Fire Aboard Small Passenger Vessel Conception, Platts Harbor, Channel Islands National Park, Santa Cruz Island, 21.5 miles South-Southwest of Santa Barbara, California

Fire Aboard Small Passenger Vessel Conception

Platts Harbor, Channel Islands National Park,

Santa Cruz Island, 21.5 miles South-Southwest of

Santa Barbara, California

September 2, 2019

Marine Accident Report

NTSB/MAR-20/03

PB2020-101011

National

Transportation

Safety Board

NTSB/MAR-20/03

PB2020-101011

Notation 65936

Adopted October 20, 2020

Marine Accident Report

Fire Aboard Small Passenger Vessel Conception

Platts Harbor, Channel Islands National Park, Santa Cruz Island,

21.5 miles South-Southwest of Santa Barbara, California

September 2, 2019

National

Transportation

Safety Board

490 L’Enfant Plaza SW

Washington, DC 20594

National Transportation Safety Board. 2020. Fire Aboard Small Passenger Vessel Conception

Platts Harbor, Channel Islands National Park, Santa Cruz Island, 21.5 miles South-Southwest of

Santa Barbara, California, September 2, 2019. Marine Accident Report NTSB/MAR-20/03.

Washington, DC.

Abstract: This report discusses the September 2, 2019, fire on board the 75-foot-long small

passenger vessel Conception, operated by Truth Aquatics, Inc., in Platts Harbor on the north side

of Santa Cruz Island, 21.5 nautical miles south-southwest of Santa Barbara, California. Thirty-

three passengers and one crewmember died. Safety issues identified in this report include the lack

of small passenger vessel regulations requiring smoke detection in all accommodation spaces, the

lack of a roving patrol, small passenger vessel construction regulations for means of escape, and

ineffective company oversight. As part of its accident investigation, the National Transportation

Safety Board makes ten new safety recommendations to the US Coast Guard, associations that

have members operating small passenger vessels with overnight accommodations, and Truth

Aquatics, Inc.; the NTSB reiterates one safety recommendation to the Coast Guard.

The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation,

railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the

Independent Safety Board Act of 1974, to investigate transportation accidents, determine the probable causes of the

accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of

government agencies involved in transportation. The NTSB makes public its actions and decisions through accident

reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,

“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are

not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal

Regulations section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to

improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In

addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an

accident in a civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code

section 1154(b)).

For more detailed background information on this report, visit the NTSB investigations website and search for NTSB

accident ID DCA19MM047. Recent publications are available in their entirety on the NTSB website. Other

information about available publications also may be obtained from the website or by contacting—

National Transportation Safety Board

Records Management Division, CIO-40

490 L’Enfant Plaza, SW

Washington, DC 20594

(800) 877-6799 or (202) 314-6551

Copies of NTSB publications may be downloaded at no cost from the National Technical Information Service, at the

National Technical Reports Library search page, using product number PB2020-101011. For additional assistance,

contact—

National Technical Information Service

5301 Shawnee Rd.

Alexandria, VA 22312

(800) 553-6847 or (703) 605-6000

NTIS website

NTSB Marine Accident Report

Contents

Contents .......................................................................................................................................... i

Figures and Tables ....................................................................................................................... iii

Acronyms and Abbreviations .......................................................................................................v

Executive Summary ..................................................................................................................... vi

1 Factual Information ..............................................................................................................1

1.1 Background .............................................................................................................................1

1.2 Accident Narrative ..................................................................................................................7

1.3 Search and Rescue ................................................................................................................13

1.4 Injuries ..................................................................................................................................18

1.5 Vessel Information ................................................................................................................20

1.5.1 Applicable Regulations .............................................................................................20

1.5.2 Main Engines and Propulsion ...................................................................................20

1.5.3 Electrical Generation and Distribution .....................................................................20

1.5.4 Air Conditioning System and Ventilation.................................................................23

1.5.5 Auxiliary Systems .....................................................................................................25

1.5.6 Galley Equipment .....................................................................................................26

1.5.7 Maintenance and Repair ...........................................................................................26

1.5.8 Certification, Inspections, and Examinations ...........................................................27

1.6 Accident Damage ..................................................................................................................29

1.7 Operations .............................................................................................................................32

1.7.1 Charter Company ......................................................................................................32

1.7.2 Company Information ...............................................................................................32

1.7.3 Company Loss Control Program ..............................................................................34

1.7.4 Watchstanding...........................................................................................................37

1.8 Survival Factors ....................................................................................................................38

1.8.1 Station Bill ................................................................................................................39

1.8.2 Passenger Manifest and Accountability ....................................................................40

1.8.3 Safety Briefing ..........................................................................................................40

1.8.4 Smoke Detectors and Firefighting Equipment ..........................................................41

1.8.5 Means of Escape and Egress .....................................................................................44

1.8.6 Lifesaving Appliances ..............................................................................................46

1.8.7 Emergency Drills ......................................................................................................47

1.9 Personnel Information ...........................................................................................................48

1.9.1 Crew Recruitment and Training ................................................................................48

1.9.2 Crew Licensing and Certification .............................................................................49

1.9.3 Toxicological Testing ...............................................................................................50

1.10 Waterway Information ..........................................................................................................51

1.11 Meteorological Information ..................................................................................................51

1.12 Postaccident Actions .............................................................................................................51

1.13 Similar Small Passenger Vessel Accidents and Related NTSB Safety Recommendations

Previously Issued ...........................................................................................................................53

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1.13.1 Passenger Ferry Andrew J. Barberi – 2003 ..............................................................53

1.13.2 Passenger Ferry Andrew J. Barberi – 2010 ..............................................................54

1.13.3 Seastreak Wall Street – 2013 ....................................................................................54

1.13.4 Island Lady – 2018....................................................................................................54

1.13.5 Vision – 2018 ............................................................................................................55

1.13.6 Red Sea Aggressor – 2019 ........................................................................................56

2 Analysis ................................................................................................................................57

2.1 General ..................................................................................................................................57

2.2 Exclusions .............................................................................................................................57

2.2.1 Weather .....................................................................................................................57

2.2.2 Alcohol and Other Drugs ..........................................................................................57

2.3 Origins and Potential Sources of the Fire .............................................................................57

2.3.1 Area of Origin ...........................................................................................................58

2.3.2 Ignition ......................................................................................................................60

2.4 Cause of Death ......................................................................................................................62

2.5 Fire Detection........................................................................................................................62

2.6 Roving Patrol ........................................................................................................................65

2.7 Means of Escape ...................................................................................................................67

2.8 Search-and-Rescue Efforts....................................................................................................69

2.9 Oversight ...............................................................................................................................69

3 Conclusions ..........................................................................................................................74

3.1 Findings.................................................................................................................................74

3.2 Probable Cause......................................................................................................................75

4 Recommendations ...............................................................................................................76

4.1 New Recommendations ........................................................................................................76

4.2 Recommendation Reiterated in this Report ..........................................................................77

Appendix A Investigation ............................................................................................................78

Appendix B Consolidated Recommendation Information .......................................................81

Appendix C Small Passenger Vessel Casualty Data Study ......................................................84

References .....................................................................................................................................87

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iii

Figures and Tables

Figure 1. Preaccident photo of Conception .................................................................................... 1

Figure 2. Port side of Conception's salon looking aft .................................................................... 2

