(WASHINGTON) — Three years after the fire aboard the Conception dive boat, the National Transportation Safety Board (NTSB) says more progress is needed on the safety recommendations it issued as a result of the investigation.
Conception was anchored in Platts Harbor, off Santa Cruz Island, Calif., when it caught fire in the early morning of Sept. 2, 2019. The vessel burned to the waterline and sank less than 100 feet from shore. The 34 people asleep below deck were trapped in the bunk room; 33 passengers and one crewmember died.
Following the investigation, the NTSB issued 10 new safety recommendations: seven to the U.S. Coast Guard, two to associations that have members operating small passenger vessels with overnight accommodations, and one to Truth Aquatics Inc., the operator of the vessel. The NTSB also reiterated its 2005 recommendation for the Coast Guard to require all U.S.-flag passenger vessels to implement a safety management system (SMS). Since 2005, the NTSB has investigated four passenger vessel accidents, including Conception, where the lack of an SMS was an issue.
Of the three associations with members operating small passenger vessels with overnight accommodations, only the Passenger Vessel Association has taken sufficient action to satisfy the NTSB recommendations, according to the agency. The Sportfishing Association of California and the National Association of Charterboat Operators have yet to respond.
The Elijah E. Cummings Coast Guard Authorization Act of 2020 mandates that the Coast Guard carry out all of the NTSB recommendations issued or reiterated as a result of the Conception investigation.
Operators of vessels with overnight accommodations are urged to:
• Install smoke detectors in all accommodation spaces and ensure they are interconnected so when one detector goes off, they all do. While the Conception berthing space did have smoke detectors, they were the only ones on the vessel and would only alarm locally in the berthing space and not throughout the entire vessel.
• Ensure that the primary and secondary emergency escape paths do not lead to the same space, which can be blocked by a single hazard. Conception had two means of escape from the lower deck bunk room, but both led into the salon on the deck above, which was filled with heavy smoke and fire. Tragically, the salon compartment was the only escape path to the outside weather deck. Because there was fire in the salon, the passengers and a crewmember were trapped below.
• Vessel owners and operators should review the requirements of the certificate of inspection (COI) and ensure they adhere to the conditions of operation such as designating and maintaining roving patrols at all times when bunks or berthing spaces are occupied. The NTSB’s investigation found that the Conception fire was uncontrollable by the time it was discovered because no crewmembers were assigned roving patrol duties on board the vessel, even though it was a condition of operation on their COI.
• Keep escape routes unobstructed at all times.
• Implement a safety management system. Had an SMS been implemented, Truth Aquatics could have identified unsafe practices and fire risks on Conception and taken corrective action before the tragedy occurred.
For more information on the lessons learned from the Conception accident and what you can do, learn about the NTSB investigation and read the accident report. Listen to the agency’s behind-the-scene podcast, and read Chairwoman Homendy’s call for action on the NTSB Safety Compass blog.