NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

The wreckage of the Conception dive boat lifted off the ocean floor on Sept 12, 2019 for further investigation. (Photo of KTLA aerial footage) title=
The wreckage of the Conception dive boat lifted off the ocean floor on Sept 12, 2019 for further investigation. (Photo of KTLA aerial footage)
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By edhat staff

The National Transportation Safety Board (NTSB) stated the Conception boat fire was preventable and the company Truth Aquatics Inc. failed to provide a roving patrol to ensure the safety of its passengers.

The NTSB conducted a board meeting Tuesday to review the agency’s investigation of the fire aboard the dive boat Conception off Santa Cruz Island on September 2, 2019. The 75-foot commercial diving vessel, with 33 passengers and six crew aboard, was anchored in Platts Harbor off Santa Cruz Island when it caught fire.

All 33 passengers and one crewmember were believed to be awake and died of smoke inhalation after they were trapped in the berthing area while a fire raged on the deck above. Both exits from the berthing area led to the fire- and smoke-filled enclosed area above, determined the NTSB.

During a media briefing, NTSB Chairman Robert L. Sumwalt stated this incident should have been prevented. He centered the blame on Truth Aquatics, the owning and operating company of the Conception, stating they failed to provide oversights and a roving patrol that would have likely saved lives.

"Clean up your act," Sumwalt directed to Truth Aquatics while saying there were a number of procedural deviations that were not standard and not following the Coast Guard, or even Truth Aquatics', own procedures. He continued by saying accidents are caused by people and organizations, and Truth Aquatics did not do what they were required to do to ensure the safety of their passengers and crew members.

The NTSB called for all vessels similar to the Conception with overnight accommodations to be required to have interconnected smoke detectors in all passenger areas. It also recommended that a secondary means of escape lead into a different space than the primary exit, in case a single fire blocks both escape paths.

Photo of Conception’s burned hull at dawn on Sept. 2, 2019, prior to sinking.
Photo of Conception’s burned hull at dawn on Sept. 2, 2019, prior to sinking. (Credit: Ventura County Fire Department)

The NTSB also called on the U.S. Coast Guard to develop and implement an inspection program to verify that roving patrols are conducted – as required – for the safety of sleeping passengers and crew. NTSB investigators found the absence of a required roving patrol on the Conception likely delayed the initial detection of the fire, allowed for its growth, precluded firefighting and evacuation efforts, and directly led to the high number of fatalities in the accident.

“The Conception may have passed all Coast Guard inspections, but that did not make it safe,” said Sumwalt. “Our new recommendations will make these vessels safer, but there is no rule change that can replace human vigilance.”

The recommendations to the Coast Guard would apply to vessels, like the Conception, that are under 100 gross tons and have overnight accommodations for 49 or fewer passengers that fall under Subchapter T of federal marine regulations. The NTSB’s recommendation on interconnected smoke detectors, meaning when one smoke detector alarms the remaining detectors also alarm, also would apply to larger Subchapter K vessels.

The NTSB also reiterated its call for small passenger vessels to be required to implement a safety management system to improve the safety culture of vessel owners and operators.

While the Conception had smoke detectors in the below-deck berthing area, they were not connected to each other or the wheelhouse, and there were no smoke detectors in the salon, the common area above the sleeping quarters where investigators believe the fire started. Because of the fire damage to Conception, which burned to the water line and then sank, there was little physical evidence for investigators to establish exactly how, when and where the fire started.

The NTSB Board determined the probable cause of the fire and subsequent sinking was the failure of Truth Aquatics to provide effective oversight of its vessel and crewmember operations, including requirements to ensure that a roving patrol was maintained, which allowed a fire of unknown cause to grow, undetected, in the vicinity of the aft salon on the main deck.

Contributing to the undetected growth of the fire was the lack of a Coast Guard regulatory requirement for smoke detection in all accommodation spaces. Contributing to the high loss of life were the inadequate emergency escape arrangements from the vessel’s bunkroom, as both exited into a compartment that was engulfed in fire, thereby preventing escape.

Sumwalt expressed his frustration with the Coast Guard and the lack of implementation of NTSB recommendations. Safety management systems were recommended in 2012 and congress mandated this ten years ago and "we're still waiting to see any semblance of a rule," he said.

He hopes this is a watershed event that will help change things in the industry and hopes this tragedy does not go to waste. The NTSB's recommendations are broad-reaching in hopes they are implemented to improve safety on all small passenger vessels. 

Ignition Source Cannot Be Determined

The NTSB states the origin of the fire on the Conception was likely inside the aft portion of the salon and the exact timing of the ignition is unclear.

Although a definitive ignition source cannot be determined, the most likely ignition sources include the electrical distribution system of the vessel, unattended batteries being charged, improperly discarded smoking materials, or another undetermined ignition source.

