NTSB Determines Roving Patrol Would Have Prevented Conception Boat Fatalities
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. (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.