The National Transportation Safety Board has released its report on the Cosco Busan incident (quick and dirty summary in the San Francisco Chronicle’s article here).

From the Executive Summary:

The National Transportation Safety Board determines that the probable cause of the
allision of the Cosco Busan with the San Francisco–Oakland Bay Bridge was the failure to safely
navigate the vessel in restricted visibility as a result of (1) the pilot’s degraded cognitive
performance from his use of impairing prescription medications, (2) the absence of a
comprehensive pre-departure master/pilot exchange and a lack of effective communication
between the pilot and the master during the accident voyage, and (3) the master’s ineffective
oversight of the pilot’s performance and the vessel’s progress. Contributing to the accident was the failure of Fleet Management Ltd. to adequately train the Cosco Busan crewmembers before their initial voyage on the vessel, which included a failure to ensure that the crew understood and complied with the company’s safety management system. Also contributing to the accident was the U.S. Coast Guard’s failure to provide adequate medical oversight of the pilot in view of the medical and medication information that the pilot had reported to the Coast Guard.

The following safety issues were identified during this accident investigation:
• Medical oversight of the Cosco Busan pilot;
• Medical oversight of mariners in general;
• Guidance for vessel traffic service operators in exercising authority to manage traffic;
• Procedures for improving the assessment of oil spills in California waters; and
• Training and oversight of the Cosco Busan crew.

Board member Deborah A.P. Hersman issued her own statement in dissent, identifying her criticism of the Coast Guard’s Vessel Traffic Service (VTS):

The taxpayers support 35 employees at VTS San Francisco to provide this protection and enforce discipline in an industry of safe professionals who may be imprudently influenced by economic pressures and who may occasionally make mistakes. VTS San Francisco’s stated purpose is to facilitate the safe and efficient transit of vessel traffic in an effort to prevent collisions, rammings, groundings, and the associated loss of life and damage to property and the environment. By not naming VTS as a contributing factor in the probable cause, the Board turned a blind eye to the public’s strongest safety advocate in the San Francisco Bay.