Board says Truth Aquatics caused boat fire, blames lack of oversight
After more than a year-long investigation, the National Transportation Safety Board determined Tuesday that the probable cause of the Conception boat fire tragedy was the failure of Truth Aquatics Inc. to provide effective oversight of the vessel and crew member operations.
The fire claimed the lives of 34 individuals near Santa Cruz Island off the Santa Barbara coast on Sept. 2, 2019.
The board discussed its findings during a virtual meeting.
The board could not determine the origin area or cause of the fire from wreckage examination. But through interviews with the five surviving crew members, examination of the similar vessel Vision and statements from previous passengers, investigators were able to predict what the origin and cause of the fire relied on.
Board members proposed 18 findings as a result of the investigation.
The key findings of what led to the fire included the lack of a requirement of a roving patrol that was codified in U.S. law for nearly 150 years, the lack of the U.S. Coast Guard regulatory requirement for smoke detection in all accommodations spaces and inadequate emergency escape arrangements from the bunk room.
These reasons and more allowed for a fire of an unknown cause to grow undetected in the vicinity of the aft salon on the main deck, preventing escape and contributing to the high loss of life, according to the NTSB.
Staff also determined the emergency response to the accident was appropriate, but unable to prevent the loss of life.
Constructed in 1981, Conception’s purpose was to take recreational divers on day and overnight trips, and was constructed with fiberglass laid over plywood. The vessel was made before 1996, missing a new set of regulations as it was classified as an “existing vessel.”
The fire burned without intervention for around an hour and 40 minutes, while passengers and crew members were asleep, sinking Conception in about 61 feet of water in the inverted position.
The potential ignition sources of the aft portion of the salon included electrical systems, charging batteries and devices, improperly discarded smoking materials or some other unknown ignition source.
It was indicated from interviews that it was a common practice of Truth Aquatics vessels to recharge 15 to 20 battery-powered devices such as flashlights and cameras overnight in the salon department, completely unattended.
Eleven months prior to the Conception tragedy, another Truth Aquatics boat, Vision, had experienced a fire from unattended lithium ion batteries being charged, but two passengers quickly extinguished the fire.
With these factors in mind, board member Jennifer Homendy said the circumstances that allowed for the accidental fire did not rely on what actually started it.
“Some people may walk away and say, ‘Well, I wish I knew what the ignition source was,’” she stated. “But the key here is that the focus should be on the conditions that were present that allowed the fire to go undetected and to grow to a point where it prevented the evacuation.”
One condition she was referring to was the lack of interconnected smoke detectors (including lack of any detectors in the room in which the fire ignited), which board members said would have awakened the passengers and crew members who were all asleep at the time.
Another condition was that the two means of escape from the bunk room where the passengers slept both led through the same space, and they were insufficient for rapid evacuation. In addition, staff pointed out flaws in the egress configuration, which would have required all 39 individuals on board to climb a ladder, crawl to the center of a bunk, stand and pull up through the hatch.
“The configuration would have been challenging for anyone to navigate without practice, and further would have been extremely difficult to evacuate an injured or unconscious person through the hatch,” said Marcel Muise, the survival factors group chairman.
Andrew Ehlers, the operations group chairman, found that the requirement for a roving watch was underscored in the vessel’s certification.
“Had a crew member been awake, it was likely he or she would have discovered the fire at an early stage,” he said. “The absence of the required roving patrol delayed detection and allowed for the growth of the fire and directly led to the high number of fatalities in the accident.”
It was also determined that crew’s training lacked in critical areas, including many examples of lack of knowledge of emergency duties.
Three crew members had not even been involved in a fire drill since they’d been working on board. On top of that, in-person safety briefings with crew members were not completed until passengers had already slept on board.
“It was clear that the company was not verifying that the newest crew members understood or even read the policies,” said Carrie Bell, the human factors group chairman.
She referred to this failure as a “normalization of deviance,” desensitizing crew members to non-standard practices, and creating a poor overall safety culture and lack of involvement.
Many more seemingly minor oversights were found to contribute to the Conception fire, including a regulation that a PA system be audible in passenger accommodation spaces. Staff did not find the status of the PA system on Conception, but did find that the PA system on Vision had been disconnected in the passenger accommodation spaces “so that people sleeping in the area would not be bothered by routine announcements.”
This led staff to believe the same could have occurred on Conception, another alert system that could have awakened the sleeping passengers.
Staff found that weather and sea conditions were not factors in the accident, the use of alcohol or other drugs by the deck crew likely was not a factor, the exact timing of ignition cannot be determined and the U.S. Coast Guard does not have an effective means of verifying compliance with roving patrol requirements for small passenger vessels.
Most notably, finding No. 17 stated, “Had the safety management system been implemented, Truth Aquatics could have identified unsafe practices and fire risks on Conception and taken corrective action before the accident occurred.”
The NTSB made 10 new safety recommendations, seven for the U.S. Coast Guard, two for the Passenger Vessel Association, the Sport Fishing Association of California and the National Association of Charter Operators, and one reiteration of a previous recommendation.
Each recommendation addresses each oversight found in the Conception investigation, and they reiterated their previous recommendation for the U.S. Coast Guard to require safety management systems for all passenger vessels, an action Robert Sumwalde, the chairman of the NTSB, said is long overdue.
“The Congress mandated that 10 years ago. The NTSB recommended it eight years ago. It’s past time to act,” he said. “The recommendations that we’ve issued today, if implemented, and that’s the key, if implemented, would reduce the risk of future passenger fires going undetected. It would ensure that escape routes exit to different spaces, improving the chances for survival for passengers and crew.
“On behalf of all my colleagues on the board and the entire NTSB, we want to give our sincere condolences to the family and friends of those who have been lost in this tragedy,” Mr. Sumwalde said. “The reason that we are meeting and the whole reason for the NTSB safety investigations is to learn from this accident to prevent similar tragedies in the future.”
Truth Aquatics Inc. did not respond to requests for comment on the matter.