Figure 3. Conception simple plan and profile views. .................................................................... 3

Figure 4. Aft main deck of Conception during a previous voyage ................................................ 4

Figure 5. Conception bunkroom arrangement ............................................................................... 5

Figure 6. Vision's and Conception's escape hatches ....................................................................... 6

Figure 7. Conception accident voyage ........................................................................................... 8

Figure 8. Devices charging in Conception's salon. ........................................................................ 9

Figure 9. Conception forward salon windows ............................................................................. 11

Figure 10. Conception on fire ...................................................................................................... 12

Figure 11. Accident site in relation to emergency response assets .............................................. 14

Figure 12. Conception prior to sinking ........................................................................................ 17

Figure 13. Salvaged hull of Conception ....................................................................................... 21

Figure 14. Bunkroom emergency lighting and public address system speaker on Vision ........... 22

Figure 15. Starboard-side main deck of Conception.................................................................... 23

Figure 16. Port side of Conception’s bunkroom. ......................................................................... 24

Figure 17. Truth Aquatics Engine Room Check Log .................................................................. 27

Figure 18. Toilets and stairway to upper deck of Conception ..................................................... 29

Figure 19. Conception wreckage layout at Port Hueneme........................................................... 30

Figure 20. Below-deck areas of Conception ................................................................................ 30

Figure 21. Conception main deck wreckage ................................................................................ 31

Figure 22. Postaccident photo of bunkroom ................................................................................ 32

Figure 23. Power cable for lighting routed through ventilation grille ......................................... 34

Figure 24. Fire at sea emergency instructions .............................................................................. 39

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Figure 25. Truth Aquatics “Welcome Aboard” information ....................................................... 41

Figure 26. Galley of Conception .................................................................................................. 42

Figure 27. Interior view of Conception bunkroom ...................................................................... 43

Figure 28. Staircase from salon leading down to bunkroom ....................................................... 45

Figure 29. Conception bunkroom escape hatch ........................................................................... 45

Figure 30. Conception firefighting equipment, lifesaving appliances, and evacuation plan ....... 46

Figure 31. Postaccident photo of Conception's skiff ................................................................... 47

Figure 32. Postaccident modifications made to Vision ................................................................ 53

Figure 33. Battery charger that caught fire on Vision. ................................................................. 55

Table 1. Initial VHF distress communications between the captain of the Conception and Coast

Guard Sector Los Angeles/Long Beach ........................................................................................ 13

Table 2. VHF communications between Coast Guard Sector Los Angeles/Long Beach and the

Grape Escape ................................................................................................................................ 15

Table 3. Summary of resources assigned in the initial response .................................................. 18

Table 4. Injuries sustained in the Conception accident ................................................................ 19

Table 5. Number of small passenger vessels by initial event type based on the NTSB

classification’s ten most common vessel types ............................................................................. 85

Table 6. Fatalities and injuries by vessel type .............................................................................. 86

NTSB Marine Accident Report

Acronyms and Abbreviations

AC alternating current

AIS automatic identification system

ATF Bureau of Alcohol, Tobacco, Firearms and Explosives

cfm cubic feet per minute

CFR Code of Federal Regulations

COI Certificate of Inspection

CPR cardiopulmonary resuscitation

DC direct current

EMT emergency medical technician

FBI Federal Bureau of Investigation

FRP fiberglass-reinforced plastic

GPS global positioning system

hp horsepower

mph miles per hour

MSD Marine Safety Detachment

MSIB Marine Safety Information Bulletin

NAVTEX Navigational Telex

NBVC Naval Base Ventura County

NTSB National Transportation Safety Board

OCMI Officer in Charge, Marine Inspection

OSC on-scene coordinator

POB persons on board

RB-M response boat-medium

SCC sector command center

SMS safety management system

UMIB Urgent Marine Information Broadcast

VCFD Ventura County Fire Department

VHF very high frequency

NTSB Marine Accident Report

Executive Summary

Accident

About 0314 Pacific daylight time on September 2, 2019, the US Coast Guard received a

distress call from the Conception, a 75-foot-long small passenger vessel operated by Truth

Aquatics, Inc. The vessel was anchored in Platts Harbor on the north side of Santa Cruz Island,

21.5 nautical miles south-southwest of Santa Barbara, California, when it caught fire. When the

fire started, 5 crewmembers were asleep in their bunks in the crew berthing on the upper deck, and

1 crewmember and all 33 passengers were asleep in the bunkroom below. A crewmember sleeping

in an upper deck berth was awakened by a noise and got up to investigate. He saw a “glow” outside.

Realizing that there was a fire rising up from the salon compartment directly below, the

crewmember alerted the four other crewmembers sleeping on the upper deck.

The captain was able to radio a quick distress message to the Coast Guard. Crewmembers

jumped down to the main deck and attempted to access the salon to assist the passengers and

crewmember in a bunkroom below the main deck but were blocked by fire and overwhelmed by

thick smoke. The five surviving crewmembers jumped overboard. Two crewmembers swam to the

stern, re-boarded the vessel, and found the access to the salon through the aft corridor was also

blocked by fire, so, along with the captain who also had swum to the stern, they launched the

vessel’s skiff and picked up the remaining two crewmembers in the water. The crew transferred to

a recreational vessel anchored nearby where the captain continued to radio for help, while two

crewmembers returned to the waters around the burning Conception to search for possible

survivors.

The Coast Guard and other first responder boats began arriving on scene at 0427. Despite

firefighting and search and rescue efforts, the vessel burned to the waterline and sank just after

daybreak, and no survivors were found. Thirty-three passengers and one crewmember died. The

surviving crew were transported to shore, and two were treated for injuries. Loss of the vessel was

estimated at $1.4 million.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the

accident on board the small passenger vessel Conception was the failure of Truth Aquatics, Inc.,

to provide effective oversight of its vessel and crewmember operations, including requirements to

ensure that a roving patrol was maintained, which allowed a fire of unknown cause to grow,

undetected, in the vicinity of the aft salon on the main deck. Contributing to the undetected growth

of the fire was the lack of a United States Coast Guard regulatory requirement for smoke detection

in all accommodation spaces. Contributing to the high loss of life were the inadequate emergency

escape arrangements from the vessel’s bunkroom, as both exited into a compartment that was

engulfed in fire, thereby preventing escape.

Investigative Constraints

The Office of the US Attorney is conducting a criminal investigation of this accident. The

Assistant US Attorney assigned to the case requested the National Transportation Safety Board

(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. The NTSB obtained

significant information from the other crewmembers; however, the Conception’s captain had many

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vii

years of experience on the same vessel, so the owner and surviving crewmembers referred many

of investigators’ questions to the captain, which remain unanswered. The Office of the US Attorney

also requested that NTSB investigators not interview the first galley hand, who was hospitalized

at the time, or any Truth Aquatics employee responsible for operations.

From September 8 to 10, 2019, the Office of the US Attorney served search warrants on

the offices and two remaining vessels of Truth Aquatics; the NTSB was not invited to participate.

The search warrants resulted in the seizure of thousands of pages of documents and records.

Computers, security camera servers, and items such as fans, smoke detectors, and heat sensors

from each vessel were also seized. Truth Aquatics was not able to provide records or information

to NTSB investigators after the search warrants were executed. Scans of the seized documents and

records were not provided to NTSB investigators until February 2020, and no electronic evidence

recovered from computers and servers was included in the materials provided.

