DEPARTMENT OF HOMELAND SECURITY 

Office of Inspector General 

Allision of the M/V COSCO BUSAN With 

the San Francisco-Oakland Bay Bridge
 

OIG-08-38 April 2008
 

 

 

 Office of Inspector General 

U.S. Department of Homeland Security 

Washington, DC 20528

 April 9, 2008 

Preface 

The Department of Homeland Security (DHS) Office of Inspector General (OIG) was 

established by the Homeland Security Act of 2002 (Public Law 107-296) by amendment 

to the Inspector General Act of 1978. This is one of a series of audit, inspection, and 

special reports prepared as part of our oversight responsibilities to promote economy, 

efficiency, and effectiveness within the department. 

This report presents the results of our review of the U.S. Coast Guard’s response to the 

November 7, 2007, allision of the M/V COSCO BUSAN with the San Francisco-Oakland 

Bay Bridge. The review was conducted pursuant to a request from the Speaker of the 

House of Representatives and the Chairman, Subcommittee on Coast Guard and 

Maritime Transportation. It is based on interviews with employees and officials of 

relevant agencies and institutions, direct observations, and a review of applicable 

documents. 

The recommendations herein have been developed to the best knowledge available to our 

office, and have been discussed in draft with those responsible for implementation. It is 

our hope that this report will result in more effective, efficient, and economical 

operations. We express our appreciation to all of those who contributed to the 

preparation of this report. 

Richard L. Skinner 

Inspector General 
Table of Contents/Abbreviations 

Executive Summary.............................................................................................................1
 

Background..........................................................................................................................2 

Results of Review ................................................................................................................4 

Vessel Traffic Service...............................................................................................4 

Recommendations.....................................................................................................9 

 Management Comments and OIG Analysis ...........................................................10 

 Marine Casualty and Pollution Investigation..........................................................11 

Recommendations ..................................................................................................16 

 Management Comments and OIG Analysis ...........................................................16 

Coast Guard Response (First 24 Hours) .................................................................18 

Recommendations...................................................................................................32 

 Management Comments and OIG Analysis ...........................................................33 

 Sector Implementation............................................................................................35 

 Medical Waivers for Federal Pilots ........................................................................35 

Appendices 

Appendix A: Purpose, Scope, and Methodology 

Appendix B: Management Comments to the Draft Report 

Appendix C: Letter from Speaker of the House, Nancy Pelosi, and the Honorable 

Elijah E. Cummings

 Appendix D: San Francisco Area Contingency Plan Authorities 

Appendix E: San Francisco Area Committee Attendance 

Appendix F: Major Contributors to this Report 

Appendix G: Report Distribution 

Allision of the M/V COSCO BUSAN with the San Francisco-Oakland Bay Bridge 
 

Table of Contents/Abbreviations 

Abbreviations 

CGVTS Coast Guard Vessel Traffic System 

FOSC Federal On-Scene Coordinator 

ICS Incident Command System 

MISLE Marine Information for Safety and Law Enforcement 

MOA Memorandum of Agreement 

MSRC Marine Spill Research Corporation 

M/V Motor Vessel 

NIMS National Incident Management System 

NRC National Response Corporation 

NTSB National Transportation Safety Board 

OPA Oil Pollution Act of 1990 

OSC On-Scene Coordinator 

OSPR Oil Spill Prevention and Response (State of California (CA)) 

OSRO Oil Spill Response Organization 

PAWSS Ports and Waterways Safety System 

RACONS Radar Beacons 

SCC Sector Command Center 

SOSC State On-Scene Coordinator 

VTS Vessel Traffic Service 

Allision of the M/V COSCO BUSAN with the San Francisco-Oakland Bay Bridge 
 

Executive Summary 

This report presents the results of our review of the U.S. Coast Guard’s response 

to the November 7, 2007, allision of the M/V COSCO BUSAN with the San 

Francisco-Oakland Bay Bridge. We assessed: (1) the actions of the Coast Guard 

San Francisco Vessel Traffic Service operations center prior to the allision; (2) the 

performance of the Coast Guard’s pollution and marine casualty investigation; 

and (3) the Coast Guard’s response during the first 24 hours following the mishap. 

The Coast Guard’s actions prior to and for the first 24 hours following the allision 

were generally consistent with the policies and procedures in place for the San 

Francisco Sector at the time of the mishap. We determined, however, the Coast 

Guard needs a national standard operating procedures doctrine for its Vessel 

Traffic Service program. Also, the guidelines for vessel movement during 

periods of restricted visibility need to be expanded and clarified. 

A number of factors in the post-accident investigation will hinder the 

government’s ability to identify all of the factors contributing to the mishap. 

Specifically, communications and navigation equipment was not secured and 

tested. In addition, the M/V COSCO BUSAN crewmembers and Vessel Traffic 

Service watchstanders were not properly and timely tested for drugs and alcohol. 

Response to an oil spill is a multifaceted and multilayered effort requiring both an 

autonomous and cooperative response on the part of each stakeholder. This 

mishap highlighted the need for federal, state, and local agencies to become 

involved early and often in Area Committee meetings and exercises. Much of the 

credit for the success of the response is due to the efforts of the Coast Guard, the 

State of California Oil Spill Prevention and Response Division, and the 

Responsible Party. 

We are making nine recommendations to improve the effectiveness of Vessel 

Traffic Service operations, post-casualty investigations, and area contingency 

plans. To its credit, the U.S. Coast Guard is taking or planning to take actions to 

implement all recommendations. 

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Background 

On November 7, 2007, at 8:30 a.m. with a reported visibility of approximately 

one-eighth to one-quarter mile due to heavy fog, the M/V (Motor Vessel) COSCO 

BUSAN, underway from Oakland, California, allided with the San FranciscoOakland Bay Bridge. This allision created a large gash (100 ft x 12 ft, located 2-

10 ft above waterline) in the port side of the vessel, which caused an estimated 

53,653 gallons of fuel oil to spill into the San Francisco Bay and coat the 

surrounding shoreline. Prior to the allision, the U.S. Coast Guard's (Coast Guard) 

San Francisco Vessel Traffic Service (VTS) was communicating with the vessel 

as well as monitoring its progress. Following the allision, the Coast Guard, State 

of California Oil Spill Prevention and Response (OSPR) Division, as well as the 

Responsible Party responded to this maritime mishap, initiated a post-mishap 

marine casualty and pollution investigation, and coordinated the clean-up effort. 

Due to concerns about the subsequent Coast Guard response and investigation, 

Speaker Nancy Pelosi and Chairman Elijah Cummings requested a 30-day brief 

and a 90-day review of this mishap (see Appendix C). The 30-day brief was 

conducted on February 12, 2008, focused on their concerns in three areas: VTS, 

Coast Guard investigation, and Coast Guard response. This report provides 

responses to the specific questions put forward by the Congress. 

The San Francisco VTS operations 

center, located on Yerba Buena Island, 

California, has an area of responsibility 

that includes oceanic departures and 

arrivals for the San Francisco Bay and 

waterways that stretch approximately 

133 miles from off shore, through the 

San Francisco Bay area, to the ports of 

Sacramento and Stockton, California. 

The primary function of the San 

Francisco VTS is to facilitate order and 

predictability on waterways by 

coordinating vessel movements. The 

San Francisco VTS is operated by the 

Coast Guard with a combined military 

and civilian staff. A four-person watch 

team mans the VTS command center. In 

2007, the San Francisco VTS center 

managed the transit of 124,762 vessels in 

its area of responsibility. 

Immediately following the allision, the Coast Guard’s Sector San Francisco 

Response and Prevention Departments initiated a pollution investigation and a 

Source: San Francisco Chronicle 

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marine casualty investigation. The purpose of a Coast Guard investigation is to 

determine the cause of a mishap, whether any remedial measures should be taken, 

and whether any violation of federal law or regulation has occurred.1 

The Coast Guard is the lead federal agency for oil spill threats within or 

threatening coastal zones.2 The Coast Guard is also responsible for designating 

Federal On-Scene Coordinators (FOSC) for each region; the Coast Guard Captain 

of the Port is normally designated the FOSC for the ports and waterways under 

his/her jurisdiction. The Coast Guard’s first priority in oil spill response is that of 

public health and safety, followed by the actual response to the oil spill. In this 

mishap, the immediate public safety concern was not the oil spill, but instead was 

the physical condition of the San Francisco-Oakland Bay Bridge. 

Coastal oil spills in the State of California are jointly managed by the Coast 

Guard, OSPR, and the Responsible Party. See Appendix D for a brief overview 

of the oil spill response and management authorities. 

Source: San Francisco Chronicle M/V COSCO BUSAN at Anchor 

1 Coast Guard Marine Safety Manual Volume V, Ch. 1, A.1., p. 1-1 (Investigative Principles). 2

 40 CFR Part 300, National Oil and Hazardous Substances Pollution Contingency Plan. 

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Results of Review 

Vessel Traffic Service 

The San Francisco VTS watchstanders followed their operating procedures for 

vessel movement the morning that the M/V COSCO BUSAN allided with the San 

Francisco-Oakland Bay Bridge. The watchstanders acknowledged the pilot's 

intentions to get underway and his intended route, and provided advisories for 

other vessel traffic that could affect the ship's transit through the San Francisco 

Bay. The watchstanders appropriately notified the pilot that visibility had been 

reported to be less than one-quarter mile all the way out to the Golden Gate 

Bridge. They also monitored the movement of the M/V COSCO BUSAN and 

queried the vessel when they became concerned about the vessel's heading. 

Given the current operating procedures and technical capabilities, there were no 

additional actions the VTS watchstanders could reasonably have taken to prevent 

the allision. However, we identified areas for improvement in the VTS program, 

including the need for a VTS national standard operating procedure and criteria 

for limiting the movement of vessels during periods of reduced visibility. 

VTS Standard Operating Procedures 

The Coast Guard does not have a VTS national standard operating procedure. 

Currently, the individual VTSs create their own local procedures based on 

guidance provided in the Coast Guard’s Marine Safety Manual. The Manual only 

provides general concepts for VTS operations and not specific requirements for 

equipment operation, emergency procedures, or drug and alcohol testing for all 

VTS centers. 

For example, the Manual does not address synchronization of radio 

communications and vessel automatic identification system data received by VTS 

centers. The San Francisco VTS operations center has the capability to record 

radio communications and automatic identification system data transmitted by 

vessels in its operating area. However, on November 7, 2007, the VTS and the 

M/V COSCO BUSAN transmissions were not synchronized to the same time 

mark. According to the Coast Guard, it is suspected that the timing signals for the 

recorded data were not resynchronized following maintenance of the San 

Francisco VTS equipment approximately a month prior to the allision. The 

failure to synchronize recorded data impairs the ability of investigators and other 

interested parties to accurately recreate the chain of events leading up to and 

following an incident. 

