NTSB Report Condemns Crew, Owners, and Coast Guard Regulations

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The remains of the MV Conception’s hull, shortly before the vessel sank later that morning (Photo: Ventura County Fire Department)

The United States’ National Transportation Safety Board (NTSB) has unanimously ruled that the fire onboard the MV Conception was caused by ‘the failure of owners Truth Aquatics to provide effective oversight of its vessel and crew member operations,’ according to its official report.

The Conception liveaboard dive boat was moored off the coast of Santa Barbara on the final night of a three-day trip around Santa Cruz island, when it caught fire in the early hours of 2 September 2019. The ensuing fire spread rapidly, killing all 33 passengers and one crew member, and burned the vessel to the waterline. Initial reports into the incident cited a lack of a night patrol and inadequacies in the escape routes from the passenger sleeping quarters.

The cause of the fire remains unknown, but sea conditions and alcohol or drug use by the crew have been ruled out by the NTSB. The investigation found that it was ‘likely’ that the fire started inside the aft portion of the salon, and while 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.’

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This image circulated by the NTSB on Twitter shows an overload of equipment on charge in the Conception’s salon (NTSB_Newsroom)

Chillingly, the NTSB’s report also concluded that most of the victims were awake during the fire, but were overcome by smoke inhalation before they were able to escape. Even if they had not been overcome, escape would likely have been difficult – perhaps impossible – as both escape routes from the sleeping quarters opened into the saloon area, in which the fire most likely began. Further, the emergency escape hatch, while conforming with design regulations, was encumbered by passenger bunks.

While the Conception was properly fitted with working smoke detectors to approved regulations, they were installed throughout the passenger sleeping quarters but, crucially, not in the saloon area where it is thought the fire began. As a result, the fire was well established before the smoke could be detected by the devices in the sleeping quarters.

In addition to the lack of smoke detectors in the location where the fire started, the NTSB singled out the failure of the Conception’s crew to provide a roving patrol during the night, a United States Coast Guard (USCG) regulation which, according to the report, was routinely violated by employees of Truth Aquatics onboard both Conception and the company’s other boats. The crew were deemed to be insufficiently trained and Truth Aquatics ‘had been deviating from required safe practices for some time.’

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The blaze spread quickly and burned the Conception down to the waterline (Photo: Santa Barabara Fire Department)

Lawyers for Truth Aquatics have previously argued that a crew member had checked the saloon area some 30 minutes before the fire is thought to have begun, however, there is no apparent confirmation that they remained awake after doing so. ‘Had a crew member been awake, and patrolling the 75-foot-long Conception on the morning of the fire,’ said NTSB investigator Andrew Ehlers, ‘it is likely that he or she would likely have discovered the fire at an early stage allowing time to fight the fire and give warning to passengers and crew to evacuate.’ 

While concluding that the ultimate responsibility for the tragedy lies with the failure of the Conception’s crew to provide a roving patrol, which would likely have detected the fire before it spread and allowed the passengers to evacuate safely, the NTSB report also rebukes failures in existing USCG regulations. Among these are the lack of a regulatory requirement for smoke detectors to be present in all spaces used by passengers, and a lack of regulation that emergency exits from the sleeping quarters open into different areas of the vessel, in case one area becomes unavailable.

‘It is amazing we have an unattended room with batteries charging in it, a griddle, two burners as well as a refrigerator and we have no regulation that requires smoke detectors,’  said NTSB Vice Chairman Bruce Landsberg.

The NTSB has submitted a list of recommendations to the US Coast Guard for new regulations to be written in light of the tragedy, especially since the vessel, at least by design, conformed to existing legislation.

‘The Conception may have passed all Coast Guard inspections,’ said NTSB Chairman Robert L. Sumwalt, ‘but that did not make it safe. Our new recommendations will make these vessels safer, but there is no rule change that can replace human vigilance.’

The NTSB’s summary report can be found at https://go.usa.gov/x7a7G


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