These impediments delayed and complicated the NTSB’s investigation, but they did not

affect its quality, as investigators used the factual information collected to complete an accurate,

safety-focused investigation (see Appendix A for more details on the investigation).

Safety Issues

The safety issues identified in this accident, some of which have been identified in previous

accidents involving passenger vessels, include the following:

• Lack of small passenger vessel regulations requiring smoke detection in all

accommodation spaces. In accordance with the fire safety regulations applicable to the

Conception in Title 46 Code of Federal Regulations Subchapter T, the only compartment

that was required to be fitted with smoke detectors was the passenger bunkroom, since it

was the vessel’s only overnight accommodation space.

The Conception was equipped with

two modular smoke detectors in the bunkroom—one mounted on the overhead of each of

the port and starboard aisles. The Conception had no smoke detectors anywhere in the main

deck salon area where crewmembers reported seeing the fire. The nearest heat detector was

well forward in the galley, a deck above the bunkroom, and was not intended to be utilized

as a fire detector for the entire salon. Additionally, all detectors aboard the vessel only

sounded locally. Although the Conception met the regulatory compliance for smoke

detectors in the bunkroom where the passengers and crewmember slept, the fire above them

in the salon would have been well developed before the smoke activated these detectors.

• Lack of a roving patrol. NTSB investigators found that, prior to the accident, the

Conception and other Truth Aquatics vessels were regularly operating in contravention of

the regulations and the vessel’s Certificate of Inspection, which required a roving patrol at

night and while passengers were in their bunks to guard against, and give alarm in case of,

a fire, man overboard, or other dangerous situation. During the investigation, NTSB staff

visited other dive boats operating from Southern California ports and harbors and spoke

with their owners/operators. During informal discussions, all owners/operators stated that

night patrols were assigned whenever passengers were aboard, but the procedures for the

patrols varied greatly. When asked by investigators, Coast Guard inspectors stated that they

According to Title 46 Code of Federal Regulations 175.400, accommodation spaces include those spaces used

as a public space, dining room or mess room, lounge or café; overnight accommodation space; or washroom or toilet

space. On board the Conception, the accommodation spaces included the salon, bunkroom, and shower room.

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viii

could not verify compliance with the roving patrol requirement, since inspections were not

conducted during overnight voyages with passengers embarked.

• Small passenger vessel construction regulations for means of escape. The

Conception was designed in accordance with the regulations in Subchapter T in force at

the time of construction. As such, the vessel was required to have at least two emergency

egress pathways from all areas accessible to passengers. The Conception had two means

of escape from the bunkroom: spiral stairs forward and an escape hatch aft, accessible from

either port or starboard aisles by climbing into one of the top aftermost inboard bunks.

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. 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 crewmember in the

bunkroom would have likely been able to escape.

• Ineffective company oversight. During the investigation, the NTSB found several unsafe

practices on company vessels, including a lack of crew training, emergency drills, and the

roving patrol. 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. If the company had been actively involved in ensuring the safe

practices required by regulations were enforced, most notably the requirement for a roving

patrol, it is likely this accident would have not happened. Had a safety management system

been in place at Truth Aquatics, it would have likely included procedures for roving patrols

that complied with regulations and a company-involved audit process for identifying and

correcting when non-conformities with the patrol requirements existed.

Findings

1. Weather and sea conditions were not factors in the accident.

2. The use of alcohol or other tested-for drugs by the Conception deck crew was not a factor in

the accident.

3. The origin of the fire on the Conception was likely inside the aft portion of the salon.

4. 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.

5. The exact timing of the ignition cannot be determined.

6. Most of the victims were awake but could not escape the bunkroom before all were overcome

by smoke inhalation.

7. The fire in the salon on the main deck would have been well developed before the smoke

activated the smoke detectors in the bunkroom.

8. 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 in the accident.

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9. 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.

10. 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.

11. The US Coast Guard does not have an effective means of verifying compliance with roving

patrol requirements for small passenger vessels.

12. The Conception bunkroom’s emergency escape arrangements were inadequate because both

means of escape led to the same space, which was obstructed by a well-developed fire.

13. Subchapter T regulations (Old and New) 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.

14. Although designed in accordance with the applicable regulations, the effectiveness of the

Conception’s bunkroom escape hatch as a means of escape was diminished by the location

of bunks immediately under the hatch.

15. The emergency response by the Coast Guard and municipal responders to the accident was

appropriate but was unable to prevent the loss of life given the rapid growth of the fire at the

time of detection and location of the Conception.

16. Truth Aquatics provided ineffective oversight of its vessels’ operations, which jeopardized

the safety of crewmembers and passengers.

17. 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.

18. Implementing safety management systems on all domestic passenger vessels would further

enhance operators’ ability to achieve a higher standard of safety.

Recommendations

New Recommendations

As a result of its investigation of this accident, the NTSB makes the following ten new safety

recommendations:

To the US Coast Guard

Revise Title 46 Code of Federal Regulations Subchapter T to require that newly

constructed vessels with overnight accommodations have smoke detectors in all

accommodation spaces. (M-20-14)

Revise Title 46 Code of Federal Regulations Subchapter T to require that all vessels

with overnight accommodations currently in service, including those constructed

prior to 1996, have smoke detectors in all accommodation spaces. (M-20-15)

Revise Title 46 Code of Federal Regulations Subchapter T and Subchapter K to

require all vessels with overnight accommodations, including vessels constructed

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prior to 1996, have interconnected smoke detectors, such that when one detector

alarms, the remaining detectors also alarm. (M-20-16)

Develop and implement an inspection procedure to verify that small passenger vessel

owners, operators, and charterers are conducting roving patrols as required by Title

46 Code of Federal Regulations Subchapter T. (M-20-17)

Revise Title 46 Code of Federal Regulations Subchapter T to require newly

constructed small passenger vessels with overnight accommodations to provide a

secondary means of escape into a different space than the primary exit so that a single

fire should not affect both escape paths. (M-20-18)

Revise Title 46 Code of Federal Regulations Subchapter T to require all small

passenger vessels with overnight accommodations, including those constructed prior

to 1996, to provide a secondary means of escape into a different space than the

primary exit so that a single fire should not affect both escape paths. (M-20-19)

Review the suitability of Title 46 Code of Federal Regulations Subchapter T

regulations regarding means of escape to ensure there are no obstructions to egress

on small passenger vessels constructed prior to 1996 and modify regulations

accordingly. (M-20-20)

To the Passenger Vessel Association, Sportfishing Association of California, and National

Association of Charterboat Operators

Until the US Coast Guard requires all passenger vessels with overnight

accommodations, including vessels constructed prior to 1996, to have smoke

detectors in all accommodation spaces, share the circumstances of the Conception

accident with your members and encourage your members to voluntarily install

interconnected smoke and fire detectors in all accommodation spaces such that when

one detector alarms, the remaining detectors also alarm. (M-20-21)

Until the US Coast Guard requires small passenger vessels with overnight

accommodations to provide a secondary means of escape into a different space than

the primary exit, share the circumstances of the Conception accident with your

members and encourage your members to voluntarily do so. (M-20-22)

To Truth Aquatics, Inc.