Additionally, the San Francisco VTS operations center did not have the correct 

quick response sheets to guide watchstander actions following an incident. The 

San Francisco VTS and Sector command centers use quick response sheets to 

guide the actions of watchstanders and to promote quick and orderly notification 

Allision of the M/V COSCO BUSAN with the San Francisco-Oakland Bay Bridge 

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of interested parties when an incident occurs. The quick response sheets that the 

VTS operations center had were those of the San Francisco Sector Command 

Center and were not tailored to meet the requirements of the VTS watchstanders. 

This may contribute to delays in reporting critical information following incidents 

in the future. 

Furthermore, according to the Coast Guard, the watchstanders were not tested due 

to a lack of awareness of the drug and alcohol testing policies. For example, 

Sector San Francisco did not comply with the VTS program manager’s practice of 

conducting post-incident drug and alcohol testing of the VTS watchstanders on 

duty when the M/V COSCO BUSAN allided with the San Francisco-Oakland Bay 

Bridge. By not administering the drug and alcohol tests, the Coast Guard is 

unable to positively rule out impairment of the VTS watchstanders as a 

contributing factor to the incident. Additional details concerning drug and alcohol 

testing are provided in the Marine Casualty and Pollution Investigation section of 

this report. 

Source: Coast Guard San Francisco VTS watchstander station 

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Specific Questions 

The San Francisco VTS watchstanders 

followed their operating procedures 

for vessel movement the morning that 

the M/V COSCO BUSAN allided 

with the San Francisco-Oakland Bay 

Bridge. The VTS watchstanders also 

complied with the procedures for 

managing vessel movement during 

periods of restricted visibility, 

including reading 

What action did the 

watchstanders at the Coast 

Guard's Vessel Traffic 

System take prior to the 

allision? 

back the vessel's plan for transiting the San Francisco Bay and 

reporting all traffic that could affect the vessel's transit. Table 1 provides a 

timeline of communications between the VTS center and the M/V COSCO 

BUSAN. 

Table 1 

Communications Between the Vessel Traffic Center and the 

M/V COSCO BUSAN Prior to the Allision on November 7, 2007 

0635 

The pilot onboard the M/V COSCO BUSAN reports to the VTS that he is 

preparing to depart Oakland for sea. At this time, the VTS center informs the 

pilot that the visibility was one-eighth to one-quarter mile all the way to the 

Golden Gate Bridge. Additionally, the VTS center confirms the vessel's 

intended track, which included transiting between the Delta and Echo 

columns of the San Francisco-Oakland Bay Bridge. 

0806 The pilot notifies the VTS center that the M/V COSCO BUSAN is getting 

underway. The VTS center acknowledges that the vessel is underway and 

reads back the vessel's intentions for transiting the San Francisco Bay, 

including passage of the vessel between the Delta and Echo columns of the 

San Francisco-Oakland Bay Bridge. 

0827 The VTS center asks the pilot whether he still intends to head out to sea and 

advises that the VTS center's equipment indicates the vessel is on a 235-

degree heading. The pilot responds that the vessel is coming around and 

that he is steering 280 degrees. 

0828 

0830 

In response to a query from the VTS center, the pilot informs the VTS center 

that it is still his intention to pass beneath the Delta Echo span of the bay 

bridge. 

The pilot informs the VTS center that he has "touched" the bay bridge. 

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Was there additional action 

that could have been taken or 

information that could have 

been provided by the 

watchstanders that may have 

prevented the allision? 

The VTS watchstanders on duty 

before the accident could not have 

taken any additional action that 

would have prevented the casualty. 

A time lag between a maneuver 

that a vessel is executing and the 

vessel movement data displayed in 

the VTS operations center 

precluded this possibility. For 

example, the VTS contacted the 

pilot onboard the M/V COSCO BUSAN pilot at 8:27 a.m. (see Table 1) to advise 

him that the VTS center’s equipment indicated that the vessel was on a 235-

degree heading; the pilot informed the VTS operations center that the vessel was 

executing a turn and that he was steering 280 degrees. By the time the VTS 

watchstanders recognized that the M/V COSCO BUSAN appeared to be out of 

position to pass between the Delta and Echo columns of the San FranciscoOakland Bay Bridge, the vessel had already started to execute its turn towards the 

bridge column. 

To its credit, the San Francisco VTS operations center has recently implemented 

procedures that require augmentation of the existing offshore and San Francisco 

Bay watchstanders with a fourth watchstander during low visibility. This fourth 

watchstander now assists the others with providing radar traffic advisories to 

vessels when visibility is a half-mile or less. The low visibility watchstander's 

duties include temporary zooming of electronic displays in order to enhance the 

ability to assess risk and issue advisories. VTS watchstanders said that previously 

they rarely zoomed their displays down to a smaller scale due to a loss of 

situational awareness for their area of responsibility. 

Does the San Francisco VTS 

center have the most up-todate technology? 

The San Francisco VTS operations 

center does not have the most upto-date traffic technology. The 

system used by the San Francisco 

VTS operations center is the Coast 

Guard Vessel Traffic System 

(CGVTS), which was installed in 

the 1990s. According to the Coast Guard, this system meets the agency’s 

requirements for vessel traffic management and has received regular software 

upgrades to enhance and maintain system capability. 

The CGVTS provided improvements over prior manual tracking of vessels by 

integrating data received from multiple sensors including radar, radio 

communications, and video. CGVTS was originally deployed in four ports, 

including San Francisco, California. The newer and more advanced vessel traffic 

management system, the Ports and Waterways Safety System (PAWSS), was only 

Allision of the M/V COSCO BUSAN with the San Francisco-Oakland Bay Bridge 

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partially installed at the San Francisco VTS operations center due to funding 

constraints that existed in 2003 and 2004 towards the end of the acquisition 

program. The partial installation nonetheless provided automatic identification 

system capabilities that were not available with the original installation of the 

CGVTS. 

Under the current CGVTS software capabilities, the electronic chart display data 

does not provide the VTS watchstander the option of zooming in and displaying 

the location of the individual San Francisco-Oakland Bay Bridge columns. With 

such capability, the VTS watchstanders could improve their situational awareness 

of vessel proximity and orientation to the individual bridge columns. A planned 

upgrade to CGVTS (version 4.6) will enable the VTS watchstanders to display the 

bridge columns. 

The San Francisco VTS already has 

the authority (capability) to prohibit 

the transit of larger commercial 

vessels and passenger ferries during 

periods of reduced visibility.3 Only 

on rare occasions does the Coast 

Guard direct the movement or actions 

of a VTS participant. These rare 

occasions have occurred when VTS watchstanders have observed obvious 

violations of regulations or dangerous conditions about which a participant may be 

unaware. 

Should VTS have the 

capability of prohibiting 

ship transits during periods 

of reduced visibility? •

Additionally, the VTS has the authority to institute and enforce measures to 

enhance navigation and vessel safety and to protect the marine environment. This 

authority includes managing vessel entry and movement, or departure to, from, or 

within a VTS area during hazardous conditions, such as restricted visibility. 

However, San Francisco VTS’ operational procedures do not currently provide 

watchstanders with the criteria necessary for determining the specific measures 

and when they should be implemented during varying conditions of restricted 

visibility. Without well-defined criteria, VTS watchstanders could fail to 

implement vessel movement measures when they are prudent or could implement 

vessel movement measures that are overly restrictive for the existing conditions. 

To their credit, the Coast Guard and the San Francisco Harbor Safety Committee 

are taking a proactive approach to preventing future occurrences of maritime 

accidents similar to the M/V COSCO BUSAN's allision with the San FranciscoOakland Bay Bridge. The Harbor Safety Committee determined that the 

guidelines for vessel movement during periods of restricted visibility need to be 

expanded and clarified. The Harbor Safety Committee is considering adding a 

number of guidelines that would advise against vessel movement during periods 

3

 33 CFR Part 161; Vessel Traffic Management. 

Allision of the M/V COSCO BUSAN with the San Francisco-Oakland Bay Bridge 

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of restricted visibility in specific locations within the San Francisco Bay. 

Specifically, the committee is considering the identification of critical 

maneuvering areas through which large vessels should not transit if visibility is 

below one-half mile. For example, the Oakland Bar Channel has been identified 

as a critical maneuvering area due to its proximity to the Bay Bridge and Yerba 

Buena Island. 

The Harbor Safety Committee also is considering the recommendation that 

vessels, when the visibility is one-half mile or less at the dock, remain at dock or, 

when proceeding to dock, should anchor unless proceeding to dock is the safest 

option. If these additional guidelines are adopted, they will be incorporated into 

the Harbor Safety Plan, San Francisco VTS' operational procedures, and the San 

Francisco Bar Pilots’ Operations Guidelines. Such new guidelines would 

represent a positive move toward increased maritime safety in the San Francisco 

Harbor.4 

Would additional Coast 

Guard authority over vessel 

traffic help prevent this type 

of situation? 

•

Current legislation already provides 

the Coast Guard with the authority 

over vessel traffic necessary to 

protect life, property, and the 

marine environment. It would be 

speculative to suggest that 

additional Coast Guard authority 

over vessel traffic in and of itself 

would prevent future mishaps in the San Francisco Bay. The Coast Guard would 

need to reevaluate several aspects of its VTS program before a decision can be 

made to change the VTS operations center’s role from being primarily a 

navigational and advisory service tool to one which exercises direct control over 

all vessel movement, similar to that of an air traffic control center. The Coast 

Guard would also need to determine whether VTS operations center equipment 

capability, manpower, training, and funding requirements are adequate for this 

expanded role, as well as assess the implications of potential liability should a 

mishap occur while a vessel was complying with VTS operations center direction. 

Recommendations 

We recommend that the Commandant of the Coast Guard: 

Recommendation #1: Ensure expedient issuance of the VTS National 

Standard Operating Procedures, which should address: (1) requirements 

4 The San Francisco Harbor Safety Committee is a state-mandated body that consists of representatives 

from commercial, private, and federal maritime communities, including port operators, commercial 

shipping, passenger ferries, the National Oceanic and Atmospheric Administration, U.S. Army Corps of 

Engineers, Coast Guard, the U.S. Navy, and environmental organizations. 

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for post-mishap drug and alcohol testing for VTS watchstanders; (2) 

establishment of policy to ensure that all VTS operations centers 

synchronize recorded audio, video, and track data, along with quality 

assurance checks to ensure the quality and synchronization of that data; 

and (3) development of VTS operations center-specific quick response 

sheets. 

Recommendation #2: In coordination with the cities of San Francisco 

and Oakland, the San Francisco Pilot's Association, and the San Francisco 

Harbor Safety Committee, develop criteria to limit vessel movement 

during varying conditions of restricted visibility. 

