Federal safety officials on Tuesday determined that a failure by Truth Aquatics — the owner and operator of the Conception dive boat — to provide effective safety oversight was the probable cause of the vessel catching fire and sinking last year, killing 34 people near Santa Cruz Island.
The Conception, a 75-foot commercial vessel based at Sea Landing at the Santa Barbara Harbor, was anchored in Platts Harbor on the north side of Santa Cruz Island when it caught fire on Sept. 2, 2019.
Five crew members were asleep in their bunks in the wheelhouse and in the crew quarters on the upper deck, while one crew member and all 33 passengers were asleep in the bunk room below.
When the crew members awoke, the fire was well developed and beyond their capability to extinguish it, according to investigators.
One crew member and 33 passengers were killed.
The National Transportation Safety Board voted unanimously Tuesday to approve the finding that the probable cause of the fire and boat sinking was the failure by Truth Aquatics to provide effective oversight of its vessel and crew member operations, including requirements to ensure that a roving patrol was maintained.
That failure, the board decided, allowed a fire of unknown cause to grow, undetected, in the vicinity of the aft salon on the main deck.
“I hate the term accident in this case because, in my opinion, it is not an accident if you fail to operate your company safely,” Jennifer Homendy, a board member for the federal agency, said at the virtual hearing held in Washington, D.C.
Homendy spoke at last year’s news conferences in Santa Barbara in the wake of the incident, and she visited a sister ship to the ill-fated Conception dive boat.
Speaking to reporters after Tuesday’s hours-long meeting, NTSB chairman Robert Sumwalt directed a message to Truth Aquatics.
“Clean up your act,” Sumwalt said, adding that the Conception had several procedural deviations that were nonstandard or not following Truth Aquatics’ own procedures and U.S. Coast Guard regulations.
“If you see one of those, it might just be a one-off event, but we saw repeated cases of procedural deviation.”
Truth Aquatics, owned by Glen and Dana Fritzler, owned and operated the Conception and similar vessels. The company reportedly had a reputation for being good operators before last year’s incident.
Sumwalt said that if Truth Aquatics had ensured that an overnight roving patrol was maintained, the fire most likely would have been detected earlier, which would have increased the chances of the occupants sleeping in the bunk area to safely escape the pre-dawn fire.
The absence of the required roving patrol on the Conception delayed detection and allowed the fire to grow, according to investigators.
During the investigation, the NTSB found several “unsafe practices” on Truth Aquatics’ vessels, including a lack of crew training and emergency drills.
“In reviewing the company’s policies and procedures, along with the Coast Guard regulations, it is clear that Truth Aquatics had been deviating from required safe practices for some time,” according to the NTSB board’s report, released after the meeting. “If the company had been actively involved in ensuring the safe practices required by regulations enforced, most notably the requirement for a roving patrol, it is likely this accident would have not happened.”
The NTSB recommended that Truth Aquatics implement a safety management system.
“This tragedy did not need to happen,” Sumwalt said. “We hope that our actions from today will prevent such disasters in the future.”
He called the fatal fire and sinking a “terrible disaster.”
“It was preventable, and it should have been prevented,” Sumwalt said.
Contributing to the growth of the deadly blaze was the lack of a Coast Guard regulatory requirement for smoke detectors in all accommodation spaces, according to the NTSB board.
“I think we need to send a strong message to the U.S. Coast Guard,” Sumwalt said.
While the Conception had smoke detectors in the below-deck berthing area, they were not connected to one another or the wheelhouse, and no smoke detectors were in the salon, the common area above the sleeping quarters where investigators believe that the fire ignited.
In addition, the NTSB recommended that small passenger vessels have smoke detectors in all accommodation spaces, and require that all vessels with overnight accommodations have interconnected smoke detectors, Sumwalt said.
An interconnected smoke detector means one smoke detector alerts the remaining detectors.
“In this particular event, the smoke detectors were just in the bunk room,” Sumwalt said of the Conception. “The fire most likely did not originate in the bunk room.”
The NTSB found that contributing to the high loss of life were the inadequate emergency escape arrangements from the vessel’s bunk room, as both exited into a compartment that was engulfed in a fire, preventing escape.
The NTSB called for major safety improvements to small passenger vessels after the Conception investigation.
In addition, the NTSB wants the Coast Guard to require small passenger vessels with overnight accommodation to provide a secondary means of escape, into a different space, than the primary exit, so that a single fire will not impact both escape routes.
“Something that we saw in this tragedy,” Sumwalt said.
The Conception had two means of escape from the bunk room, according to investigators.
“However, both paths led to the salon, which was filled with heavy smoke and fire, and the salon compartment was the only escape path to exterior (weather) decks,” according to the NTSB’s post-meeting report. “Therefore, because there was fire in the salon, the passengers were trapped, and the crew was not able to reach them.
“If regulations had required the escape hatch to exit to a space other than the salon, optimally directly to the weather deck, the passengers and crew member in the bunk room would have likely been able to escape.”