Implement a safety management system for your fleet to improve safety practices

and minimize risk. (M-20-23)

NTSB Marine Accident Report

Recommendation Reiterated in this Report

As a result of its investigation of this accident, the NTSB reiterates Safety Recommendation

M-12-3, which is currently classified as “Open—Unacceptable Response”:

To the US Coast Guard

Require all operators of U.S.-flag passenger vessels to implement SMS, taking into

account the characteristics, methods of operation, and nature of service of these

vessels, and, with respect to ferries, the sizes of the ferry systems within which the

vessels operate. (M-12-3)

NTSB Marine Accident Report

1 Factual Information

1.1 Background

Figure 1. Preaccident photograph of the Conception. (Source: www.seawayboats.net)

Owned by the Fritzler Family Trust and operated by Truth Aquatics, Inc. (hereafter referred

to as Truth Aquatics), the 75-foot-long small passenger vessel Conception was constructed in 1981

by Seaway Boats, Inc, in Long Beach, California. The dive vessel was purpose-built to take

recreational divers on one-day and overnight trips to dive sites around the Channel Islands. The

Conception was constructed of fiberglass laid over plywood and had three decks: the upper deck,

main deck, and below deck.

Vessel particulars of the Conception were as follows:

Length: 75 feet

Beam: 26 feet

Draft: 4 feet

Tonnage: 97 gross register tons

Crew: 6

Passenger capacity: 99 (or 46 overnight passengers)

Engine: Two 550-horsepower (hp), 2-stroke, turbo-charged, 92 series, V8 Detroit

Diesel engines

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Figure 2. Port side of the Conception's salon looking aft. (Source: M. Ryan)

The Conception’s main deck ran the full length of the vessel, with exterior (open) decks

and an enclosed salon and galley.

The salon had food service counters along the centerline and

fixed dining tables on either side. Installed benches along the port and starboard bulkheads

provided seating outboard of the tables, and plastic (outdoor-type) chairs provided seating inboard

of the tables. The galley was forward of the seating area. The center window of three windows on

the forward bulkhead of the galley could be opened from the inside by turning a hand screw and

pushing the window outward at the bottom, since it was hinged at the top. On the forward starboard

side of the salon, two sets of spiral stairways led down below to a shower room (forward) and a

bunkroom (aft). Doors at the aft end of the salon opened to a large, open aft deck. According to

the owner, the doors were always kept open when passengers were on board. There were no other

doors to the exterior from the salon.

During interviews, the crew of the Conception referred to the entire salon and galley space as the “galley.” For

clarity, this report will refer to the full space as the “salon,” unless specifically referring to the food preparation area.

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Figure 3. Conception simple plan and profile views.

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Three small restrooms, each with a single toilet and a small sink, were located just aft of

the salon. Aft of the portside restroom door, a sign posted on the bulkhead identified the location

as the muster area. Exterior walkways on either side of the salon and restrooms extended from the

bow to the aft open deck. Fire hose stations were located on both port and starboard walkways

adjacent to the restrooms (see figure 30 for the location of all firefighting equipment and lifesaving

appliances).

The open deck aft of the salon had a raised platform centerline with racks on either side for

storing scuba tanks and other gear. The raised platform also contained hatches for accessing the

engine room (forward) and lazarette (aft).

On the stern of the vessel, a large swim platform

accessible by stairs from the open deck was raised and lowered using an electrically powered

hydraulic winch. When in the raised position, the metal swim platform served as a cradle for a

small outboard-powered inflatable skiff.

Figure 4. Aft main deck of the Conception during a previous voyage. (Source: Profundo no Mundo,

YouTube, annotated by NTSB)

Below the main deck, the vessel was divided into four compartments. The forwardmost

space was an anchor room that was accessible via a small hatch on the forward weather deck. The

shower room was aft of the anchor room, followed by the bunkroom. The bunkroom contained

33 bunks, arranged around 2 aisles, with bunks on either side of each aisle (figure 5). Twelve

double bunks, which allowed two people to sleep in the same bunk, were stacked two-high and

located on the outside of the aisles. One additional double bunk was located underneath the forward

stairway on the starboard side. The remaining 20 bunks were single bunks, with 4 sets of bunks

A vessel’s lazarette is its aftermost compartment below the main deck, typically accessed by a deck hatch.

NTSB Marine Accident Report

stacked three-high arranged along the centerline, and 2 sets arranged athwartship (across the ship

from side to side) along the aft bulkhead. A two-high set of single bunks was located along the

forward bulkhead on the port side (the upper bunk was reserved for a crewmember). The maximum

occupancy of the bunkroom was 46 persons. Each of the bunks had a privacy curtain that could be

pulled fully across the aisle-accessible side of the bunks.

Figure 5. Conception bunkroom arrangement, with escape hatch location added by NTSB. (Source: Truth

Aquatics; annotated by NTSB)

An escape hatch provided an alternate means of exiting the bunkroom (the stairway at the

forward end was the primary means). The escape hatch, which consisted of a removable wooden

panel that was about 22 inches by 22 inches in size, was located in the overhead between the

aftmost centerline bunks.

It could be reached from either aisle by climbing a wooden ladder

installed on the side of each centerline aft set of bunks. The hatch exited into the aft end of the

The measurements for the escape hatch are from Truth Aquatics’ similar vessel, the Vision, which was built

from the design of the Conception. There was no difference in the design of the escape hatch between both vessels.

NTSB Marine Accident Report

salon, and thus both escape routes from the bunkroom exited into the salon. The upper bunks

nearest the emergency escape hatch had passengers assigned to them during the accident voyage.

Figure 6. Photo left is the escape hatch, viewed from the bunkroom, on the Vision, a Truth Aquatics dive

vessel with arrangements nearly the same as the Conception. (Source: NTSB) Photo right, taken during a

previous voyage, shows the escape hatch, viewed from aft in the salon, on the Conception. (Source: J.

Palmer, annotated by NTSB)

A watertight bulkhead divided the bunkroom from the engine room, which contained the

vessel’s two main propulsion engines and a single electrical generator. Fuel tanks that supplied the

engines and generator were located forward in the engine room, outboard of each of the main

propulsion engines. The generator was located aft of the port main propulsion engine. Two air

compressors used for filling scuba diving tanks were mounted aft of the starboard main propulsion

engine. A 40-gallon, 220-volt electric hot water heater was located in the engine room forward of

the starboard main engine.

The lazarette was the aftmost space below the main deck and contained the steering gear

for two rudders, a refrigerator/freezer for storing seafood caught during dives, a clothes dryer, and

a generator/compressor for enriched-oxygen air—commonly referred to as nitrox—used in

diving.

The generator produced nitrox on demand and did not store the compressed gas within

the system. (Compressed air and nitrox were stored only in scuba tanks brought on board by

Nitrox, with respect to underwater diving, is an air mixture composed of nitrogen and an elevated percentage of

oxygen (when compared to atmospheric air). It is created by passing compressed air through a semi-permeable

membrane, which removes a portion of nitrogen, thus increasing the amount by volume of oxygen in the resultant air

mixture. Typical oxygen percentages used in recreational diving are 32 and 36 percent by volume. Using nitrox-

enriched oxygen air while diving is advantageous because the diver is exposed to less nitrogen and its negative effects.

Divers aboard the Conception paid an extra fee in order to be supplied with nitrox.

