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The U.S. Coast Guard has released the marine casualty investigation report for the November 7th 2007 collision involving the 900-foot Cosco Busan vessel and the San Francisco-Oakland Bay Bridge.

The report outlines the contributing factors that led to the accident that resulted in the discharge of more than 53,000 gallons of oil into San Francisco Bay.

The report indicates the main causes of the accident were:

* Navigational error by the pilot of the Cosco Busan, who navigated the vessel at a high, unsafe speed in near-zero visibility, failed to properly monitor the vessel's position and progress, and lost situational awareness;

* Failure of the master of the Cosco Busan to adequately monitor the navigational actions of the pilot and to maintain sufficient situational awareness to question or correct navigational errors made by the pilot;

* Failure of the pilot and master to effectively communicate relevant navigational information with each other during the course of the voyage leading up to the casualty;

* Failure of the pilot and master to conduct a proper pilot-master exchange prior to getting underway;

* Failure of the master to adhere to restricted-visibility procedures in the vessel's safety management system; and

* Failure of the pilot and Cosco Busan's crew to employ proper bridge management team principles.

The US Coast Guard said the purpose of its marine casualty investigation was to "examine the causes of a marine casualty and to make recommendations to help avoid a similar incident."

The marine casualty investigation does not address spill response operations in detail.

The oil spill response was extensively investigated when the Coast Guard chartered a multi-agency Incident Specific Preparedness Review panel.

The panel issued a detailed report of its findings in Jan. 2008 and reported that despite early incorrect spill quantity estimates, spill response personnel acted on a "worst case scenario" basis, resulting in one of the most aggressive and successful responses in recent history, yielding an approximate 40 percent recovery rate of spilled oil.