Management Comments and OIG Analysis 

The Coast Guard concurred with the above findings and 

recommendations in the report. Both recommendations will remain 

open until the VTS National Standard Operating Procedures are 

issued and our analysis determines the procedures adequately address 

our recommendations. Coast Guard's complete management 

comments to this report are provided in Appendix B. 

The Coast Guard provided supplemental and technical comments to 

the draft report. We reviewed the comments and made revisions as 

appropriate. 

Management Comments to Recommendation #1: CONCUR 

The Coast Guard concurred with our recommendation for 

expedient issuance of the VTS National Standard Operating 

Procedures. According to the Coast Guard, the standard operating 

procedures, which are in final draft form, will address 

requirements for post-incident drug and alcohol testing. Further, 

the synchronization of VTS equipment and the development of 

VTS-specific quick response sheets will be included in future 

changes to the standard operating procedures. 

OIG Analysis 

We agree with the actions the Coast Guard plans on taking to address 

the intent of our recommendation. The Coast Guard needs to ensure 

the timely issuance of the standard operating procedure which have 

been under development for several years. This recommendation will 

remain open until the Coast Guard issues the VTS National Standard 

Operating Procedures. 

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Management Comments to Recommendation #2: CONCUR 

The Coast Guard concurred with our recommendation for the 

development of criteria to limit vessel movement during varying 

conditions of restricted visibility. According to the Coast Guard, it 

is involved with the development of local policies affecting vessel 

movement, including the affects of extreme environmental 

conditions. Once the policies are finalized, the VTS will ensure 

that specific procedures are developed and documented in its 

operating procedures, and watchstanders are trained to implement 

them. 

OIG Analysis 

We agree with the actions the Coast Guard plans on taking to address 

the recommendation. This recommendation is resolved but will 

remain open until Coast Guard provides us documentation 

demonstrating that the policies have been finalized and incorporated 

in the VTS' operating procedures and training curriculum. 

Marine Casualty and Pollution Investigation 

Deficiencies in the Sector San Francisco’s marine casualty and pollution 

investigation of the allision of the M/V COSCO BUSAN resulted in a lost 

opportunity to collect and preserve all evidence relevant to this mishap. Further, 

although the initial estimate of the amount of oil spilled was inaccurate, the Coast 

Guard based its initial response to the oil spill on a worst case scenario rather than 

on the initial estimate. A more accurate estimate earlier in the day would have 

been ideal, and was also possible; however, both the Coast Guard and the 

California State Office of OSPR reported that such an estimate would not have 

altered the response of the Unified Command, which includes the Coast Guard 

and the State of California. Considering the lack of consistent information 

immediately following the allision, the Coast Guard’s assumption on which it 

based its response efforts was both adequate and appropriate. 

Experience and Training 

The level of experience and training of the investigators, as well as inadequate job 

aids used by the investigators, may have contributed to deficiencies in collecting 

and preserving evidence related to the mishap. During the M/V COSCO 

BUSAN’s outbound transit from the Oakland Inner harbor, visibility was 

estimated to be less than one-quarter mile. Therefore the pilot, master, and bridge 

team relied on the vessel’s navigational systems, and nearby fixed and floating 

aids-to-navigation to transit the Oakland Bar Channel and approach the San 

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Francisco-Oakland Bay Bridge. The navigational systems include the global 

positioning system, Electronic Chart Display and Information System, and 

collision-avoidance system of the vessel. The pilot also relied on radar beacons 

(RACONS) affixed to the Bay Bridge that were intended to mark the center of the 

delta-echo span of the bridge. These RACONS were installed and maintained by 

the California Department of Transportation.5 

Immediately following the mishap, Sector San Francisco dispatched three marine 

casualty investigators to the scene. Upon arrival, they collected a wide array of 

evidence (charts, logbooks, and other miscellaneous documentation). They also 

initiated breathalyzer testing of the M/V COSCO BUSAN master and bridge 

team. They did not, however, take action to secure critical aids to navigation (i.e., 

RACONS) or the vessel’s communications and navigational systems to ensure 

that they were fully operational. The marine casualty investigators also did not 

secure the Voyage Data Recorder, because they were unaware of its existence on 

the vessel. Nonetheless, the Voyage Data Recorder captured the settings and 

output from the M/V COSCO BUSAN’s communications and navigational 

equipment, thereby helping the investigators recreate the events that occurred 

prior to and during the allision. 

Marine casualty investigators did not drug and alcohol test VTS watchstanders on 

duty during the mishap. 46 CFR § 4.07-1 states that marine casualty 

investigations are responsible for determining, whether the Coast Guard caused or 

contributed to the cause of the mishap and whether further investigation is 

warranted. By not conducting drug and alcohol testing, the opportunity to rule 

out physical or mental impairment as a contributing cause of the mishap was lost. 

Neither the current Job Aid nor the Marine Safety Manual referred to the drug and 

alcohol testing policies set forth in the Coast Guard Personnel Manual and 

Department of Transportation Order 3910.1C. Drug and alcohol testing should 

have been part of normal investigative practices regardless of these requirements. 

Failing to secure shipboard systems and aids to navigation, or conducting drug 

and alcohol testing may be attributed to the level of training and qualifications of 

the individuals assigned to the M/V COSCO BUSAN investigation. For example, 

the three individuals assigned to the investigation were not qualified marine 

casualty investigators. However, according to a Sector San Francisco standard, 

they were permitted to conduct investigations under the supervision of a fully 

qualified marine casualty investigator, and according to Coast Guard, this did 

occur. Further, five of the six investigators assigned to marine casualty 

investigation billets at Sector San Francisco were not qualified at the time of the 

mishap. The training and qualifications of the investigators assigned raise doubts 

about the quality of marine casualty investigations conducted by Sector San 

Francisco. 

5

 RACONS are radio beacons that return a Morse Code signature signal indicating range and bearing when 

triggered by a radar interrogator. 

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Specific Questions 

Was the Coast Guard’s initial 

investigation, including the 

securing of evidence and 

estimation of the extent of the 

oil release, adequate? 

A number of deficiencies in the Coast 

Guard’s post-accident investigative 

efforts may have hindered the 

government’s ability to identify all of 

the factors, circumstances, and 

conditions that led to the M/V 

COSCO BUSAN allision and oil spill. 

Investigation Classification 

The Coast Guard misclassified the marine casualty investigation of the M/V 

COSCO BUSAN. Coast Guard casualty investigation classification criteria 

include a minimum threshold for property damage. In the M/V COSCO BUSAN 

mishap, the property damage was estimated by the Coast Guard to be well above 

the minimum threshold for a formal investigation. Additionally, although the 

amount of oil spilled did not meet the quantitative measures of a major spill under 

the law, it did meet the requirement that an oil spill is considered to be major, 

regardless of the quantity spilled, if that spill “. . . poses a substantial threat to 

public health or welfare of the U.S. or the environment or results in significant 

public concern. . . ”7

 As such, the M/V COSCO BUSAN investigation should 

have been classified as formal. 

Both informal and formal investigations require that Coast Guard investigators 

generate a timeline of events, conduct causal/human error analysis, draw 

conclusions, and issue safety recommendations if warranted. A formal 

investigation also requires that there be evidence to corroborate every fact, which 

makes the preservation and securing of evidence critical. In this mishap, as 

previously stated, the investigators did not take action to secure the ship's 

communications and navigational equipment and the privately-maintained radar 

beacons (RACONS) affixed to the San Francisco-Oakland Bay Bridge for the 

purpose of conducting independent post-accident testing. Additionally, the 

marine casualty investigators did not take steps to ensure drug and alcohol testing 

of VTS watchstanders. This resulted in the inability to identify all potential 

contributing causes in Coast Guard’s investigation and may impede the ability of 

other investigations to determine the probable cause. This also hinders the 

institution of measures to prevent similar mishaps from occurring in the future. 

7

 40 CFR § 300.5. 

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Estimation of Oil Released Into the Bay 

Information collected by the Coast Guard and provided by the crew of the M/V 

COSCO BUSAN within the first hour of the allision varied, hindering an accurate 

estimate of the extent of the oil spill. Due to the uncertainties about the initial 

estimate of 142 gallons, the photograph of the damage to the ship, and the 

observations of the oil on the water by Pollution Investigators, the Coast Guard’s 

Response Department assumed that the spill was likely greater than first 

estimated. 

Methods to quantify the volume of oil discharged from a ship, as described by the 

Coast Guard’s Response Department, include observation and calculations of the 

dimensions of oil visible on the water, review of the ship’s oil log book to 

determine the amount of oil originally onboard, and sounding the ship’s fuel and 

oil tanks to determine the amount of oil left in the tanks. 

A number of factors prevented the Coast Guard from using these methods to 

quantify the volume of oil discharged from the ship. The dense fog on the day of 

the mishap made it impossible for the Coast Guard to conduct observation flights 

until later that same afternoon. Observation flights would have provided an 

immediate overview of the size and location of the oil spill. In addition, pollution 

investigators at Sector San Francisco currently have limited experience with the 

heavy bulk oil spilled, and have more experience with light oil or sheen, which 

may have hindered their ability to determine density or dimensions. Due to 

language problems between the pollution investigator and the ship’s chief 

engineer, the Coast Guard was not able to verify the accuracy of the figures in the 

oil logbook or on the ship’s gauges. Finally, pollution investigators are not 

trained to sound ships’ tanks without the assistance and cooperation of the crew. 

Due to the technical complexities, this function is normally performed by the 

vessel’s crew under the oversight of a qualified casualty investigator or by an 

independent contractor. 

Based on the available though varying information, the Coast Guard made the 

assumption that the first estimate of 142 gallons was not accurate. 

Representatives of the Coast Guard’s Response Department stated that initial 

estimates are never accurate and that until a more accurate number can be 

determined, first estimates are not necessarily the guide for determining response 

efforts. 

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Was drug and alcohol testing of 

maritime personnel conducted 

according to applicable Coast 

Guard regulation? 

Drug and alcohol testing of 

maritime personnel was not 

conducted according to applicable 

Coast Guard regulations. 

M/V COSCO BUSAN Officers 

and Crew: It is the marine 

employer’s responsibility to 

conduct alcohol testing within 2 hours, and drug testing within 32 hours, of all 

employees directly involved in serious marine incidents. It is the Coast Guard’s 

responsibility to ensure the testing is conducted in a timely and complete manner 

as part of its investigatory responsibilities. In this case, Coast Guard investigators 

administered breath alcohol tests to the master, chief engineer, third officer, and 

an able seaman who were all on the bridge at the time of the accident. 

