• Most of the victims on Conception were awake but could not escape the bunk room before all were overcome by smoke inhalation.
• The source of ignition was not confirmed, although the electrical distribution system of the vessel, unattended batteries being charged and improperly discarded smoking materials were the most likely sources.
• Interconnected smoke detectors in all accommodation spaces on Subchapter T and Subchapter K vessels would increase the chance that fires would be detected early enough to allow for successful firefighting and the evacuation of passengers and crew.
• Emergency escape arrangements in Conception’s bunk room were inadequate because both means of egress led to the same space, which was obstructed by a well-developed fire.
• Implementing safety management systems on all domestic passenger vessels would further enhance operators’ ability to achieve a higher standard of safety.