However, the probable cause was determined to be a failure of Truth Aquatics to provide effective oversight of its vessel and crewmember operations, including requirements to ensure that a roving patrol was maintained, which allowed a fire of unknown cause to grow, undetected, in the vicinity of the aft salon on the main deck. 

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 below deck.

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.

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, owned 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 have offered to settle the lawsuit with dozens of victims’ family members.

 

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15 Comments

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ChemicalSuperFreak Oct 20, 2020 07:41 PM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

Ultimately responsible, yes. However, the captain has to sleep too, and if they delegate this task and it's not done because the crewmember is lazy then how much responsibility would you put on the captain for that? I've personally witnessed Captain Jerry Boylan ban a diver from going in the water for the day because the diver was still intoxicated in the morning and smelled of liquor after a late night of drinking. My impression from that incident is that Jerry was a very strict captain and didn't take the rules, at least that one, as a suggestion. How he managed the crew and oversaw that they completed their duties at night is unknown to me. That said, I've done countless multiday dives on the Vision and Conception and never once saw a night watch while at anchor, and yes I'd often awaken in the middle of the night to get a snack from the salon or to use the bathroom. Again, this is when we'd anchor at a cove overnight. Often on these multiday dives the boat would drive 8-12 hours overnight to move from Santa Barbara Island to Santa Cruz Island, for example, and a very small contingent of the crew would be active throughout the night during the passage.

Basicinfo805 Oct 20, 2020 08:43 PM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

So what are you saying chemfreak? Sounds like negligence was routine on that vessel but also that you think the capt. was ... I'm not sure. I've been a USCG licensed captain and I can tell you he is THE one person responsible for the boat and everyone on it. Period. I feel sorry for the whole thing, captain included, but the passengers and their families were the victims of big time negligence here. End of story.

ChemicalSuperFreak Oct 20, 2020 10:01 PM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

BASIC: My impression of the captain was that he seemed responsible, and I acknowledged that the buck stops with him in the end. If he identified a crew member not doing their duty, he should have removed that member from the crew. However I was merely a passenger and without knowledge of the regulations you captains must adhere to. Some additional thoughts. During the safety briefing, which included a "blink and you'll miss it" mention and gesture towards the safety hatch in the floor of the salon, we were never told that a night watch would be employed, nor were we told of fire suppression systems or smoke detectors. The briefings mainly discussed that the boat was dive-tracker enabled, where the life rafts/vest were, how to go up and down the stairs safely, and what to do if we heard the underwater alarm. This was the standard briefing, regardless of which boat I was on or who the captain was, and I've been on all three boats multiple times. In hindsight, much more could have been explained or emphasized. Knowing now that a night watch was required all those nights I'd slept aboard, I'd have to agree with you that negligence was routine in that respect. Additionally, I always had concerns about the charging stations, which were habitually overloaded with smartphones, tablets, laptops, and dive batteries for lights and cameras. The salon was always light up like a Christmas tree and it seemed to get worse each passing year. More importantly, the charging stations were in the salon, where a "wetsuits are okay" policy was in place, and most of the charging stations were inches from diver's rear ends, still dripping wet from their last dive.

A Little Birdy Oct 20, 2020 08:55 PM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

I know that the Captain was personal friends with many members of the dive charter group who charted the trip and ulimately perished. I can't imagine how horrible he and the crew must feel about being the only survivors and for being responsible for the massive loss of life on their watch. I know that is sounds like the Captain (and Truth Aquatics) are ultimately responsible, but feel that the Captain and crew has suffered enough. I lost a dear friend on this fateful voyage and think that this experience is more than enough punishement for him and his crew. Jail time will not bring our loved ones back. Lets please hope that regulations are instated and this never happens again.
Peace

a-1603253116 Oct 20, 2020 09:05 PM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

I wish those who still suffer from this disaster well. But it's obvious a watch would've helped. Why wasn't someone on duty overnight?! This is why regulation is needed, because people, organizations, companies don't do what they should or follow best practice. How would any of you feel if hospitals weren't regulated by written regulations, or didn't follow them? If entities such as fishing charters don't follow public, published regulations, they deserve punishment.

Lucky 777 Oct 21, 2020 07:18 AM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

I waited for the report to see who it was who was assigned to be the Night Watch, because it was that person's negligence that let the fire catch and spread before detected. NOW we know that, contrary to maritime convention and law, it was the standard to NOT HAVE a night watch on this boat. Inexcusable.

Alexblue Oct 21, 2020 01:37 PM
NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities

Birdy, I am so sorry for your loss and for all
Those who lost loved ones on the Conception. I hope that the legacy of this is industry wide change to make sure it doesn’t happen again. I can’t imagine the Captain’s life in the wake of this, just brutal and crushing guilt I would think. I don’t know that putting him in jail would be of any benefit, personally I don’t think so, but I might feel differently if I’d lost someone on that boat—I probably would.

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