NTSB Marine Accident Report

passengers and secured in the outer main deck racks.) In addition to the mechanical equipment,

wet suits were dried and stored in the lazarette.

On the upper deck, the Conception’s wheelhouse sat atop the forward end of the salon. In

addition to controls for the engines and rudders, the wheelhouse contained radar and depth sounder

displays, global positioning system (GPS) receivers, a very high frequency (VHF) radio, and an

electronic charting system. Two crew bunks with privacy curtains were installed at the back of the

wheelhouse. A short passageway led aft from the wheelhouse to a door out to the sun deck. Two

small crew staterooms were located on either side of the passageway; the portside room contained

two crew bunks, and the starboard side room held a single bunk. A small shower room on the

starboard side aft was also accessed from the passageway. The sun deck contained benches and

large boxes for storing the vessel’s lifejackets and life floats, and there were two additional life

floats on top of the wheelhouse.

A single staircase on the starboard side of the sun deck, aft,

provided access between the main deck and the sun deck.

1.2 Accident Narrative

The Conception had been chartered by Worldwide Diving Adventures, Inc., a scuba diving

tour, instruction, and guide company, to take a group of 33 passengers on a 3-day dive trip to

locations around the Channel Islands, California, over the 2019 Labor Day weekend. The voyage

was scheduled to get under way from Santa Barbara, California, at 0400 on Saturday, August 31,

and return by 1700 on Monday, September 2. Truth Aquatics encouraged customers to board the

vessel the night before early morning departures, and passengers for the accident voyage began

arriving in the evening on August 30, embarking via the main deck. Per Truth Aquatics’ website

and the company’s General Information Handbook, passengers were instructed to sign a posted

manifest upon boarding, store their gear, and then proceed to their bunks below deck.

On the accident voyage, all bunks had assigned occupants, except for numbers 7U, 9L,

24U, and 26L (these were the upper and lower bunks of the three-high single bunks running

athwartships on the aft bulkhead). Four of the ten double bunks were occupied with two

passengers; the remaining double bunks had a single occupant. A Conception deckhand told

investigators that passengers on the accident voyage kept to the posted sleeping arrangements.

According to the deckhand, luggage was stowed below some of the bunks and above them, in a

designated area, and the aisles between the bunks were clear of luggage at all times. Some

passengers kept personal items and effects, such as purses and backpacks, with them in their bunk

spaces.

The second captain (mate) was the first of the vessel’s six crewmembers to arrive at the

Conception, embarking sometime between 2200 and 2300.

The first and second galley hands were

next to arrive, boarding separately between 2300 and midnight. They each told investigators that

after boarding, they went to their bunks on the upper deck and went to sleep. The first deckhand

stated that he and the second deckhand arrived at the vessel at 0320 the next morning, and,

according to crewmembers interviewed after the accident, the captain boarded about 10 minutes

Life floats are buoyant primary lifesaving devices designed to support a number of persons partially immersed

in the water, unlike life rafts that keep people completely out of the water.

According to crewmembers, passenger bunks were generally assigned by the charterer.

The vessel was required to have a credentialed master and mate, although there is no mate’s credential for

vessels of this size. “Second captain” was the term used by Truth Aquatics and the Conception crew in lieu of mate.

NTSB Marine Accident Report

later.

Once on board, the deck crew began conducting pre-underway checks of the vessel’s

equipment. The generator was then started and shore power removed, a visual inspection of the

bilges was performed, and the main engines were started and tested. The deckhands cast off lines,

and, according to the vessel’s automatic identification system (AIS), the Conception was under

way at 0404 outbound from Santa Barbara Harbor.

The captain took the helm for the outbound

voyage, while the rest of the crew went to sleep until about 0600.

During Truth Aquatics’ dive trips, the destinations were at the discretion of the captain and

based on weather conditions and the charterer’s preferences. For this voyage, the captain of the

Conception chose to head toward Santa Cruz Island, which provided dive sites that were protected

from moderate-to-high winds in the area. The vessel transited to the south side of the island and

anchored at a dive site near Albert Anchorage at 0830 that morning. Once anchored, the passengers

gathered in the salon to eat breakfast and listen to a safety brief.

Figure 7. Conception accident voyage reconstructed from AIS data, with selected diving and anchoring

sites at Santa Cruz Island. (Background source: Google Earth)

The standard safety brief included information on the lifejackets and other lifesaving

equipment, escape routes from the passenger bunkroom and salon, the location for mustering in

the event of an emergency, and dive safety information. During the accident voyage, the safety

briefing, which was being conducted by the first deckhand, was interrupted when a passenger

The agency’s investigation of this accident was conducted in parallel with the Office of the US Attorney’s

ongoing criminal investigation. The criminal investigation resulted in the NTSB having limited access to key

personnel of Truth Aquatics working at the time of the accident, including the captain of the Conception, the first

galley hand, or any employee responsible for operations. While on scene, investigators interviewed the remaining

surviving Conception crewmembers; the owner of Truth Aquatics, former Truth Aquatics crewmembers, passengers,

contractors, and service providers; and several first responders. See Appendix A

for more details regarding the

investigation.

AIS is a maritime navigation safety communications system. At 2- to 12‑second intervals on a moving vessel,

the AIS automatically transmits vessel information, including the vessel’s name, type, position, course, speed,

navigational status, and other safety‑related information, to appropriately equipped shore stations, other vessels, and

aircraft. The rate at which the AIS information is updated depends on vessel speed and whether the vessel is changing

course. AIS also automatically receives information from similarly equipped vessels.

NTSB Marine Accident Report

fainted. After the passenger was revived and his vital signs checked, the remainder of the safety

brief was conducted by the captain, who, according to the deckhand, provided “an abridged

version” of the dive safety section of the brief.

Over the next two days, the Conception transited between sites around Santa Cruz Island,

anchoring at each location to allow the passengers to dive. The vessel spent the first night anchored

at Smugglers Cove on the eastern side of the island. The next day, Sunday, September 1, the vessel

transited to various dive sites on the north side of the island.

Between 2030 and 2130, seventeen divers conducted a night dive at a location known as

Quail Rock on the northwest side of the island. While the divers were in the water, the second

galley hand opened the electrical circuit breakers for the galley burners and griddle. (He told

investigators that this had been the normal practice each night, ever since a burner had been left

on inadvertently on a previous voyage.) He also closed the circuit breakers for the air conditioning

unit to allow the bunkroom to cool before the passengers went to sleep.

Once the divers were back on board,

the flashlights and cameras that they used

during the dive were stowed on the two aft

tables in the salon. During interviews,

crewmembers stated that some of these

electronics, along with cell phones and tablets,

were plugged in to recharge via 110-volt

alternating current (AC) receptacle outlets

located between the bench seat padding and on

the aft bulkhead (figure 8). Crewmembers

remembered seeing at least one passenger-

owned power strip being used to recharge the

electronics.