Subsequent testing by a third party was incomplete in that he collected a urine 

sample from the master of the M/V COSCO BUSAN and not from the rest of the 

vessel’s crew. The error was not identified by Coast Guard investigators until 

after the 32-hour period had passed. The drug and alcohol testing of the 

remainder of the M/V COSCO BUSAN crew was completed on November 9, 

2007 (53 hours after the mishap). 

San Francisco VTS Watchstanders: The Coast Guard did not test VTS active 

duty personnel watchstanders involved in the mishap for drugs or alcohol 

according to agency policy nor did they test Coast Guard civilian VTS 

watchstanders working at the time of the incident for drugs, as authorized by 

Department of Transportation Order 3910.1C. Marine casualty investigators 

assigned to this incident were not aware that VTS employees are subject to drug 

or alcohol testing in mishaps such as this. 

The Coast Guard explained that VTS watchstanders were not tested due to a lack 

of awareness of the drug and alcohol testing policies on the part of Sector San 

Francisco management. The Coast Guard’s omission of such tests, as well as the 

marine employer’s lack of timely testing of the M/V COSCO BUSAN’s 

crewmembers, may prevent authorities from being able to rule out the use of 

drugs or alcohol as a contributing cause of the mishap. 

Did the Coast Guard provide 

all records relating to the 

incident to the National 

Transportation Safety Board 

in a timely manner? 

According to the National 

Transportation Safety Board, the 

Coast Guard cooperated fully, 

providing all relevant information 

on the mishap in a timely matter. 

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Recommendations 

We recommend that the Commandant of the Coast Guard: 

Recommendation #3: Update Coast Guard policies and procedures as 

they relate to marine casualty investigations, addressing: (1) The 

collection of evidence by marine casualty investigators to ensure all 

relevant evidence is collected, for example, identification of the presence 

of a Voyage Data Recorder and securing it, as appropriate; and (2) The 

requirements for drug and alcohol testing of Coast Guard civilian and 

military personnel involved in a mishap. 

Recommendation #4: Clarify the role and responsibility of the Coast 

Guard in quantifying the volume of pollutants released as a result of a 

marine casualty or pollution mishaps. Also, determine whether pollution 

investigators should independently quantify or verify the volume of 

pollutants released. Employ quantification experts or conduct an analysis 

of the costs and benefits to upgrading the training of nationwide pollution 

investigators in independently quantifying the volume of pollutants 

released in marine casualty mishaps. 

Recommendation #5: Ensure that all Coast Guard marine casualty 

investigation billets are filled with trained and qualified marine casualty 

investigators. 

Management Comments and OIG Analysis 

Recommendations number #3 and #5 are considered resolved but 

will remain open until documentation is provided on actions taken 

and we can determine the corrective actions adequately address the 

recommendations. Recommendation #4 is unresolved. Coast 

Guard's complete management comments to this report are 

provided in Appendix B. 

Management Comments to Recommendation #3: CONCUR IN 

PART 

The Coast Guard concurs in part with our recommendation that 

Coast Guard policies and procedures be updated regarding the 

collection of evidence in marine casualty investigations, 

specifically the Voyage Data Recorder and drug and alcohol 

testing of Coast Guard military and civilian personnel. According 

to the Coast Guard, the Voyage Data Recorder is already included 

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 in the Job Aid and no further action is required in this regard. The 

Coast Guard also states that the marine casualty investigations 

program does not have the authority to direct the drug and alcohol 

testing of Coast Guard military and civilian personnel, but rather 

testing of this nature falls under the authority of the unit’s chain of 

command. Finally, the Coast Guard states that its authority to drug 

and alcohol test its military and civilian personnel is discretionary 

rather than a legal requirement and that the report should be 

modified to reflect the authority as such. 

OIG Analysis 

We agree that the Voyage Data Recorder is already included as 

evidence to be collected in the Job Aid (referred to as Course 

Recorder) used by marine casualty investigators and needs no 

further action in that regard. The Job Aid, however, needs to be 

updated to include post-incident drug and alcohol testing 

requirements that will be included in the VTS National SOP (See 

the Coast Guard’s response to OIG Recommendation #1). The 

Marine Safety Manual, the Job Aid and the VTS National SOP 

must be consistent with regard to the drug and alcohol testing 

requirements. 

While Coast Guard investigators may not have the authority to 

direct drug and alcohol testing of Coast Guard military and civilian 

personnel, the Coast Guard is authorized to do so. The Coast 

Guard is also required to conduct investigations of marine 

casualties, which require that the Coast Guard determine whether 

its own personnel contributed to the cause of the mishap. To this 

end, investigators in the case of the M/V COSCO BUSAN allision 

should have been requested by the unit’s chain of command to 

conduct drug and alcohol tests of VTS watchstanders to rule out 

Coast Guard personnel as a contributing cause of the mishap. 

Finally, the only drug and alcohol testing requirement referred to 

in the report is Coast Guard’s VTS program policy. According to 

the Coast Guard, effective immediately, this requirement will be 

included in the VTS National SOP and in formal guidance to all 

VTSs making them aware of the policy and to provide guidance in 

developing local drug and alcohol testing procedures. Coast Guard 

should also direct the guidance to marine casualty investigators. 

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Management Comments to Recommendation #4: CONCUR IN 

PART 

The Coast Guard concurred in part with the recommendation and 

requests that the recommendation be modified. The requested 

modification is that the Coast Guard should update contingency 

plans to ensure that qualified persons are available to assist in 

quantifying the volume of oil spilled. The Coast Guard will also 

update investigation and response training to ensure that all Coast 

Guard personnel understand the complexities and limitations of 

determining the volume of a spill and how that information should 

be used in pollution investigation and response. 

OIG Analysis 

The suggested Coast Guard change to the recommendation does 

not require the Coast Guard to clarify the role and responsibility of 

Coast Guard pollution investigation personnel in quantifying the 

volume of pollutants released in a mishap. Therefore, the 

recommendation will not be revised. 

Management Comments to Recommendation #5: CONCUR 

The Coast Guard concurred with this recommendation and agreed 

to modify the recommendation to require that all Coast Guard 

marine casualty investigation billets be filled with trained and 

qualified marine casualty investigators and not only those at Coast 

Guard’s Sector San Francisco. 

OIG Analysis 

This recommendation is modified accordingly. The 

recommendation is considered resolved. 

Coast Guard Response (First 24 Hours) 

The Unified Command’s response to the mishap was based on tenets of the San 

Francisco Area Contingency Plan. The Coast Guard’s response adhered to the 

plan; however, there are areas where the Coast Guard’s response could have been 

improved. For example, the Coast Guard did not complete initial notifications as 

required by the San Francisco Area Contingency Plan. This incomplete 

notification did not delay the oil spill response, as it began within 1 hour of the 

allision. The San Francisco Area Contingency Plan, which is on a triennial 

update cycle, will be updated in 2008. This update cycle provides the Area 

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Committee members with an opportunity to incorporate a volunteer plan, 

developed and implemented by both the City of San Francisco and the State of 

California OSPR Division. 

The San Francisco Area Contingency Plan is adequate for the size and type of fuel 

oil spilled in this allision, as the plan is based on the worst case scenario and the 

maximum impact discharges of the largest vessel calling on the San Francisco 

port. According to the Oil Pollution Act of 1990, the contingency plan includes 

extensive plans and procedures for the rapid response to incidents affecting 

marine wildlife and fisheries. Drills are conducted to test the wildlife response 

section of the contingency plan; the most recent was conducted in 2006. 

Specific Questions 

Did the Unified Command 

effectively manage the 

resources available to the 

Coast Guard to effect 

containment and 

remediation of the spill? 

The Unified Command effectively 

managed the resources it had available 

to contain and remedy the spill. The 

Unified Command’s response was led 

by the Federal On Scene Commander 

(Sector San Francisco Commander). 

Additionally, the Responsible Party, 

representing the vessel owner, 

voluntarily fulfilled statutory 

requirements for oil spill removal as a 

member of the Unified Command, which also included the State of California. 

The Responsible Party is required to have a Vessel Response Plan, which lists oil 

spill response resources under contract for a particular region. Two local Oil Spill 

Response Organizations’ (OSRO) responded within 30 minutes of the mishap; the 

two companies brought in additional resources throughout the clean up period as 

required. The San Francisco Area Contingency Plan provides a link to the 

Regional Contingency Plan, which contains an extensive list of oil response 

providers located in the Western United States. This list, available at 

www.wrrl.us, highlights the capabilities of responders in terms of equipment and 

resources--booms, boats, etc. 

The San Francisco Area Contingency Plan did not have an Incident Command 

Post location identified in advance. The Incident Command Post is the physical 

space in which the Unified Command operates. The Incident Command Post for 

this mishap was moved from its initial location at the Coast Guard Sector on 

Yerba Buena Island to the Fort Mason firehouse, which had been abandoned for 

10 plus years. The Command Post was relocated one additional time to the 

Nimitz Center on Treasure Island. According to the Coast Guard, the first 

location was “terrible” because it had only one phone line and limited cell phone 

reception. The second Incident Command Post, the Fort Mason firehouse, could 

only be used for 2 days, as a wine tasting was scheduled there on the weekend. 

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Additionally, there was no cell phone service in this location. The final location 

at the Nimitz Center was a large, workable facility, according to the Coast Guard. 

For more efficiency and effectiveness in the future, the San Francisco Bay and 

Delta Area Committee needs to predesignate a physical location (s) suitable for 

Unified Command operations. All future oil spill response and other all-hazard 

exercises should be managed from this location to ensure maximum suitability for 

this type of operation. 

Active participation by all Unified Command members in the Joint Information 

Center could have improved the management and dissemination of critical 

information. A Joint Information Command was set up shortly after noon on 

November 7, 2007. Although all Unified Command members were invited, only 

Coast Guard personnel attended during the first 24 hours. By day 2, other Unified 

Command members participated, but the Joint Information Command was not 

attended in full until day 4 or 5 of the mishap. The lack of non-Coast Guard 

members in the Joint Information Center placed the responsibility of responding 

on behalf of the Unified Command in the first 24 hours solely and inappropriately 

on the Coast Guard. Our answer to the question regarding the adequacy of the 

San Francisco Area Contingency Plan in guiding the oil spill response provides 

more detail on the Unified Command’s efforts. 

To what extent was the 

delay in notification of 

local authorities and 

emergency responders 

of the size of the oil spill 

a result of inadequacies 

in the San Francisco 

Area Contingency Plan? 

Local notification delays did not occur 

due to inadequacies in the San 

Francisco Area Contingency Plan. 

