Lack of Fire Training and Lithium-Ion Batteries Highlighted in Conception Boat Fire Report
By edhat staff
A collection of documents released by the National Transportation Safety Board (NTSB) points to lithium-ion batteries and electrical systems as potential sources of the Conception boat's deadly fire, as well as a lack of fire training for crew members.
Over 1,677 pages became available Wednesday showing details of NTSB's investigation of an incident that killed 34 people, the worst maritime disaster in California since the sinking of Brother Jonathan in 1865.
NTSB's factual report on "Fire and Explosions" concluded the cause of the fire is undetermined as no physical evidence was recovered that could be identified as an ignition source or indicate a specific ignition location. However, a small fire in 2018 involving lithium-ion batteries on Conception's sister boat pointed to a possible ignition source.
Labor Day, 2019
On Monday, September 2, 2019, the U.S. Coast Guard received a distress call at 3:14 a.m. of fire aboard the 75-foot small passenger vessel Conception, owned by Truth Aquatics. The vessel was anchored in Platts Harbor on the north side of Santa Cruz Island. It was carrying 39 persons, 6 of whom were crew.
The wood and fiberglass vessel had three levels: the upper deck, which included the wheelhouse, two crew staterooms, and a sun deck; the main deck, which included a salon with a galley and a large exterior deck; and the lower deck within the hull, which included passenger berthing (bunkroom), a shower room, an engine room, and a lazarette.
The Conception diving vessel (Photo: Truth Aquatics)
At the time the fire started, 5 crewmembers were asleep in their bunks in the wheelhouse and in the crew staterooms on the upper deck, and 1 crewmember and all 33 passengers were asleep in the bunkroom.
A crewmember sleeping in an upper deck stateroom was awakened by a noise and got up to investigate. He saw a fire at the aft end of the sun deck, rising up from the salon compartment below. The crewmember alerted the four other crewmembers sleeping on that deck.
As crewmembers awoke, the captain radioed a quick distress message to the Coast Guard before evacuating the smoke-filled wheelhouse. Unable to use the aft ladder, which was on fire, the crewmembers jumped down to the main deck (one crewmember broke his leg when he jumped) and tried to access the salon to reach the passengers below. The salon was fully engulfed by fire at the aft end and by thick smoke in the forward end.
Unable to open a window at the forward end of the salon and overwhelmed by smoke from the fire, the crew jumped overboard. Two crewmembers swam to the stern and re-boarded the vessel. Access to the salon through the aft corridor was blocked by fire, so, along with the captain who had also swum to the stern, they launched a small skiff and picked up the remaining two crewmembers in the water.
They transferred to a recreational vessel anchored nearby where the captain continued to radio for help, while two crewmembers returned to the waters around the burning Conception to search for possible survivors. No survivors were found.
About 78 minutes after the initial distress call, Coast Guard and other first responder boats arrived on the scene to extinguish the fire and search for survivors. Helicopters also aided in search efforts. The vessel burned to the waterline and, just after daybreak, sank in about 60 feet of water.
Thirty-three passengers and one crewmember died.
Lithium-Ion Batteries and Electrical Systems Possible Culprits
The NTSB report states the descriptions of the fire from the interviews of the crew indicate that the fire did not begin in the chain locker, the engine room, the lazarette, the galley, or the upper deck. The crew descriptions consistently identify the aft portion of the salon compartment on the starboard side as exhibiting more intense fire involvement at the time of discovery.
Based on the crew interviews and statements from previous passengers it is believed that there were numerous electronic devices being charged overnight in the aft portion of the salon. Batteries, specifically lithium-ion batteries, have a known and documented history of initiating accidental fires, the report states.
Safety recalls have been issued due to fires caused by electronic devices with defective batteries and chargers, the NTSB has investigated accidents in which battery failures led to fires, and the Federal Aviation Administration has strict regulations on the carriage of lithium-ion batteries aboard passenger aircraft based on a long history of incidents involving fires.
Additionally, a small fire involving the charging of a lithium-ion battery took place on board the Vision, a nearly identical boat of the Conception also owned by Truth Aquatics. On October 8, 2018, after 4:00 a.m., an awake passenger in the galley heard a “hissing” noise and a loud “bang” that came from the bookshelf located at the aft starboard side of the salon. The Conception did not have a bookshelf in the same area.
Another passenger also heard the noise stated that the fire looked like a “torch” flame, and a battery charger (which was charging two lithium-ion batteries) was emitting smoke. The passenger in the galley grabbed a dry chemical extinguisher from the galley, and both passengers went to the battery charger. The passenger without the fire extinguisher unplugged the charger, grabbed the unburnt end of the charger, brought it out to the main deck, and threw it into the rinse bin located under the stairs to the sun deck.
The passenger with the fire extinguisher stated he discharged one “shot” on the bookshelf after the battery charger had been removed to extinguish the smoldering paper books on the shelf. He then grabbed a sponge and wetted the bookshelf and items on it to prevent reignition.
The two batteries that caught fire were for an underwater diving light, and, according to the owner, the batteries had been removed from the light and were connected to a separate charger and plugged into a power strip on the bookshelf. The batteries were original to the dive light and were not replacements.
Afterward, the passenger went to the wheelhouse and informed the captain, who in turn examined the batteries and charger in the rinse bin. The batteries and charger were removed from the rinse bin and thrown overboard.
According to the captain on the Vision at the time, he photographed the charger and sent this to another captain in the Truth Aquatics fleet. Upon returning from the trip, he stated informed the owner of Truth Aquatics, Glen Fritzler, as well as the captain that took the Vision on its next trip.