There was little physical evidence for investigators to establish exactly when, how and where the blaze started because the vessel was damaged, according to the NTSB. The Conception burned to the ocean waterline and sank. It was recovered from the seabed.
The investigation relied on the interviews with surviving crew members, and their descriptions of the blaze at the time they discovered it, as well as previous boat passengers and an examination of a similar vessel in the Truth Aquatics fleet.
“Some people may walk away and say, ‘Well, I wish I knew what the ignition source was,’” Homendy said. “But the key here is that the focus should be on conditions present that allowed the fire to go undetected and to grow to a point where it prevented the evacuation. Those are the safety issues that we need to be focused on.”
Electrical systems, charging lithium batteries and devices, and improperly discarded smoking materials were potential ignition sources in the portion of the Conception’s salon.
According to investigators, Truth Aquatics had a small fire caused by unattended batteries being charged on the Conception’s sister vessel, the Vision, several months before the tragedy on the Conception. Two passengers caught that blaze, and it was quickly extinguished.
“This is something that needs to be taken seriously,” Sumwalt said of batteries. “We can’t say for certain what may have led to this (Conception) fire. We do know the Vision had a fire earlier.”
Interviews with the crew members and statements from previous passengers indicated that it was a common practice to recharge battery-powered devices overnight in the salon compartment, according to investigators.
The U.S. Attorney’s Office is conducting a criminal investigation of the accident, according to the NTSB.
“The assistant U.S. attorney assigned to the case requested the NTSB not interview the captain of the Conception out of concern that the interview could hinder the ability of their office to bring criminal charges against the captain,” a synopsis from the NTSB’s report stated.
“The NTSB obtained significant information from the other crew members; however, the Conception’s captain had many years of experience on the same vessel, so the owner and surviving crew members referred many of investigators’ questions to the captain, which remain unanswered.”
Investigators said the coroner’s reports documented that some of the passengers were wearing shoes, suggesting the occupants were awake and attempting to escape before being overcome with smoke. Staff believe most of the victims were awake but could not flee the bunk room before all were overcome by smoke inhalation.
All of the victims died of smoke inhalation, according to the Coroner’s Bureau.
The fire was already “well developed” when the captain made his distress call, investigators said.
“No one anticipated that this tragedy could happen in the way that it did,” NTSB vice chairman Bruce Landsberg said. “Sadly, we have learned otherwise.”
The five-member board voted unanimously Tuesday on the following findings:
» Weather and sea conditions were not factors in the accident.
» The use of alcohol or other tested-for drugs by the Conception deck crew was not a factor in the accident.
» The origin of the fire on the Conception was most likely inside the aft portion of the salon.
» Although 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.
» The exact timing of the ignition cannot be determined.
» Most of the victims were awake but could not escape the bunk room before all were overcome by smoke inhalation.
» The fire in the salon on the main deck would have been well-developed before the smoke activated the smoke detectors in the bunk room.
» Although the arrangement of detectors aboard the Conception met regulatory requirements, the lack of smoke detectors in the salon delayed detection and allowed for the growth of the fire, precluded firefighting and evacuation efforts, and directly led to the high number of fatalities.
» Interconnected smoke detectors in all accommodation spaces on subchapter T and subchapter K vessels would increase the chance that fires will be detected early enough to allow for successful firefighting and the evacuation of passengers and crew.
» The absence of the required roving patrol on the Conception delayed detection and allowed for the growth of the fire, precluded firefighting and evacuation efforts, and directly led to the high number of fatalities in the accident.
» The U.S. Coast Guard does not have an effective means of verifying compliance with roving patrol requirements for small passenger vessels.
» The Conception bunk room’s emergency escape arrangements were inadequate because both means of escape led to the same space, which was obstructed by a well-developed fire.
» Subchapter T (old and new) regulations are not adequate because they allow for primary and secondary means of escape to exit into the same space, which could result in those paths being blocked by a single hazard.
» Although designed in accordance with the applicable regulations, the effectiveness of the Conception’s bunk room escape hatch as a means of escape was diminished by the location of bunks immediately under the hatch.
» The emergency response by the Coast Guard and municipal responders to the accident was appropriate but unable to prevent the loss of life given the rapid growth of the fire at the time of detection and location of the Conception.
» Truth Aquatics provided ineffective safety oversight of its vessels’ operations, which jeopardized the safety of crew members and passengers.
» Had a safety management system been implemented, Truth Aquatics could have identified unsafe practices and fire risks on the Conception and taken corrective action before the accident occurred.
» Implementing safety management systems on all domestic passenger vessels would further enhance operators’ ability to achieve a higher standard of safety.
“This tragedy did not need to happen,” Sumwalt said. “We hope that our actions from today will prevent such disasters in the future.”
In September, more than 100 reports and documents, including interview transcripts, photographs, and other investigative materials, were made public in advance of an October hearing on the disaster at Santa Cruz Island.
— Noozhawk staff writer Brooke Holland can be reached at bholland@noozhawk.com. Follow Noozhawk on Twitter: @noozhawk, @NoozhawkNews and @NoozhawkBiz. Connect with Noozhawk on Facebook.