Delays in notifying local authorities 

and emergency responders of the size 

of the oil spill were due to problems in 

communication and coordination 

among members of the Unified 

Command, including the Coast Guard 

and the State of California, as opposed 

to inadequacies in the Contingency 

Plan. Communication issues included 

releasing the first estimate despite 

accuracy concerns, and the subsequent delay in releasing the updated estimate to 

the public. Coordination issues resulted in a delay in transporting the OSPR 

expert to the ship to calculate the volume of oil discharged, and back to the Coast 

Guard’s Command Center with the updated estimate. 

Communication of Estimates 

The Coast Guard has admitted that releasing the first estimate to the public was a 

mistake and has since taken steps to prevent repeating this error in the future. The 

first estimate of 142 gallons was obtained by the Coast Guard pollution 

investigator from the ship’s chief engineer and communicated to the SCC at 

approximately 10:50 a.m. Pollution investigators expressed concern about the 

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accuracy of that estimate; however, the estimate was nonetheless released to the 

public. On November 7, 2007, at approximately 5:00 p.m., after receiving the 

updated estimate of at least 58,000 gallons, the Unified Command agreed that this 

was an accurate estimate. The Coast Guard did not release this information to the 

public until about 9:00 p.m. The Coast Guard stated that it was “remiss” in not 

having released the information earlier. A Sector public affairs officer on duty 

that day said that heavy workloads and the time required for the press release 

approval process contributed to the delay. 

Coordination 

Coordination issues resulted in a delay in transporting the OSPR expert to the ship 

to calculate the volume of oil discharged, and back to the Coast Guard’s 

Command Center with the updated estimate. According to OSPR, the state 

quantification expert on duty the day of the mishap was ready and waiting at 

approximately 9:35 a.m. to be ferried to the ship to work on quantifying the 

volume of the oil spilled. Because the state did not possess a boat that could be 

used for this purpose, the expert had to wait for approximately 2 1/2 hours at the 

dock before being transported to the ship by the Coast Guard. After boarding the 

ship, the expert took approximately 1 hour to estimate that “at least” 58,000 

gallons had been released from the M/V COSCO BUSAN. Despite the damage to 

the tanks, the expert was able to sound the tanks without the aid of the ship’s 

crew. 

After calculating the estimate, the expert again waited for transportation back to 

the SCC to relay the information to his supervisor. The expert arrived and 

delivered the information at approximately 4:30 p.m. The expert explained that 

he did not want to use his cell phone to relay this information from the ship 

because of privacy concerns. Had the delays in transportation and 

communications not occurred, the Unified Command could have received 

quantification of the oil spill as early as 2:00 p.m. 

Did the delay in notification of 

the size of the oil spill 

adversely impact the response 

of Coast Guard, state and local 

governments and Responsible 

Party to the mishap? 

According to the Coast Guard and 

OSPR, having the accurate estimate 

earlier would not have changed 

their response efforts. Coast Guard 

pollution investigators gathered the 

information they needed to 

determine whether a violation had 

occurred and whether observation 

and clean up efforts had begun in a 

timely manner. 

The delay in notification of the size of the oil spill did not have an impact on the 

emergency response. According to the National Contingency Plan, upon release 

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or discharge of a hazardous substance equal to or greater than the reportable 

quantity, a notification must be made to the National Response Center. 8 

In this mishap, the Responsible Party immediately notified the San Francisco 

VTS. We further discuss the delays and notification failures in answering 

questions below, regarding whether provisions of the San Francisco Area 

Contingency Plan were followed in response to the incident. 

The Coast Guard was described by the environmental unit leader for OSPR as 

having almost “over responded” to the oil spill, from the time the allision 

occurred until the Unified Command obtained an accurate estimate of the quantity 

of oil spilled. The Coast Guard based its initial response on the worst case 

scenario for several reasons: (1) the Coast Guard was unable to conduct flights 

over the scene immediately after the allision due to dense fog; (2) the Coast Guard 

pollution investigators were not able to quantify the release of oil by sounding the 

tanks due to damage to the sounding tubes; and (3) there were wide variances in 

information gathered on the extent of the spill during the first hour after the 

allision. 

The unit leader said that the Coast Guard responded quickly with assets (staffing 

and equipment) based on the "potential" oil spilled and not the "reported" oil 

spilled. The Coast Guard primarily conducted its response based on the following 

facts: (1) the M/V COSCO BUSAN had struck the San Francisco-Oakland Bay 

Bridge and suffered damage as a result; (2) oil had been spilled from the vessel; 

(3) the type of oil released and the preliminary trajectory prediction for the oil in 

the water was determined, including firsthand observation of the oil on the water; 

and (4) scientists and volunteers had observed and communicated concerning 

conditions along the coast. 

To what extent was there 

local involvement in the 

development of the San 

Francisco Area 

Contingency Plan? 

The extent of local involvement in 

initial development of the San 

Francisco Area Contingency Plan in 

1993 is unknown. However, from 

2005 through 2007, there was some 

limited local participation in the San 

Francisco Bay and Delta Area 

Committee for San Francisco, which 

develops and updates the San 

Francisco Area Contingency Plan. Appendix E details membership attendance at 

San Francisco Area Committee meetings from October 11, 2005, to September 

18, 2007. According to the Oil Pollution Act of 1990, Area Committees were 

established and are responsible for the development of Area Contingency Plans 

8

 40 CFR § 300.125. 

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22 
 

 

for "areas under the direction of the Federal on-scene coordinator.”9 Further, 

according to the State of California, Area Contingency Plans “... are adopted by 

amendments to the State Contingency Plan to facilitate and coordinate ongoing 

work with local municipalities and coastal communities...The objective is to 

create consistency between the local, State and national contingency plans.”10 

The City of San Francisco Department of Emergency Management stated that, in 

retrospect, oil spill response should have been, and now will be, included on its 

All-Hazards Response List. The exclusion was due to the infrequent nature of oil 

spills as compared to the frequency of other All-Hazard events; prior to the M/V 

COSCO BUSAN mishap, the San Francisco Department of Emergency 

Management had not interacted with the Coast Guard on oil spills. In this mishap, 

Source: USCG Muir Beach Cleanup 

the city chose to deploy its 

own boom in advance of 

any Coast Guard or 

Unified Command 

direction, which may or 

may not have been 

consistent with Unified 

Command booming 

strategies. The City of 

San Francisco stated that, 

for the future, it will take a 

more active role in Area 

Committee meetings, 

which provide input to the 

San Francisco Area 

Contingency Plan. The 

city has also created a 

Regional Emergency 

Coordination plan, which calls for involvement by federal, state, and local 

organization and agencies. 

There was a feeling of marginalization by some in the local communities as 

untrained volunteers who initially asked to assist were turned away. California 

Code of Regulations stipulates that all people working with hazardous materials 

must receive specific training and that volunteers will not be used for direct 

recovery of oil. The Area Contingency Plan contains a detailed volunteer plan, 

which outlines training requirements for volunteers, including specific hazardous 

material training. Certain positions, particularly those involving the care of oiled 

9

 Memorandum of Agreement between the State of California and the Eleventh Coast Guard District June 

2, 1993. 

10 Memorandum of Agreement between the State of California and the Eleventh Coast Guard District June 

2, 1993. 

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23 
 

birds, require as much as 24 hours of training. According to the San Francisco 

Area Contingency Plan, “Human health and safety is the first priority in decisions 

regarding the use of volunteers at an oil spill incident.” 11 Previously trained 

volunteers, such as those associated with the Oiled Wildlife Care Network and the 

Gulf of Farallones Beach Watch, were available and integral to the response. 

However, due to the overwhelming number of available volunteers, on the fifth 

day of oil spill response, the Cities of San Francisco and Berkley developed an ad 

hoc plan with OSPR regarding volunteer training and credentialing and executed 

the process in such a manner that personnel were not pulled from their roles in the 

Unified Command. Volunteers were trained and credentialed in a timely manner 

and helped response crews with oiled debris clean-up at Berkley Marina and 

Ocean Beach. This process will be documented and incorporated into the city’s 

future oil spill response plans. 

Lastly, Contra Costa County collected oil on its own, outside of the San Francisco 

Area Contingency Plan and the Unified Command Structure. Since this effort 

was not officially documented and was not accomplished in coordination with 

OSPR, the amounts and the source of the oil collected cannot be verified. It 

remains unknown whether or not that oil was spilled from the M/V COSCO 

BUSAN. Contra Costa County attended one meeting of the San Francisco Area 

Committee on August 24, 2006. 

Is the San Francisco Area 

Contingency Plan adequate to 

guide the response to a spill 

the size and type of fuel oil 

encountered in this allision? 

According to California OSPR 

environmental response personnel, 

the San Francisco Area 

Contingency Plan is adequate to 

guide a response of the size and 

type encountered in this allision. In 

their opinion, the plan also was 

executed as written by both OSPR 

and the Coast Guard. 

All area contingency plans are required to “...address removal of a worst case 

discharge and to mitigate or prevent a substantial threat of such a discharge...”12 

The San Francisco Area Contingency Plan presents both a worst-case scenario, as 

well as a maximum, most probable discharge scenario, for the San Francisco Bay 

and Delta. The worst-case scenario is based on the discharge of a vessel’s entire 

cargo in adverse weather conditions, or the largest foreseeable discharge of a 

facility in adverse weather conditions. Three other scenarios depicted are 

Discharges of Maximum Impact, which detail the potential trajectory of oil from a 

mishap in the San Francisco Bay and in proximity to wetlands. The San 

Francisco Area Contingency Plan uses the capacity of the largest vessel calling on 

11 San Francisco Area Contingency Plan, Volume I, Section 9730.2. 

12 40 CFR § 300.5. 

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the San Francisco port, in addition to the hazards and risk of collision along the 

route it would take into the port, as a baseline for calculations. 

In the case of the M/V COSCO BUSAN, neither the amount of oil spilled 

(approximately 53, 653 gallons) nor the total oil load (about 2 million gallons) 

met the worst-case scenario of approximately 50 million gallons outlined in the 

San Francisco Area Contingency Plan. Further, according to the Vessel Response 

Plan for the M/V COSCO BUSAN, the worst-case discharge would be 

approximately 2 million gallons, also well below the threshold. 

Were the provisions of the 

San Francisco Area 

Contingency Plan followed 

during the response to this 

incident? 

