Original article from Undercurrent Magazine:
Full NTSB report can be found here
October 22, 2020
Trapped in a Tinderbox
The Conception Final Inquiry
Dear Fellow Diver
The National Transportation Safety Board members met October 20 to report on the tragic 2019 Labor Day fire aboard the California liveaboard dive boat MY Conception, which claimed 34 lives. While it is highly possible that the fire started among the passenger’s equipment batteries that were being charged in the vessel’s salon area, they could not confirm that. They could not discount the unsafe disposal of cigarettes, matches, etc., in a nearby garbage receptacle. NTSB Chairman Robert Sumwalt said, regardless of the fire source, the 33 passengers and one crew member below decks probably could have escaped if there had the blaze been detected early.
They confirmed that the fire had begun in the salon area of the fast burning fiberglass-over-plywood vessel (a common construction material for many sport craft). It went undiscovered for too long because, contrary to U.S. Coast Guard regulations, no crew member was awake and performing roving patrol duties, so there was no one to stem the fire before it got out of hand. Tourist vessels such as the Conception are required to have a permanently roving crew member at night while passengers are aboard, whether at sea or at the dock. Before departing, the Conception’s operator allowed passengers to overnight aboard while the vessel was still dockside. Neither night was there a roving crew patrol. The NTSB cited both the boat’s captain, Jerry Boylan, and Truth Aquatics Inc. for failing to provide a roving watch.
Thirty-two passengers and one crew member slept below decks in a crowded bunk room, arranged to include as many people as possible. Their exit was via a curved stairwell or an emergency hatch that was far from accessible; it was positioned over a top bunk and led into the same area as the stairs. NTSB member Jennifer Homendy described how she had encountered extreme difficulty when she tried to exit the bunkroom of Conception’s sister vessel Vision)via this emergency hatch exit; she suggested a lifejacket would have further impeded her.
The night of the fire, four of the crew of five were asleep in quarters on the top deck. They were awakened only by the crackling noise of the fire, which had already engulfed critical areas of the boat, so it was both impossible for them to either fight the fire or rescue the passengers and the fifth crew member below.
There were no smoke detectors in the salon where the fire took hold. Smoke rises, so the smoke detectors in the bunkroom would not have been triggered until it was too late. Some divers, trapped by the fire engulfing the salon, had put on their shoes before being overcome by smoke, indicating they were aware of the fire and were unable to escape, contrary to earlier speculation that they had died in their sleep. Furthermore, the PA system to the bunkroom in both the Conception and the Vision had been disconnected, so even if the fire had been caught earlier, the sleeping divers could not have been notified.
“It is amazing we have an unattended room (the salon) with batteries charging in it, a griddle, two burners as well as a refrigerator, and we have no regulation that requires smoke detectors,” NTSB Vice Chairman Bruce Landsberg said. An NTSB member recommended that all passenger areas in such craft should be fitted with interconnected smoke detectors, including, in this case, the salon.
The NTSB agreed that the perceived 30-year “safety record” of the boat’s owner, Truth Aquatics Inc., was, in fact, nothing more than a record of good luck. The NTSB censured the owner of the MY Conception noting that the crew had no proper safety management system; they had failed to provide a safety briefing before the vessel left port; and the crew had neither regularly practiced safety training nor held fire drills. Despite the company’s vessels being moored within feet of the company office, the owner, Glen Fritzler, had claimed that he had not been on board for a long time.
While admitting that fires do happen aboard vessels from time to time, the NTSB said it was the duty of the captain and the owner to mitigate the risk. A board member noted that since there was no escape from a vessel at sea, a fire aboard always needed to be discovered early if the passengers and vessel were to survive. It was clear that Truth Aquatics Inc. had ignored required safe practices for some time with all its vessels.
Years back, on the Conception’s sister vessel, the MY Vision, a battery recharging issue had caused a fire. It was apparently reported to Fritzler by both the passengers who tossed the offending battery over the side and the captain of Vision. A fire extinguisher had then been deployed to fight fires, but when asked about it, the owner denied knowledge, despite the damaged area of that boat being repaired.
The NTSB was also critical of both Truth Aquatics Inc. for its failure to keep proper records and the U.S. Coast Guard for its lack of oversight regarding the use of roving night patrols. It called on the Coast Guard to develop and implement an inspection program to verify that roving patrols are conducted as required.
This reporter was surprised that no one mentioned the FSS Code or International Code for Fire Safety Systems, a set of international treaties organized by the International Maritime Organization under the SOLAS Convention that are designed to reduce the risk of fire and aid in emergency response aboard commercial vessels.
NTSB Chairman Robert Sumwalt said, “The Conception may have passed all Coast Guard inspections, but that did not make it safe.”
Safety comes at a price. You may conclude that people lost their lives through negligence of the highest order by the U.S. Coast Guard, the Conception’s owner, and its captain.
You can read the NTSB report here.