The aft section moved off the reef and sank.

About 200 tonnes of heavy fuel oil were lost to the sea. A substantial amount of cargo in the
containers was lost. The vessel became a total loss on 11 October 2011.

Case Study 6

Pilot says Cosco Busan's captain directed vessel into bridge Wednesday, November
14, 2007, Demian Bulwa, Kevin Fagan,Carl Nolte, Chronicle Staff Writers
The pilot of the freighter that struck the Bay Bridge last week, fouling the bay with
58,000 gallons of fuel, told federal investigators that the accident occurred after the
ship's radar failed and the captain of the vessel made a monumental error, a lawyer
for the pilot said Tuesday. The most startling of the day's revelations came from
attorney John Meadows, who represents John Cota, the pilot of the Cosco Busan last
Wednesday. Cota said the Chinese captain of the ship guided the freighter toward a
bridge tower in the fog, the attorney said. Meadows said his client told him and
investigators for the National Transportation Safety Board, which is looking into the
crash, that the Cosco Busan's radar "conked out" flickered twice - first before
departure and again as the ship was near the lighthouse on Yerba Buena Island.
Cota was forced to rely on an electronic chart display, showing the track of the vessel
and its speed, plus charts of San Francisco Bay. Meadows said the pilot told him he
was "not familiar" with the electronic system on the Cosco Busan. "They are all
different," Meadows said. Cota asked Mao Cai Sun, the captain of the Cosco Busan,
to point on the display to the center of the bridge span between the Delta and Echo
towers on the western side of the Bay Bridge. "The master pointed that out,"
Meadows said. "In fact, several times during the trip. That's what the pilot was
heading for." The channel between the two towers is 2,210 feet wide and is marked
with a transponder device, which should have been picked up by radar or the
electronic chart, mariners say. The channel is commonly used by large ships going to
and from the Port of Oakland. "The pilot had to go along with what the master
indicated on the electronic chart display was the center of the span," Meadows said.
"That turned out to be the tower instead."
The Coast Guard's vessel traffic service says it warned Cota that the Cosco Busan was
off course shortly before the collision. Cota disputed that view, then changed course.
Moments later, while the ship was going 11 knots, the Chinese lookout in the ship's
bow shouted in Chinese and rang a warning bell, reporting that he could see the
bridge tower dead ahead. The pilot had the helm turn hard to the right, Meadows
said, and "that saved the ship from going head-on into the tower." Meadows said
problems also cropped up in "bridge management," the communication between
the pilot, who had years of experience on the bay, and the ship's officers, who had
never navigated the bay in the Cosco Busan. All were supposed to work together and
exchange information on how to successfully navigate the harbor.
"While some information was exchanged, perhaps it could be said it wasn't a full
transfer of information. It was enough for the pilot to work with the master and get

the ship ready for sea," Meadows said. Meadows said Cota gave his account to the
NTSB in a three-hour meeting Monday. NTSB investigators plan to examine the ship's
on-board voice and data recorder, which is supposed to pick up conversations
between the ship's operators.
Pilot Charges - 09 December 2007
A California maritime agency has filed misconduct charges against the American
captain at the helm of a Chinese container ship that hit the San Francisco-Oakland
Bay Bridge on Nov. 7, spilling 58,000 gallons of fuel and fouling 40 miles of shore.
The agency, the Board of Pilot Commissioners, accused the captain, John J. Cota, of
piloting the ship at an unsafe speed despite heavy fog that posed an obvious threat
in navigating the 900-foot vessel under bridge. Mr. Cotas lawyer, John Meadows,
would not answer questions on Friday, but has previously said Mr. Cota complained
about faulty equipment and radar that flickered as he tried to maneuver through a
narrow channel. The matter is in the hands of the State Board of Pilot Commission,
and we cannot comment, Mr. Meadows said. Mr. Cota is very sad at all the loss of
animal life and the threats to his career. Mr. Cota, a 25-year shipping veteran who
could lose his license, has 15 days to respond. He is entitled to a hearing before the
state panel, which cited errors in judgment and misconduct.
State suspends license of pilot who ran ship into bridge
Carl Nolte, Chronicle Staff Writer Saturday, December 1, 2007
The state has suspended the license of the ship pilot who was in charge of navigation
on the container ship Cosco Busan when it ran into the Bay Bridge last month. A
pending full investigation could cost him his job. Cota, 60, was piloting the Cosco
Busan when it sideswiped the bridge in a thick fog Nov. 7. The accident ruptured two
fuel tanks, spilling 58,000 gallons of heavy fuel oil into San Francisco Bay. The spill
spread to the bay's shoreline and ocean beaches from San Mateo County to Point
Reyes, killing more than 2,700 birds. Cota, a ship pilot for more than 26 years, has
been in difficulties with the pilot commission before. Last year, commissioners
reprimanded him after a ship he was piloting ran aground in the San Joaquin River
near Antioch. He was counseled on several other occasions for problems with his ship
handling.
In announcing the suspension of Cota's license at a meeting in San Francisco,
commission President Knute Michael Miller said the panel's action "should not be
viewed as prejudgment of pilot error." It is rare for the commission to suspend a
pilot's license. Miller, however, said doing so is "protocol when there is reason to
believe public interest requires it during an ongoing investigation.". Cotas attorney,
John Meadows, offered a vigorous defense, saying the commission was "rushing to
judgment ahead of time." Meadows has maintained that the master of the Cosco
Busan, who has been identified as Capt. Mao Cai Sun, gave the pilot "wrong
information" when the radar malfunctioned and that Cota was unable to decipher the