Some response provisions of the 

San Francisco Area Contingency 

Plan were followed. Other 

provisions relating to initial 

awareness, assessment, and 

notification were not followed. In 

general, according to the National 

Contingency Plan, the on-scene 

coordinator shall investigate and 

determine relevant information, such as the threat to public health or the 

environment. The type, quantity, and source of the threat also must be 

determined. The on-scene coordinator should then classify the size and type of 

the spill and decide on the best course of action in response. The National 

Contingency Plan lists four operational response phases for oil spills.13 

Phase One – Discovery or Notification 

This phase stipulates that, upon discharge from any facility or vessel, any person 

in charge of a vessel or facility shall immediately notify the National Response 

Center or, if not practicable, notify the Coast Guard or Environmental Protection 

Agency predesignated on-scene coordinator for that geographic area. 14 Once the 

National Response Center is in receipt of notification, it shall “...promptly notify 

the on-scene coordinator. The on-scene coordinator shall ensure notification of 

the appropriate state agency... affected by the discharge.” 15 The San Francisco 

Area Contingency Plan incorporates an initial notification checklist, which the 

Sector San Francisco Situational Unit incorporated into its Quick Response 

Checklist. 

All phase one requirements in response to the M/V COSCO BUSAN mishap were 

not addressed in a timely manner. The San Francisco VTS notified Sector San 

Francisco at 8:30 a.m. that the M/V COSCO BUSAN had allided with the San 

Francisco-Oakland Bay Bridge. According to the San Francisco Area 

13 40 CFR Part 300 National oil and Hazardous Substances Pollution Contingency Plan. 14 40 CFR § 300.300.
 15 40 CFR § 300.300. 

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Contingency Plan initial notification checklist, the Sector San Francisco 

watchstander was required to ask the reporting party, in this case the San 

Francisco VTS, whether the National Response Center and the State Office of 

Emergency Services had been notified. According to the Coast Guard telephone 

record transcripts and Sector San Francisco Watchstander Logs, the Sector San 

Francisco watchstander did not ask the required questions, nor did the 

watchstander make any required notifications. The Responsible Party notified the 

National Response Center at 9:51 a.m., and the State Office of Emergency 

Services at 9:42 a.m. As required, the National Response Center notified the San 

Francisco Sector Command Center of the mishap at 10:01 a.m., and subsequently 

contacted the State Office of Emergency Services. 

The failure by the Sector San Francisco watchstander to make the notifications 

resulted in approximately a 1-hour delay in contacting the National Response 

Center and the State Office of Emergency Services. This notification delay did 

not have any impact on the spill response, the Responsible Party made its contacts 

as required, and response efforts got underway. However, the delay could have 

slowed State Office of Emergency Services and National Response Center 

notifications of other parties not already informed of the mishap. Table 2 is an 

outline of the notifications that occurred in the first 24 hours. 

Table 2 

Summary of Phase One Response Actions 

Time Agency Action 

0830 M/V COSCO BUSAN allision 

0830 VTS Notifies Sector San Francisco of allision 

0925 Coast Guard OSPR personnel at Sector San Francisco notified of spill 

0942 O’Brien’s Group Responsible Party notifies California Office of Emergency 

Services 

0951 O’Brien’s Group Responsible Party notifies National Response Center 

0951 O’Brien’s Group Activates Marine Spill Research Corporation (OSRO) 

1000 SF Police Dept Offers Assistance to Sector San Francisco 

1001 NRC Notifies Sector San Francisco and State Office of 

Emergency Services 

1007 O’Brien’s Group Identifies to Unified Command as Qualified Individual and 

Responsible Party 

1041 O’Brien’s Group Activates National Response Corporation (OSRO) 

1100 OSPR Oiled Wildlife Care Network placed on standby 

1143 OSPR California State Fish & Game notifies area trustees of 

mishap 

1200 Unified Command holds first press conference 

1348 Unified Command Conference call with San Francisco Mayor’s Office, City 

of San Francisco, Port Partners 

1358 OSPR Notifies local California State Senate & Assembly via 

Sacramento Liaison 

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Phase Two - Preliminary Assessment and Initiation of Action 

In the second phase, the on-scene coordinator is responsible “for promptly 

initiating a preliminary assessment” of the mishap using all available information, 

including, if possible, an on scene inspection.” 16 Additionally, the on-scene 

coordinator is to “evaluate the magnitude and severity of the discharge or threat to 

public health or welfare of the United States or the environment. Assess the 

feasibility of removal; and... identify the potentially responsible parties.”17 Also, 

according to the Code of Federal Regulations, the on-scene coordinator “may 

allow the responsible party to voluntarily and promptly perform removal actions” 

and “shall ensure adequate surveillance over whatever actions are initiated.”18 

To its credit, the Responsible Party in this mishap, self-identified and proceeded 

with its role in the response. However, this was the ideal or model situation and 

the federal and state government may not always be able to rely upon the 

Responsible Party to perform as required. 

In any event, the Coast Guard was underway with the pollution response team 

within 34 minutes of the mishap. The Delta span of the bridge was evaluated 

within 43 minutes of the mishap, and the pollution response team was alongside 

the M/V COSCO BUSAN 65 minutes after the mishap occurred. It is also 

important to remember that visibility was approximately one-eighth to onequarter mile at this time, making on-scene inspection difficult. Due to the heavy 

fog, it was impossible to make an accurate evaluation of the severity and size of 

the spill, as the traditional use of aerial observation was unavailable. 

Key actions related to the Phase Two-Preliminary Assessment and Initiation of 

Action are depicted in Table 3. The Unified Command was established within 1 

hour and 15 minutes of the mishap. The first formal meeting with all three 

Unified Command members – FOSC, State On-Scene Coordinator (SOSC), and 

Responsible Party – did not take place until 4:00 p.m.; however, this had no 

impact on the response which was already underway. 

16 40 CFR § 300.305. 

17 40 CFR § 300.305. 

18 40 CFR § 300.305. 

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Table 3 

Summary of Phase Two Response Actions 

Time Agency Action 

0830 M/V COSCO BUSAN allision 

0833 VTS SF Notifies Caltrans of allision 

0836 VTS SF Issues Safety Notice to Mariner’s Broadcast on Ch 16 

0840 Sector SF Notifies CG District 11 Bridge Section 

0845 Station SF Notified by Sector San Francisco of mishap 

0850 Sector SF Briefs Sector SF Incident Management Division 

0903 Station SF Underway to scene of mishap with pollution response team. 

0905 VTS SF Notifies Army Corps of Engineers of debris field in water 

0913 Station SF On scene at Delta span of bridge – inspecting for damage 

0920 Station SF Enroute to COSCO BUSAN 

0925 OSPR Personnel to inspect Ferry Terminal Area & West Span 

0935 Station SF Station SF on scene with COSCO BUSAN 

0945 OSPR OSPR assumes SOSC 

0945 Unified Command established at Yerba Buena Island 

(OSPR & CG) 

0955 Station SF Station SF embarked a pollution response team to COSCO 

BUSAN 

1030 Sector SF .4MT Initial estimate provided to CG by Chief Engineer 

1045 Sector SF Issues Notice of Federal Interest to COSCO BUSAN 

1126 OSPR Confirmed discharge was Intermediate Fuel Oil 380 

1200 CALTRANS Bridge is structurally sound 

1210 UC holds first press conference 

1223 Sector SF OSPR Quantification Expert underway to COSCO BUSAN 

1230 CG Aids to 

Navigation 

Team 

All navigation aids in vicinity of mishap working properly 

Phase Three – Containment, Countermeasures, Cleanup, and Disposal 

According to the U.S. Code of Federal Regulations, in the event of oil spills, 

“defensive actions shall begin as soon as possible to prevent, minimize or mitigate 

threat to the public health or welfare of the United States or the environment.”19 

19 40 CFR § 300.310. 

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 Specific actions mentioned include analyzing water samples to determine the 

source and spread of the oil; controlling the source of the discharge; placement of 

physical barriers to deter the spread of the oil; and protecting natural resources 

and sensitive ecosystems. 

The San Francisco Area Contingency Plan places its first priority on the 

protection of human health and safety after a mishap. According to the State of 

California Oil Spill Response Organization requirements for the San Francisco 

Area Contingency Plan, the resources are to be on site within 2 hours and on 

scene within 6 hours. The first OSRO (National Response Corporation) was on 

scene and skimming within 1 and 1/2 hours of the mishap, which is well within 

the 6-hour requirement. The second OSRO (Marine Spill Response Corporation) 

was on scene and skimming within 2 hours of the mishap. The California 

Transportation representatives were on scene at the damaged bridge span within 

69 minutes of the mishap. 

Source: NTSB Damaged Bridge Column 

Table 4 provides a brief timeline of the response actions. Both OSROs were on 

scene well before the mandated time. OSPR Shoreline Cleanup Assessment 

Teams started their shoreline assessments within 3 1/2 hours of the mishap and 

booming operations were also underway by that time. Additionally, the U.S. 

Army Corps of Engineers had removed 2 tons of debris from the water by the 

evening of the mishap. 

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Table 4 

Summary of Phase One Response Actions 

Time Agency Action 

0830 M/V COSCO BUSAN allision 

0905 NRC (OSRO) Receives report of vessel hitting bridge 

0910 NRC Dispatch skimmers to bridge 

0930 NRC On scene – Heavy Fog – reports oil smell at 0935 

0939 CALTRANS On scene checking damage to bridge 

0940 NRC Dispatches additional boats 

0940 MSRC (OSRO) Mobilizes 2 skimmers and 4 boom boats 

0950 MSRC Skimmer on scene – conducts air monitoring and site 

assessment 

1000 NRC Vessels ‘in oil’ and skimming 

1030 MSRC Commences skimming operations 

1045 MSRC Two boom boats on scene w/1250 ft boom each 

1110 MSRC Two additional boom boats on scene 

1125 MSRC Skimmer on scene to skim and place boom 

1130 NRC 2500 feet of boom placed Pier 39 & Aquatic park 

1140 MSRC Skimmer on scene 

1200 OSPR/Coast Guard SCAT depart for assessment of SF Piers 

1246 NOAA Oil trajectory completed and given to UC 

1327 OSPR Protective boom placed at Seal Cove – Pier 39 

1443 ACOE Two tons of debris recovered from bridge abutment 

1445 MSRC Skimmer Sentinel on scene 

1500 MSRC Booming of Crissy Field and Aquatic Park commences 

1515 NRC Directed to place boom on Crissy Field 

1530 MSRC Boom boat LCM on scene 

1600 MSRC Booming complete (Crissy Field & Aquatic Park) 

1603 NPS Closing affected beaches 

1630 NRC 2500 ft of boom deployed and Skimmer JBF on scene 

1630 MSRC 8000 ft of boom deployed and 3 additional skimmers on 

scene 

1636 ACOE 95% of bridge piling fenders recovered 

1730 UC Water operations discontinued due to safety concerns at night 

1820 UC Approximately 8000 gallons of product recovered 

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Phase Four – Documentation and Cost Recovery 

This final phase in oil spill response, Documentation and Cost Recovery, 

addresses the need for those involved to document all actions taken in response to 

a mishap in order to support and validate recovery costs.20 

Cost recovery is beyond the scope of the first 24 hours of the mishap, which is 

outside the scope of our review. 