After the night dive, the Conception

relocated to Platts Harbor, a natural,

semi-protected anchorage to the east of

Quail Rock, to anchor for the night. The

second captain remembered seeing a large

sportfishing boat (later identified as the

Grape Escape) in the anchorage when the

dive boat arrived about 2300. According to the

second captain, the crew conducted a

walkthrough of the main deck to check for trip

hazards and to stow loose gear. The doors to

the salon remained open, as they always were when passengers were on board. Sometime before

midnight, each of the crewmembers went to bed: the second deckhand slept in the passenger

bunkroom, and the other crewmembers slept in berths on the upper deck. Crewmembers reported

that a few passengers were still awake when they left the salon to head to their berthing. There

were no crewmembers assigned to monitor the position of the Conception while it rode at anchor

(according to the second captain, there was an alarm in vessel’s wheelhouse to notify the crew if

the anchor was dragging).

Figure 8. Photo taken during accident voyage

(August 31, 2019) of devices plugged in to charge

at the port side aft corner of the salon on the

Conception. (Source: J. Dignam).

NTSB Marine Accident Report

According to the second galley hand, he woke up about 0130 on Monday, and, as was his

usual practice when he awoke in the middle of the night, he went down to the galley to collect and

wash any used coffee cups and other dishes and to conduct general cleaning. He told investigators

that there were no passengers or crew awake or in the salon at the time he was working in the

galley. After cleaning up, he used one of the restrooms on the aft main deck and went to his bunk

on the upper deck to go back to sleep. He stated that as he came out of the restroom, he looked up

at a wall clock and noted that it was 0235.

Sometime later, the second galley hand was awoken by the sound of what he thought was

a plastic chair sliding on the salon deck. He stated that then he heard a noise that “sounded like

someone fell.” He considered getting up, concerned that a person might be injured, but then heard

what he thought to be the sound of the restroom door shutting. He continued to lay in his bunk,

and next heard what he thought was a person yelling, “ahhh!” The second galley hand got out of

his bunk to go check on the person and, looking out through the door to the sun deck, saw a yellow

glow emanating from the main deck below the aft starboard side of the sun deck. Realizing what

he was seeing, the second galley hand turned around and yelled “fire! fire!” to wake up the four

other crewmembers sleeping on the upper deck.

The first galley hand told investigators that he had heard “a pop, and then a crackle

downstairs.” He then heard the second galley hand jump down from his bunk, and shortly

thereafter yell, “fire!”

After warning the crew, the second galley hand ran to the staircase at the aft end of the sun

deck to attempt to get down to the main deck. He stated that when he reached the staircase and

looked down, the restroom at the bottom of the staircase was on fire, and flames blocked the way

down. He returned to the upper deck stateroom area, told the other crewmembers that the way was

blocked, and then proceeded to the port side of the sun deck. There, he climbed over the railing

and lowered himself down onto the main deck.

The second galley hand stated that he ran back to the open deck, intending to enter the

salon through the open rear doors to retrieve fire extinguishers. However, he could not get into the

salon because the entire entryway was on fire. He told investigators that the area where the

bunkroom escape hatch was located was engulfed in flames and was not visible, and the fiberglass

on the ceiling of the entryway to the salon was melting and dripping down. He said that he ran aft

toward the stern, but, realizing there was nothing that he could do there, he turned around again.

The second captain and first deckhand slept in the bunks in the wheelhouse, and when

awakened by the second galley hand, they had both proceeded aft toward the door to the sun deck

and saw the flames on the aft starboard side. They were met at the door by the second galley hand,

who told them that the staircase to the main deck was blocked. Returning to the wheelhouse, the

second captain and the first deckhand were instructed by the captain to lower themselves to the

main deck via the wheelhouse wing stations. In a statement to investigators, the captain wrote that

he opened the wing station doors on either side of the wheelhouse.

The second captain exited through the wing station door on the port side and lowered

himself down to the main deck. From there, he looked to go aft, but he said that the exterior

passageway was blocked by smoke and flames emanating from the salon windows. He stated that

he proceeded forward and opened the bow gate on the port side, reasoning that if passengers could

escape the bunkroom and get to the main deck bow, they would be able to more easily evacuate

through the open gate.

NTSB Marine Accident Report

From the aft deck, the second galley hand saw a crewmember lowering himself down to

the main deck, so he ran forward through the smoke along the port exterior passageway. About the

same time, the first galley hand was attempting to jump down to the main deck from the port

wheelhouse wing station. The first galley hand told investigators that he misjudged the distance to

the deck and landed with all his weight on his left leg, breaking his leg as he hit the deck. He

landed in front of the second galley hand, who leapt over him and continued forward to the bow.

The first deckhand had also exited the wheelhouse via the port wing station. Once on the

main deck, he looked aft and saw that the port exterior passageway was blocked by smoke and

flames coming out of the salon windows and wrapping around the sun deck above. He proceeded

to the bow and tried to open the center window on the forward bulkhead of the salon, which looked

into the galley area, in an attempt to reach the passengers. The center window was the only window

on the front of the salon that was designed to open, but it was secured from the inside by threaded

knobs (it was not a designated emergency exit). The deckhand, aided by the second galley hand,

struggled to pry the window open, but could not. The two crewmembers told investigators that the

window was warm, but not hot, and when they looked through the window, the view was

completely obscured by thick, black smoke.

Figure 9. Preaccident photo of Conception forward salon windows. In this photo, the center window is open.

However, during the accident, the window was closed and secured as the crew attempted to access the

space. The port and starboard windows were not designed to be opened. (Source: T. Thompson)

During this time, the captain was in the wheelhouse making a distress call over VHF radio.

At 0314, he transmitted, “Mayday, Mayday, Mayday. Conception, Platts Harbor, north side Santa

Cruz.” When Coast Guard Sector Los Angeles/Long Beach watchstanders responded to the distress

call, the captain transmitted, “39 P-O-B. I can’t breathe. 39 P-O-B. Platts.” The smoke filling the

wheelhouse then forced the captain out of the space, and he jumped into the water from the

starboard side wheelhouse wing station.

As the first deckhand continued to try to open the forward salon window, he remembered

a fire axe mounted in the wheelhouse. He looked up to the wheelhouse and was about to yell to

the captain to get the axe when he and the second captain saw the captain leap into the water. As

the captain jumped, smoke followed him down to the water. Both the first deckhand and the second

captain believed the captain was on fire as he jumped. Consequently, the second captain dove into

the water on the starboard side to attend to the captain.

NTSB Marine Accident Report

Attempting to find another way to reach passengers, the first deckhand opened the anchor

locker hatch on the bow. Looking inside, he saw that there was no access aft to the shower room

and bunkroom below, and there was no smoke in the space at the time. He then checked the port

and starboard exterior passageways, and both were blocked by smoke and flames.

According to the first deckhand, the captain then told the remaining three crew on the bow

to jump into the water. The first galley hand was in a great deal of pain due to his broken leg, but

he eventually entered the water through the port bow gate. The second galley hand and the first

deckhand also entered the water. The first and second galley hand then swam away from the vessel,

while the first deckhand swam toward the stern.

After finding that the captain was unharmed, the second captain swam to the stern and re-

boarded the Conception via the vessel’s swim platform, which was in the raised position with the

inflatable skiff stowed on it. He proceeded up onto the open main deck and toward the salon, where

he found that the entire deckhouse was being consumed by fire. He said that he “could see the aft

escape was fully engulfed in flames.” He stated that he opened the engine room hatch but was

blocked from entering by black smoke, though he did not see flames.