Fritzler stated he was only made aware of the small fire on the Vision after the accident on the Conception and stated that at the end of each trip, each captain was required to complete a “Trip Payment Report,” which included a section to write any notable incidents that occurred. Investigators reviewed the completed form for the October 7–10 trip for the Vision and found
no entries in this section, according to the report.
"It is therefore reasonable to include lithium-ion battery failure as a possible ignition source in this fire scenario," the report states.
Another potential source of ignition is the vessel’s electrical system in the salon compartment. An energized electrical system has the potential to become a source of ignition when elements of the system age, are improperly installed or are accidentally damaged.
Crew interviews revealed that sometimes electrical work such as the replacement of lighting electrical fixtures in the salon was done by crew members who were not licensed electricians. Although examination of the Conception’s electrical system was not possible, NTSB examined theVision as the similarity of the two vessels would suggest similar electrical installations and condition, according to the report.
A Coast Guard inspection found 19 electrical system deficiencies throughout the vessel. Some of the deficiencies cited were a result of work being done at the time. Deficiencies in the salon and galley area included corrosion, improper connectors, and signs of overload on a power strip.
Deficiencies of this type can lead to electrical system failure conditions capable of initiating a fire. It is reasonable to include the vessel’s salon electrical distribution system as a possible ignition source in this fire scenario, the report states.
Roving Patrols and Fire Training
Conception crewmembers and former crewmembers interviewed by NTSB investigators stated that there was no formal watch rotation for the vessel. When passengers boarded the vessel the night before an early departure, it was common for there to be no crew onboard until hours after the passengers had arrived. While at anchor, no watch was set, and all crewmembers normally slept after the day’s activities had ended until the next morning, according to the report.
Per U.S. law (Title 46 United States Code Section 8102), "the owner, operator, or charterer of a vessel carrying passengers during the nighttime shall keep a suitable number of watchmen in the vicinity of cabins or staterooms and on each deck to guard against and give alarm in case of fire or other danger.”
The Conception's certificate of inspection included a provision requiring a roving patrol when passengers were in their bunks. Fritzler stated that there were no company-wide policies or procedures regarding watchstanding onboard its vessels; watches were at the discretion of the captain of each dive boat.
A captain of the Vision stated that he believed that having one of the crew sleep in the bunkroom “somehow fulfilled” the roving watch requirement. He said he had followed the practice that was shown to him when he began working for Truth Aquatics, and he thought “the boat's been operating this way for so long successfully after so many inspections that it must be fine.”
Further documentation and investigation show that crewmembers were not adequately trained by Truth Aquatics as required by law.
The owner, operator, or master of a small passenger vessel must “instruct each crew member, upon first being employed and prior to getting underway for the first time on a particular vessel and at least once every three months, as to the duties that the crew member is expected to perform in an emergency including, but not limited to, the emergency instructions listed on the emergency instruction placard.”
For small passenger vessels, the emergency instruction placard must include the actions to be taken in the event of fire, heavy weather, or man overboard. Training of crewmembers must be logged or otherwise recorded.
Current and former crewmembers interviewed by NTSB investigators described the hiring and training process for employees on board Truth Aquatics vessels.
A prospective employee was first invited to participate in a voyage without pay. During this voyage, the prospective employee was provided the opportunity to interact with and work alongside the crew, and the captain evaluated the person to determine whether they would be a “good fit.” Upon completion of the unpaid voyage, a suitable candidate was offered a job if there was an opening on the vessel. Once hired, the new employee began work immediately in their assigned position. Current and former crewmembers stated that there was no formal training (company-wide or aboard the vessel) for new employees prior to getting underway as a paid employee, according to the report.
The second captain, first deckhand, and second galleyhand told investigators that they had not participated in a fire drill aboard the Conception. The first deckhand stated that he had never pulled out a firehose on the vessel and had “never done a dry run on anything, with the exception of during the Coast Guard inspections.” Other former crewmembers told investigators that they had never participated in a fire drill.
Pending Lawsuits and Criminal Charges
Lawsuits from families of 32 of the victims and one crewmember have been filed against the Conception's operating company, Truth Aquatics, alleging the boat was in violation of Coast Guard regulations. Namely the lack of an overnight "roving safety watch," failure to provide a safe storing and charging area for lithium-ion batteries, and a lack of accessible emergency exits for below deck passengers.
In turn, Truth Aquatics, own by Glen and Dana Fritzler, has filed a legal claim to shield them from damages under a maritime law that limits liability for vessel owners.
The Conception's Captain, Jerry Boylan, may also face criminal charges including a federal manslaughter charge, as a federal grand jury has begun looking into whether a crime was committed.
Boylan was briefed in July on the evidence prosecutors have against him. Legal experts predict an obscure federal law known as the Seaman’s Manslaughter Statute may be enacted as it's used to punish negligent captains, engineers and pilots for deadly accidents, according to the Associated Press.
Simple negligence or misconduct by the captain or crew would need to be proven and a conviction could carry up to 10 years in prison.
A lawsuit filing by the Fritzler's show the company's owners has offered to settle the lawsuit with dozens of victims’ family members.
The thorough report covered everything from witness statements, toxicology reports, licenses and certifications, and vessel engineering.
Earlier this month the NTSB announced it will hold an Oct. 20 meeting on the agency's investigation of the fire. Their board will vote on the agency's findings, probable cause, and recommendations, as well as any changes to the draft final report.