The Oil Pollution Act of 1990 

required development of a rapid 

response plan for the treatment 

of marine resources, wildlife, 

and fisheries. 

Is that plan currently in place and 

was it followed during the response 

to this incident? 

Was it adequate to guide this 

aspect of the response? 

Do the relevant federal agencies 

conduct drills specifically 

related to fish and wildlife 

protection? 

The San Francisco Area 

Contingency Plan 

incorporates a rapid response 

plan for the treatment of 

marine resources, wildlife, 

and fisheries, per the Oil 

Pollution Act of 1990. This 

plan was followed, in 

conjunction with the San 

Francisco Area Contingency 

Plan’s Volume II’s sitespecific containment and 

protection strategies for 

environmentally sensitive 

sites. According to 

California State OSPR 

scientists, as well as National 

Marine Fishery Service 

personnel, the plan was, and 

is, adequate to guide this 

aspect of the response. 

Further, federal agencies conduct drills specifically related to fish and wildlife 

protection. The Coast Guard participated in the Sulfur Springs Creek Exercise in 

2006. This exercise was designated as a full scale, Marine Environmental 

Protection Exercise designed to validate the information and procedures contained 

in the Regional Contingency Plan, Area Contingency Plan, California Wildlife 

Contingency Plan, and Valero Benicia Refinery Oil Spill Contingency Plan. The 

exercise also identified weaknesses to correct subsequent versions of the 

contingency plans, identified strengths to share best practices with the response 

community, and tested command and control processes within an incident 

command/unified command framework. 

20 40 CFR 300.315. 

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The California Code of Regulations outlines state drill and exercise requirements 

for contingency plans. According to California State Law, it is mandatory that the 

“entire plan is exercised at least once every 3 years....”21 The Coast Guard 

participated in the Safe Seas 2006, Exercise, which tested the San Francisco Area 

Contingency Plan, the Region IX Regional Response Plan, and the Harley Marine 

Services Vessel Response Plan. Numerous federal, state and local agencies, 

including the Coast Guard, National Marine Fisheries Service, National Marine 

Sanctuaries Fish and Wildlife Service, and OSPR jointly conducted this multipart 

exercise. 

Safe Seas 2006 commenced with a Table Top Exercise, which focused on initial 

spill notifications, followed by a Command Post Exercise largely centered on 

initial Incident Command Post standup. Safe Seas 2006 terminated with a Field 

Training Exercise, which combined extensive technology demonstrations with 

actual field deployments. One of the objectives and major lessons learned during 

Safe Seas 2006 was demonstration of the ability to conduct initial environmental 

assessments and forecasts and development of the appropriate plans for such 

matters as shoreline protection, wildlife protection, cultural resource protection, 

dispersant use, and place of refuge. 

Recommendations 

We recommend that the Commandant of the Coast Guard: 

Recommendation #6: Review current Sector San Francisco Command 

Center Standard Operating Procedures to ensure all Quick Response 

Checklists are current and accurately reflect the San Francisco Area 

Contingency Plan. 

Recommendation #7: Ensure Sector San Francisco Command Center 

watchstanders and supervisors receive recurrent training on the use of 

Quick Response Checklists. 

Recommendation #8: Collaborate with all stakeholders on the San 

Francisco Area Committee to predesignate a location(s) for the Unified 

Command’s Incident Command Post, including adequate space for the 

Joint Information Center, and regularly use this space for oil spill response 

and other all-hazards exercises. 

Recommendation #9: Collaborate with all stakeholders of the San 

Francisco Area Contingency Plan to develop policies and procedures for 

managing, training, and credentialing large numbers of volunteers who 

offer assistance during oil spills. 

21 14 CCR § 820.01. 

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Management Comments and OIG Analysis 

The Coast Guard concurred with the above recommendations. The 

recommendations will remain open until more specific details and 

documentation are provided on actions taken so that we can 

determine whether these actions adequately address the 

recommendations. 

Management Comments to Recommendation #6: CONCUR 

The Coast Guard concurred with the recommendation for 

developing current and accurate Quick Response Sheets for San 

Francisco Sector Command Center as well as the San Francisco 

VTS. According to the Coast Guard, the development of these 

Quick Response Sheets aligns with planned future construction of 

an integrated Sector Command Center in which both the Command 

Center and the VTS will be located. Construction of this building 

is estimated to be complete by 2011. 

OIG Analysis 

We agree with the actions the Coast Guard plans on taking to 

address the intent of our recommendation. This recommendation 

will remain open until the Coast Guard provides us with 

documentation demonstrating the development of the Quick 

Response Sheets for the VTS and Sector Command Center. Colocation of the Sector Command Center and VTS will serve to 

improve communications during mishaps. We consider 

recommendation #6 resolved. 

Management Comments to Recommendation #7: CONCUR IN 

PART 

The Coast Guard concurred in part with the recommendation that 

Sector San Francisco Command Center watchstanders and 

supervisors receive recurrent training on the use of Quick 

Response Checklists. According to the Coast Guard, the 

watchstanders already receive qualification and recurrent training 

on the procedures they are required to accomplish including the 

use of Quick Response Checklists. The Coast Guard recommends 

a revision of the recommendation based on the above comments. 

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OIG Analysis 

We agree with the actions the Coast Guard plans on taking to 

address the intent of our recommendation. This recommendation 

will remain open until the Coast Guard provides us with 

documentation demonstrating that the recurrent training was 

accomplished. We consider recommendation #7 resolved. 

Management Comments to Recommendation #8: CONCUR 

The Coast Guard concurred with the recommendation that the Area 

Committee predesignate an Incident Command Post (s) in the San 

Francisco Area Contingency Plan. According to the Coast Guard, 

Sector San Francisco will incorporate this change in the next 

revision of the Area Contingency Plan. 

OIG Analysis 

We agree with the Coast Guard’s actions to address the intent of 

our recommendation. This recommendation will remain open until 

the Coast Guard provides us with documentation outlining the 

designation of an Incident Command Post location (s) in the San 

Francisco Area Contingency Plan, as well as plans to use the 

location (s) for exercises and drills. We consider recommendation 

#8 resolved. 

Management Comments to Recommendation #9: CONCUR 

The Coast Guard concurred with our recommendation that all 

stakeholders of the San Francisco Area Contingency Plan 

collaborate to develop policies and procedures for managing, 

training, and credentialing large numbers of volunteers. According 

to the Coast Guard, the Area Committee will update the San 

Francisco Area Contingency Plan with a volunteer management 

plan developed and implemented by the State of California. This 

plan will address the use of volunteers at all levels, including 

county and local jurisdictions affected by the oil spill. The first 

Volunteer Sub-committee meeting of the Area Committee was 

held on January 14, 2008. 

OIG Analysis 

We agree with the actions the Coast Guard plans on taking to 

address the intent of our recommendation. This recommendation 

will remain open until the Coast Guard provides us documentation 

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demonstrating that a volunteer management plan, as discussed, has 

been formally included in the San Francisco Area Contingency 

Plan. We consider recommendation #9 resolved. 

Sector Implementation 

The request for a 90-day review of the M/V COSCO BUSAN mishap, asked for 

an assessment of whether the Coast Guard’s reorganization contributed to the 

deficiencies in its Coast Guard’s response. We were unable to assess the impact 

of the Coast Guard’s reorganization into Sectors on the oil spill response. 

Prior to 2005, the Coast Guard was organized around its operational programs. 

The Coast Guard was reorganized in August 2005 around core operational service 

delivery processes, such as prevention of mishaps, or responses to mitigate the 

effects of mishaps. This Sector structure is comprised of Command Staff, 

Response Department, Prevention Department, and Logistics Department. Sector 

San Francisco was officially commissioned when the Coast Guard merged the 

former Marine Safety Office San Francisco, Group San Francisco, and San 

Francisco VTS. Sector San Francisco is a unit of District Eleven. To properly 

assess the impact of this reorganization, and in the interest of improving Coast 

Guard operations, a more in-depth review of the overall changes, including roles 

and responsibilities, would be required. 

Medical Waivers for Federal Pilots 

During the course of our review, concerns were raised about granting medical 

waivers to federal pilots, as well the length of time required to process license 

applications and renewals. According to the Coast Guard, centralization and 

medical review of all mariner physicals will serve to enhance maritime safety. 

The Coast Guard should maintain adequate medical staff that possess the 

credentials necessary to ensure all physicals are reviewed in a timely and accurate 

manner. Further, 46 USC § 7101 requires that pilots must have a "thorough 

physical examination each year," in addition to a physical examination that is 

required every 5 years for license renewal. 

However, the process by which a pilot is required to submit an annual report of 

physical examination by a physician has changed since the M/V COSCO BUSAN 

pilot in the mishap submitted his most recent physical examination. Prior to 

2007, a pilot was only required to submit an annual report of physical 

examination to the Coast Guard upon request. In September 2006, the Coast 

Guard published notice in the Federal Register exercising its authority to require 

routine submission of the physical examination reports. With this change, pilots 

were required to submit their latest physical report to the Regional Examination 

Center that issued their license by December 2006. This submission date was 

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later changed to April 2007. Pilots were also required to submit their annual 

exams within 30 days of completion each year thereafter. 

The M/V COSCO BUSAN pilot’s most recent physical examination report was 

submitted, as required, to the Regional Examination Center in San Francisco 

where it was verified but not reviewed. In October 2007, the Regional 

Examination Centers began forwarding all annual physical examinations to the 

National Maritime Center where they were reviewed by medical professionals at 

its Medical Evaluation Branch. Had the pilot in the M/V COSCO BUSAN 

mishap submitted a physical examination report after October 2007, the National 

Maritime Center’s medical staff could have flagged the submission for further 

review and possible denial. 

When concerns are raised regarding medical conditions of active mariners that 

may have significant potential to affect maritime safety, the cases are referred to 

local Coast Guard Investigating Officers for resolution. If the Coast Guard 

determines, after coordinating with the examining physician and other specialists 

consulted, that a disqualifying medical condition exists which cannot be waived, 

the Coast Guard is required to initiate proceedings to suspend or revoke the pilot’s 

federal license. However, it is not likely that Coast Guard suspension and 

revocation proceedings, had they been initiated prior to this mishap, would have 

been completed prior to the incident based on typical processing timelines. 

The Coast Guard is currently transitioning to a centralized 100% medical review 

of all mariner physicals by healthcare professionals. Upon full implementation in 

September 2008, this process should significantly decrease the future risks of 

significant medical conditions not being identified in federal pilot applicants and 

renewal candidates. 

