|
The ''Cosco Busan'' oil spill occurred at 08:30 UTC-8 on 7 November 2007 between San Francisco and Oakland, California, in which of IFO-380 heavy fuel oil, sometimes referred to as "bunker fuel", spilled into San Francisco Bay after the container ship ''Cosco Busan'', operated by Fleet Management Ltd., struck Delta Tower of the San Francisco – Oakland Bay Bridge in thick fog. Investigators found that maritime pilot John Cota was impaired because of his use of prescription pharmaceuticals while piloting the container vessel, which rendered him unable to use the onboard radar and electronic navigation charts correctly. This occurred despite the fact that the Vessel Traffic Service of the United States Coast Guard warned Cota that the vessel was headed for the bridge. Cota was sentenced to 10 months in federal prison for his role in the incident. Then California Governor Arnold Schwarzenegger declared a state of emergency after meeting federal, state and local officials overseeing the cleanup. The proclamation made additional state personnel, funding and equipment available to assess and clean up the environmental damage. == Causes == The National Transportation Safety Board determined the following probable causes of the accident: #the pilot's degraded cognitive performance from his use of prescription medications, despite his completely clean post accident drug test, #the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between Pilot John Cota and Master Mao Cai Sun during the accident voyage, and # (''Cosco Busan'' Master) Sun's ineffective oversight of Cota's piloting performance and the vessel's progress. Other contributing factors included:〔 #the failure of Fleet Management Ltd. to train ''Cosco Busan'' crewmembers (which led to such acts of gross negligence as the bow lookout eating breakfast in the galley instead of being on watch) and Fleet Management's failure to ensure that the crew understood and complied with the company's safety management system; # the failure of Caltrans to maintain foghorns on the bridge which were silent despite the heavy fog;〔bridge recording from Cosco Busan〕 # the failure of Vessel Traffic Safety (VTS) to alert Cota and Sun that they were headed for the tower. VTS is legally required to alert a vessel if an accident appears imminent, yet they remained silent;〔 # the malfunctioning radar on ''Cosco Busan'', which led Captains Cota and Sun to use an electronic chart for the rest of the voyage. Although Coast Guard investigators found the radar to be in working order, they did not examine it until days after the accident (allowing time for faulty equipment to be fixed, which is not uncommon after a marine accident) # Captain Sun's incorrect identification of symbols on the electronic chart; # the U.S. Coast Guard's failure to provide adequate medical oversight of Cota, in view of the medical and medication information he had reported to the Coast Guard.〔 In addition, investigations conducted by independent experts from the international maritime community also highlighted the potential effects of insufficient Human-machine interface design, contributing to such accidents even though "human error" is often directly used as the main cause without further investigating shortcomings in the HMI. This is, even though HMI has been accepted as a significant factor in aviation accidents for many decades: 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「Cosco Busan oil spill」の詳細全文を読む スポンサード リンク
|