ship's electronic charts. "The master gave him (Cota) the wrong information,"
Meadows said. "And he repeated it three times."
Instead of heading toward the 2,210-foot channel between two bridge towers, the ship
ran into the wooden fenders at the base of one of the towers, ripping a 200-foot-long
scrape on its port side. After the commission meeting, Meadows said he has been
prevented from forming a full defense for his client because he has not been allowed
to speak to any member of the ship's Chinese crew, from captain on down. "I have
never had a case in my experience like this," he said. The commission's incident
review committee has until Dec. 13 to decide whether to bring misconduct charges
against Cota. He will be entitled to a full hearing before an administrative law judge if
he is accused. Cota's license could be suspended permanently or revoked if he is
found guilty.

NTSB member Debbie Hersman said the


Cosco Busan's crew members have hired
lawyers and are now declining to speak
to investigators, a roadblock that is
complicating the investigation. New
criminal and civil investigations have
apparently prompted the crew to refuse
interviews, she said. As for the crew
members, the NTSB can't force them to
talk. "We absolutely would prefer to be
able to interview all of the crew
members," Hersman said. "We'd like to
know what they were thinking. We'd
like to understanding what happened
with respect to communications and
decision-making." But if investigators
can't interview the crew, the NTSB will
still "conduct a thorough investigation
and determine probable cause" by using
information from the voyage-data
recordings and other sources, she said.

The Coast Guard has been criticized for


a lapse of several hours between when
officials knew the spill was 58,000
gallons -- not 140 gallons as initially
reported -- and when that information
was made public. Congressman and
subcommittee chairman Elijah
Cummings (D-Maryland) said he is
concerned the Coast Guard was
unprepared for the spill or unaware of
the extent of the disaster. He wants to
find a better way to handle such an event
in the future. "There is an extreme
difference between the 140 gallons of
spilled oil initially reported by the Coast
Guard and the nearly 60,000 gallons that
we now hear have been spilled,"
Cummings said. "The hearing will
examine the adequacy of the system for
reporting oil spills and the effectiveness
of the Coast Guard response."

Jan 18 Feds Probe Ship Pilot's Drug Use SAN FRANCISCO (AP)

The ship pilot who was at the helm when a freighter spilled 58,000 gallons of fuel into San
Francisco Bay in November suffers from a sleep disorder and was on prescription
medication to ward off drowsiness, people close to the investigation told The Associated
Press. Investigators want to know whether the disorder, or even the medication itself,
contributed to the accident. Federal officials and others, speaking on condition of
anonymity, said John Cota has sleep apnea, a breathing condition that can disrupt sleep all
night long and leave sufferers severely fatigued during the day. Sleepapnea is blamed for
countless auto accidents every year in which drivers nodded off at the wheel. Cota, 59, was
also said to be taking a sleep-apnea drug whose known side effects include impaired
judgment. Under Coast Guard policy, a sleep disorder can be grounds for disqualification,
but is not automatically so

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