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Appendix A 

Purpose, Scope, and Methodology 

We conducted this review in response to a request from the Speaker of the House 

of Representatives and the Subcommittee on Coast Guard and Maritime 

Transportation of the House of Representatives. We assessed the first 24 hours of 

the Coast Guard’s response to the oil spill that followed the allision of the M/V 

COSCO BUSAN with the San Francisco-Oakland Bay Bridge. Specifically, our 

objectives were to assess: 

•	 The actions taken by the San Francisco VTS to prevent the M/V COSCO 

BUSAN from striking the San Francisco-Oakland Bay Bridge. 

•	 The actions taken by the Coast Guard in response to the allision between the 

M/V COSCO BUSAN and the San Francisco-Oakland Bay Bridge; and 

•	 The actions taken by the Coast Guard in evaluating the volume of oil spilled 

from the M/V COSCO BUSAN. We also evaluated the Coast Guard’s efforts 

to execute the San Francisco Area Contingency Plan during the first twentyfour hours following the mishap. 

We reviewed Coast Guard’s documents related to the oil spill response, including 

the National Contingency Plan; Regional Contingency Plan; San Francisco Area 

Contingency Plan; Sector San Francisco Organization Manual; Incident 

Command System; audio, video, and computerized files; and transcripts of the 

time period leading up to and following the mishap. 

We conducted fieldwork at Coast Guard headquarters in Washington, DC, and 

made site visits to Coast Guard Sector San Francisco, California; VTS, San 

Francisco, California; VTS, New York, New York; and Coast Guard Command 

and Control Engineering Center, Portsmouth, VA. Interviews were conducted 

with the California Office of Oil Spill Prevention and Response, City of San 

Francisco Emergency Management, and Coast Guard personnel. Fieldwork was 

conducted from January 2008 to March 2008. 

Our review was conducted under the authority of the Inspector General Act of 

1978, as amended, and according to the Quality Standards for Inspections issued 

by the President’s Council on Integrity and Efficiency. 

Contractor support was used to assist in the review of the adequacy of the San 

Francisco Area Contingency Plan. RHH Associates, Inc. provides consulting 

services to private sector and public sector clients in marine safety, environmental 

protection, operational and regulatory compliance, maritime security, and marine 

emergency response management and mitigation, including planning, training, 

and exercises. The contractor provided subject matter expertise on oil spill and 

marine emergency response planning, and oil spill response management. The 

contractor has 22 years of experience in the Coast Guard, specializing in marine 

safety operations and emergency response management. Specifically, the 

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Appendix A 

Purpose, Scope, and Methodology 

contractor was involved in the development of the first five United States Area 

Contingency Plans in New England, and the design and execution of several 

domestic and international oil spill response exercises. The contractor has been a 

member of numerous oil spill management teams, and conducted training on the 

Incident Command System and other aspects of emergency response management 

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Appendix B 

Management Comments to the Draft Report 

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39
 
Appendix B 

Management Comments to the Draft Report 

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40
 
Appendix B 

Management Comments to the Draft Report 

Allision of the M/V COSCO BUSAN with the San Francisco-Oakland Bay Bridge 

41
 
Appendix B 

Management Comments to the Draft Report 

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42
 
Appendix B 

Management Comments to the Draft Report 

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43
 
Appendix C 

Letter from Speaker of the House Nancy Pelosi, and the Honorable 

Elijah E. Cummings 

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44
 
Appendix C 

Letter from Speaker of the House, Nancy Pelosi, and the Honorable 

Elijah E. Cummings 

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45
 
 

 

 

 

Appendix D 

San Francisco Area Contingency Plan Authorities 

The Coast Guard, the State of California OSPR, and the Responsible Party 

jointly manage coastal oil spills in California. A brief overview of the oil 

spill response and management authorities is discussed below followed by 

a flowchart of authorities for oil spill response in the United States. 

Oil Pollution Act of 1990: The Oil Pollution Act of 1990 was enacted 

after the Exxon Valdez mishap in 1989. According to 40 CFR Part 300, 

the National Contingency Plan provides “the organizational structure and 

procedures for preparing for and responding to discharges of oil...22 ” 

Flowing downward from the National Contingency Plan are the 

requirements for Regional Contingency Plans (RCP) and Area 

Contingency Plans (ACP). San Francisco’s Area Contingency Plan falls 

under the Region IX Region Contingency Plan. The San Francisco Area 

Contingency Plan (SFACP) of 2005 was in effect during the M/V COSCO 

BUSAN mishap. 

National Response Plan: The intent of The National Response Plan, 

developed in response to Homeland Security Presidential Directive 

(HSPD)-5, is to, “...align Federal coordination structures, capabilities and 

resources into a unified, all discipline and all-hazards approach to 

domestic incident management.” 23 The National Response Plan uses the 

National Incident Management System (NIMS) as its infrastructure. 24 

Integral to NIMS is the Incident Command System (ICS), which uses a 

Unified Command or Single Incident Commander concept to manage allhazards including oil spills. 

A Unified Command was established for the M/V COSCO BUSAN 

mishap and was manned by the Coast Guard as the FOSC, the State of 

California as the SOSC and the O’Brien’s Group as the Responsible Party 

for the M/V COSCO BUSAN. The Unified Command used the ICS as its 

framework in order to “... enable effective and efficient incident 

management by integrating a combination of facilities, equipment, 

personnel, procedures, and communications operating within a common 

organizational structure” 25 The National Response Plan provides the 

framework within which the tenets of the Oil Pollution Act of 1990 are 

enacted. 

22 40 CFR § 300.1. 

23 National Response Plan; December 2004, Page i. 

24 The National Response Plan was superseded by the National Response Framework on March 22, 2008. 25 National Incident Management System, FEMA 501/December 2007 (draft), Page 43. 

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Appendix D 

San Francisco Area Contingency Plan Authorities 

San Francisco Area Contingency Plan Authorities: The Oil Pollution 

Act of 1990 set forth the establishment of area committees in areas 

designated by the President. Federal, state, and local agencies compose 

these area committees. Additionally, each area committee is responsible 

for developing an Area Contingency Plan (ACP) under the direction of the 

Federal On-Scene Coordinator (FOSC). This contingency plan “...shall 

be adequate to remove a worst case discharge of oil or a hazardous 

substance, and to mitigate or prevent a substantial threat of such a 

discharge, from a vessel, offshore facility, or onshore facility operating in 

or near the geographic area” 26 Additional responsibilities of the area 

committees include pre-planning joint response efforts, shoreline cleanup, 

protection of sensitive environmental areas and the protection, rescue and 

rehabilitation of fisheries and wildlife. 

Memorandum of Agreement Between State of California and Coast 

Guard: A Memorandum of Agreement (MOA) was signed on June 2, 

1993, between the State of California and the Eleventh Coast Guard 

District. This MOA is an agreement of cooperation between the Coast 

Guard and the State of California with regard to each entity’s roles and 

responsibilities in oil pollution prevention and response. 

26 San Francisco Area Contingency Plan; October 2005; Section 1100. 

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National Contingency

Plan 

 

 

M/V COSCO 

BUSAN Response

 

 

 

 

 

 

Appendix D 

San Francisco Area Contingency Plan Authorities 

Homeland Security 

Presidential Directive

(HSPD-5) 

National Response Plan

National Response

Framework (3/22/08)

National Incident 

Management System 

(NIMS)

Incident Management 

System (ICS)

Unified Command

Federal On-Scene Coordinator 

(FOSC)

U.S. Coast Guard

State On-Scene Coordinator (SOSC)

Oil Spill Prevention & Response

Responsible Party (RP)

Regional Contingency

Plan (IX)

San Francisco Area

Contingency Plan 

Oil Pollution Act of 1990 

Homeland Security 

Presidential Directive 

(HSPD-5) 

National Response Plan 

National Response 

Framework (3/22/08) 

National Incident 

Management System 

(NIMS) 

Incident Management 

System (ICS) 

Unified Command 

Federal On-Scene Coordinator 

(FOSC) 

U.S. Coast Guard 

State On-Scene Coordinator (SOSC) 

Oil Spill Prevention & Response 

Responsible Party (RP) 

National Contingency 

Plan 

Regional Contingency 

Plan (IX) 

San Francisco Area 

Contingency Plan 

M/V COSCO 

BUSAN Response

 Oil Pollution Act of 1990 

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Appendix E 

San Francisco Area Committee Attendance 

San Francisco Bay and Delta Area Committee Meetings Attendees From: 

October 2005 to September 2007 

Source: ISPR 

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Appendix F 

Major Contributors to this Report 

Richard Johnson – Director, Coast Guard and Maritime Security Operations Division 

Robert Greene – Supervisory Auditor 

Lorinda Couch – Management Analyst 

Andrea Rambow – Management Analyst 

David DeHaven – Auditor 

Joseph Stone – Management Analyst 

Tessa May-Fraser – Program Analyst 

Robert Hazelton – Contractor Support 

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Appendix G 

Report Distribution.
 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chief of Staff 

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

USCG Audit Liaison 

Commandant, USCG 

Assistant Secretary, Policy 

Assistant Secretary, Public Affairs 

Assistant Secretary, Legislative Affairs 

Chief Privacy Officer 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees, as appropriate 

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Additional Information and Copies 

To obtain additional copies of this report, call the Office of Inspector General 

(OIG) at (202) 254-4199, fax your request to (202) 254-4305, or visit the OIG web 

site at www.dhs.gov/oig. 

OIG Hotline 

To report alleged fraud, waste, abuse or mismanagement, or any other kind of 

criminal or noncriminal misconduct relative to department programs or 

operations: 

• Call our Hotline at 1-800-323-8603; 

• Fax the complaint directly to us at (202) 254-4292; 

• Email us at DHSOIGHOTLINE@dhs.gov; or 

• Write to us at: 

DHS Office of Inspector General/MAIL STOP 2600, Attention: 

Office of Investigations - Hotline, 245 Murray Drive, SW, Building 410, 

Washington, DC 20528. 

The OIG seeks to protect the identity of each writer and caller. 

Additional Information and Copies 

To obtain additional copies of this report, call the Office of Inspector General 

(OIG) at (202) 254-4199, fax your request to (202) 254-4305, or visit the OIG web 

site at www.dhs.gov/oig. 

OIG Hotline 

To report alleged fraud, waste, abuse or mismanagement, or any other kind of 

criminal or noncriminal misconduct relative to department programs or 

operations: 

• Call our Hotline at 1-800-323-8603; 

• Fax the complaint directly to us at (202) 254-4292; 

• Email us at DHSOIGHOTLINE@dhs.gov; or 

• Write to us at: 

DHS Office of Inspector General/MAIL STOP 2600, Attention: 

Office of Investigations - Hotline, 245 Murray Drive, SW, Building 410, 

Washington, DC 20528. 

The OIG seeks to protect the identity of each writer and caller.