The second captain’s next thought was to launch the skiff so that the crew could pick up

any survivors that had made it off the Conception. He stated that as he proceeded aft, he noted that

the lights were still on in the lazarette (the hatch was normally left open), so he knew that the

vessel still had electrical power. He energized the hydraulic pump for the winch that raised and

lowered the swim platform and prepared to lower the skiff into the water. By this time, the first

deckhand had also climbed up on the stern of the Conception, and he assisted the second captain

in launching the skiff.

Once the boat was in the water, the second captain assisted

the captain, who had swum to the stern of the Conception, into the

boat. Meanwhile, the first deckhand went up onto the back deck

of the dive boat to once again look for a way to help any

passengers. The fire had continued to consume the vessel, and he

found no way to get into the salon or to the bunkroom below. The

fire also prevented the deckhand from accessing the fire hose and

the fire pump remote start control, which were located on the port

side of the vessel. He next attempted to reach the fire pump in the

engine room but was prevented from entering the space due to

smoke at the hatchway. (He also reported seeing no flames in the

engine room.) The captain yelled at him to get in the skiff, so he

went aft and boarded the small boat.

After the three crewmembers got the engine on the skiff

running, they drove to where the two galley hands had swum away

from the Conception and helped both into the boat. The first

deckhand then took the controls and drove the skiff over to the

anchored sportfishing boat Grape Escape. When they arrived at

the vessel, the crewmembers yelled and banged on the hull and

back door to the salon until the Grape Escape’s owners were

awakened. The Grape Escape owners described their first sight of

the Conception as “completely on fire from one end to the other. It

was already completely engulfed. There wasn’t a spot on that boat

Figure 10. Cell phone photo of

Conc

eption

on fire, taken from

sportfish

ing boat Grape Escape

(Source: S. Hansen)

NTSB Marine Accident Report

that wasn’t on fire.” One of the owners then took the captain and second captain up to the

wheelhouse to make radio calls to the Coast Guard shortly before 0329, while the other owner

assisted the remaining crewmembers. The first deckhand and second galley hand assisted the

injured first galley hand onto the Grape Escape.

1.3 Search and Rescue

The Coast Guard Sector Los Angeles/Long Beach Command Center (SCC), located in San

Pedro, California, maintained command, control, and communications for Coast Guard operations

in the area. The SCC received the Conception’s initial distress call by VHF radio at 0314:23. The

SCC made repeated call-outs, which went unanswered after the crew abandoned the vessel. Using

the VHF radio direction finder, the SCC was able to estimate the vessel’s position and issued an

Urgent Marine Information Broadcast (UMIB) at 0322:54.

Table 1. Initial VHF distress communications between the captain of the Conception and Coast Guard

Sector Los Angeles/Long Beach.

Time

(PDT)

Originator Message

03:14:23 Conception Mayday, mayday, mayday! Conception. Platts Harbor, north side Santa

Cruz. Help.

03:14:34 Coast Guard Vessel under distress, this is Coast Guard Sector Los Angeles on Channel

one-six. What is your position and number of persons on board? Over.

03:14:42 Conception [unintelligible] three-nine P-O-B. I can't breathe.

Three-nine P-O-B. Platts.

03:14:54 Coast Guard Vessel in distress, Coast Guard Sector Los Angeles. Roger. You have 29

persons on

board and you can't breathe. What is your current GPS

position? Over.

03:15:20 Coast Guard Vessel in distress, Coast Guard Sector Los Angeles on Channel one-six.

What is your GPS position? Over.

03:16:06 Coast Guard Vessel in distress, Coast Guard Sector Los Angeles on Channel one-six.

The SCC then telephoned Coast Guard Station Channel Islands Harbor at 0323 and

requested that they proceed to the scene for a medical emergency, based on the Conception

captain’s transmission of “I can’t breathe.”

While the crew prepared to get under way, the

Station’s Officer of the Day called the Ventura County Fire Department dispatch by radio to request

support (at least one paramedic and advanced life support equipment) to get under way with them.

At 0324, the SCC requested Coast Guard air assets located at Naval Base Ventura County (NBVC)

Point Magu conduct search and rescue. The SCC also directed the Coast Guard cutter Narwhal,

which was 5 hours away, about 6.5 miles southeast of Long Beach and already under way, to

proceed to the accident location.

An Urgent Marine Information Broadcast (UMIB) is a request for assistance from any available mariners. It is

broadcasted on VHF Channel 16 and by Navigational Telex (NAVTEX).

Unless otherwise noted, “Station” in this report refers to Coast Guard Station Channel Islands Harbor.

USCGC Narwhal (WPB87335) was an 87-foot patrol boat homeported in Corona Del Mar, California.

NTSB Marine Accident Report

Figure 11. The accident site in relation to emergency response assets. The red triangle marks the site of

the Conception fire. (Background: Google Maps)

At 0329, the owner of the Grape Escape called the Coast Guard on VHF radio, stating “We

have a Mayday. I have a commercial boat on fire. Santa Cruz Island.” This was the first notification

to the Coast Guard that the nature of the distress was a fire. He gave the position of the vessel, and

then the second captain got on the radio and reported to the Coast Guard that there were “33 souls”

trapped in the bunkroom.

The Conception captain took over the radio from the second captain

and explained the situation in more detail to the SCC.

The second captain and first deckhand next re-boarded the skiff to go search for survivors,

while the two galley hands and the captain remained on the Grape Escape. The second captain

stated that while the skiff circled the burning Conception, he and the first deckhand heard several

“explosions.” The crew did not locate any survivors, and they returned to the Grape Escape. Later,

at the SCC’s request, they made additional searches, also without success.

The SCC watchstander misheard the Conception captain say the passengers were “locked” below deck when

they were actually “blocked” by fire. The second captain mistakenly omitted the missing crewmember in his initial

report by radio, stating there were “33 souls” still aboard.

NTSB Marine Accident Report

Table 2. VHF communications between Coast Guard Sector Los Angeles/Long Beach and the Grape

Escape.

Time

(PDT)

Originator Message

03:29:30 Grape Escape Pan-Pan, Pan-Pan, Coast Guard, Coast Guard.

03:29:35 Coast Guard

Vessel Conception, Coast Guard Sector Los Angeles on Channel

one-six. Over.

03:29:39 Grape Escape This is a -- actually it's a mayday. I have a commercial boat on fire.

It's on Santa Cruz Island at ah --

03:29:57 Coast Guard Vessel hailing Coast Guard Sector Los Angeles, come back or say

again your last. Couldn't understand it. Over.

03:30:05 Grape Escape We're at Platts Harbor on Santa Cruz Island.

03:30:12 Coast Guard Say again the harbor name. Over.

03:30:17 Grape Escape Platts Harbor. Platts Harbor.

03:30:20 Coast Guard Roger, Captain. What is the, what is the emergency? Over.

03:30:30 Coast Guard

Vessel Conception, Coast Guard Los Angeles. What is the

emergency? Over.

03:30:35 Grape Escape Hang on just a second.

03:30:40 Conception second

captain on Grape

Escape

Hello. This is crew of Conception. Our boat is on fire. We are on a

neighboring vessel. We have 33 souls on board down below trapped

in the bunkroom. We cannot evacuate them off the vessel.

03:30:57 Coast Guard Vessel reporting a vessel on fire. Roger, Captain. Your vessel is on

fire; is that correct?

03:31:07 Conception Second

Captain

The vessel's on fire, the vessel's name is Conception.

