Ineffective oversight named probable cause of Conception fire; NTSB calls for safety changes

WASHINGTON, D.C.—The National Transportation Safety Board (NTSB) found the probable cause of the fire onboard Conception was the failure of Truth Aquatics Inc. – the vessel’s owner – to provide effective oversight of its vessel and crew member operations including requirements to ensure a roving patrol was maintained.

NTSB’s five-member board voted to approve the investigators’ findings, probable cause, recommendations and the draft final report on the investigation into the deadly fire, Oct. 20. The blaze broke out in the early morning hours of Sept. 2, 2019 aboard the 75-foot commercial diving vessel while it was anchored in Platts Harbor off Santa Cruz Island. All 33 passengers and one crew member who were sleeping below deck when the blaze broke out died in the accident. Five crew members above deck were able to escape.

According to information presented by investigators on Oct. 20, the exact cause of the fire could not be determined but investigators identified electrical systems, charging batteries and devices, improperly discarded smoking materials or another unknown source as the most likely ignition source.

“The examination of the wreckage did not reveal evidence that indicated a probable origin area and cause of the fire,” NTSB Fire and Explosion Investigator Joseph Panagiotou said.

Panagiotou said because the vessel burned and sank, they had to rely on crew member statements, examination of a similar vessel in the Truth Aquatics fleet, Vision, and statements from previous passengers about typical operating practices on board to determine the cause and origin of the fire. They determined the fire originated in the aft part of the salon. Several crew members told investigators it was common for cameras, flashlights and other devices to be charging in the salon overnight.

Investigators told board members the absence of the required roving patrol delayed detection of the fire, allowed it to grow and directly led to the high number of fatalities. According to investigators, the captain said he believed having one staff member sleeping in the bunkroom fulfilled the roving patrol requirement.

Investigators also said Truth Aquatics provided ineffective safety oversight of its vessels’ operations, which jeopardized the safety of crew and passengers. Investigators went on to say Truth Aquatics lacked a Safety Management System and did not follow its Loss Control Program, lacked training in critical areas, lacked company oversight and had a poor overall safety culture.

“A grim picture of a charter boat company that repeatedly disregarded its procedures,” said NTSB Board Chair Robert Sumwalt.

The investigation also called into question U.S. Coast Guard regulations. Records show the Conception passed all recent safety inspections.

Investigation findings found a lack of U.S. Coast Guard regulations for smoke detection in all accommodation spaces in small vessels with overnight accommodations and the configuration of exits from the bunkroom contributed to the fire and its deadliness.

Current Coast Guard’s Chapter T regulations require two exits from the bunkroom but do not prohibit them from exiting into the same space. On Conception, the exits from the bunkroom, a spiral staircase and escape hatch above the top bunks, both led to the salon where investigators believe the fire started.

“Staff believes Chapter T regulations are not adequate because they allow for primary and secondary means of escape into the same space,” NTSB marine investigator Marcel Muise said.

The size of the emergency hatch – 22 inches by 22 inches – also came into question despite meeting Coast Guard requirements. Board members criticized it as inadequate.

The smoke detectors in the bunk area were not connected together in a unified fire detection and alarm system and there were no smoke detectors in the salon, but met current regulations.

“By the time smoke could reach the passenger bunkroom the fire would have grown and made the salon compartment impassable,” Panagiotou said.

NTSB made a slew of recommendations to the Coast Guard, including revising Chapter T regulations to require all small passenger vessels with overnight accommodations to have smoke detectors in all accommodation spaces, requiring vessels built prior to 1996 to have interconnected smoke detectors, requiring all small passenger vessels with overnight accommodations to provide a secondary means of escape into a different space than the primary exit, modifying regulations for small passenger vessels with overnight accommodations constructed prior to 1996 to ensure there are no obstructions to egress and coming up with an effective means of verifying compliance with the roving patrol requirement.

The board recommended until the Coast Guard requires a secondary means of exit into a different space, that the Coast Guard share the circumstance of the Conception accident with members and encourage members to make the change voluntarily.

A separate criminal investigation into the fire is still ongoing.