The National Transportation Safety Board (NTSB) has identified causes of an accident in which a container ship spilled thousands of gallons of fuel oil into the San Francisco Bay after striking a tower. According to the NTSB report, "a medically unfit pilot, an ineffective master, and poor communications between the two" were the factors that contributed to the November 7 crash.

The incident occurred in heavy fog when the container ship Cosco Busan left the Port of Oakland destined for South Korea. The report says the San Francisco Bay pilot issued directions that led the ship directly toward the support tower.

Although a direct hit was avoided, there was a 212-foot-long gash in the ship, and two fuel tanks and a ballast tank were breached. As a result, more than 50,000 gallons of fuel oil were released into the Bay, contaminating some 26 miles of shoreline and killing thousands of birds.

Stated Acting NTSB Chairman Mark V. Rosenker: "How a man who was taking a half-dozen impairing prescription medications got to stand on the bridge of a 68,000-ton-ship and give directions to guide the vessel through a foggy bay and under a busy highway bridge is very troubling." He said the crash "raises a great many questions about the adequacy of the medical-oversight system for mariners."

Rosenker said that, given the pilot's medical condition, the Coast Guard should have revoked his license. And the pilot should have provided better precommunication briefings. NTSB has made several recommendations in the wake of the incident. Among them is a requirement that "mariners report any substantive changes in their health or medication use that occur between required medical evaluations."