03:31:10 Coast Guard Roger. Are you on board the Conception?

03:31:13 Conception Second

Captain

We're on board a neighboring vessel. We abandoned ship.

03:31:19 Coast Guard Roger. And there's 33 people on board the vessel that's on fire; they

can't get off?

03:31:24 Conception Second

Captain

That is correct.

03:31:27 Coast Guard Roger. Are they locked inside the boat?

03:31:32

Conception Second

Captain

That’s correct, sir.

03:31:37 Coast Guard Roger. Can you get back on board and unlock the boat or unlock the

doors so they can get off?

03:31:43 Conception Second

Captain

Every escape path was on fire.

03:31:48 Coast Guard Roger. You

don’t have any firefighting gear at all? No fire

extinguishers or anything?

NTSB Marine Accident Report

Time

(PDT)

Originator Message

03:32:05 Conception Captain [The captain relieved the second captain on the radio.] Coast Guard

Sector LA, we could not get to the bunkroom. The fire absorbed the

wheelhouse and --

03:32:26 Coast Guard Roger, that. Is this the captain of the Conception?

03:32:30 Conception Captain

Yes. My name is [redacted]. I got one mayday out. Smoke, in the

wheelhouse there was flames at the back door and the side door. We

had to jump from the wheelhouse off the boat.

03:32:59 Coast Guard Roger. Was that all the crew that jumped off?

03:33:04 Conception Captain Five of the crew from the wheelhouse jumped out. One crew is down

in the bunkroom. Thirty-four people still on board, okay?

03:33:22 Coast Guard Roger. Is the vessel fully engulfed right now?

03:33:26 Conception Captain To the deck. Fully engulfed to the deck.

At 0335, the SCC broadcast another UMIB with the name and position of the vessel and

indicating that the vessel was on fire. The crew at Coast Guard Station Channel Islands Harbor

overheard the radio conversation between the Conception crew on board the Grape Escape and

the SCC, and between 0342 and 0349, they launched two 45-foot response boats-medium (RB-

Ms). At 0343, the Ventura County Fire Department (VCFD) Engine 53 company captain requested

an additional engine company respond aboard Channel Islands Harbor Patrol Boat 15, a 32-foot

fire boat jointly operated with the VCFD.

Channel Islands Harbor Patrol overheard the Coast Guard radio traffic on both VHF and

VCFD frequencies, retrieved the Conception’s AIS position from an online source, and

immediately prepared its Boat 15 to respond once an engine company arrived. Boat 15 was under

way with the crew of Engine 54 at 0404 (Ventura City Harbor Patrol’s fireboat, Boat 1, later got

under way, with Engine 26, at 0448).

Multiple additional agencies responded to the Coast Guard Channel Islands Station, where

an Incident Command Post was set up at 0358.

The first Coast Guard RB-M arrived on scene at 0427 after travelling 27 miles and crossing

the channel through conditions of reduced visibility; they found the Conception completely

engulfed in flames and began searching for survivors. The second Coast Guard RB-M, with VCFD

Engine 53 embarked, arrived on scene immediately after and assumed the role of on-scene

coordinator (OSC).

Two firefighters (a paramedic and an emergency medical technician [EMT])

from the second RB-M boarded the Grape Escape to assess the injured Conception crewmembers,

and then the boat began searching the area for any other survivors.

Agencies responding to Coast Guard Channel Islands Station included the VCFD, Channel Islands Harbor

Patrol, Ventura County Sheriff’s Department, VCFD Public Affairs, Ventura County Coroner’s Office, Channel

Islands Parks Service, and the owner of the Conception.

The on-scene coordinator is the designated vessel or aircraft assigned to coordinate the activities of all

participating search units.

NTSB Marine Accident Report

Each RB-M was equipped with a P6 portable dewatering pump, which was the only

equipment that could be used for firefighting.

Since Boat 15 was en route with more pump

capacity and the firefighting foam required to fight a fire of this size, the two RB-Ms searched for

survivors in the water, deeming it a higher priority after concluding that there were likely no

survivors in the wreck given the mass conflagration.

A Coast Guard helicopter arrived on scene about the same time as the Coast Guard RB-Ms.

When the paramedic and EMT from the RB-M had boarded the Grape Escape, they determined

that the first galley hand needed to be evacuated. However, due to the risk of entanglement with

the rescue litter and the Grape Escape’s rigging, the Engine 53 crew determined that it was safer

to leave the injured crewmembers on the Grape Escape rather than transfer them to the helicopter.

The two RB-Ms, the Conception skiff, other small boats, and Coast Guard helicopters

continued to search the area and the shoreline for survivors and found none.

Channel Islands Harbor Patrol Boat 15 arrived on scene at 0455, followed by Santa Barbara

Harbor Patrol’s Boat 3, and commenced fire suppression efforts. Shortly after, at 0502, the

Retriever II, a 30-foot, rigid-hull, inflatable boat owned by TowBoatUS Ventura, arrived on scene

and began towing the burning wreck away from the shallow water with a grappling hook to a

location where the fire boats could better reach it.

The fire was first reported extinguished at 0508 but re-flashed several times in the area of

the fuel tanks and on the bow. Burned-out through-hull penetrations—where the main engine

exhausts had been—eventually submerged, and the vessel sank stern first at 0654, approximately

20 yards from shore, in 61 feet of water. First responders were not able to safely board the vessel

before it sank. Underwater recovery divers later found the wreckage lying on the seafloor in an

upside-down position.

Figure 12. Small passenger vessel Conception at sunrise prior to sinking. (Source: VCFD)

The Grape Escape departed the accident site at 0516 to transport the surviving Conception

crew to Coast Guard Station Channel Islands Harbor, arriving about 0735. The Conception captain

The CG-P6 gasoline motor-driven dewatering pump is used primarily for emergency dewatering of vessels. It

has a rated output of 250 gallons per minute at a 12-foot suction lift. Under load, this pump will dewater for

approximately 4–5 hours on the gasoline supplied with the kit.

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stayed on scene aboard one of the RB-Ms until it departed the scene at 0743 and returned to the

Station.

At 0804, the remains of four victims were recovered on the surface and transported to Santa

Barbara Harbor, where they were transferred to the Santa Barbara County coroner’s office. Air and

surface search and rescue efforts continued thereafter until suspended by the Sector Commander

at 0938 on September 3. No equipment damage or first responder injuries were reported.

Over nine days, divers from several local law enforcement agencies and the Federal Bureau

of Investigation (FBI) dove on the wreck. They recovered all but one of the remaining victims,

most of whom were found in the bunkroom or nearby on the seafloor. The last victim was

recovered on the surface in shallow water along the shore, near the accident site, on September 11.

Table 3. Summary of resources assigned in the initial response.

Name/hull/tail

number

Type and affiliation Role Arrival time at

scene

CG 45643 Response Boat-Medium - Coast Guard

Station Channel Islands Harbor

First search and

rescue unit on

scene

0427

CG 6540 HH-65 helicopter - Coast Guard Air Station

San Francisco (forward deployed to NBVC

Point Mugu)

Search and rescue,

medical response,

and first OSC

0432

CG 45739 Response Boat-Medium - Coast Guard

Station Channel Islands Harbor with VCFD

Engine 53 embarked

Search and rescue,

OSC

0432

Boat 15

Fire boat - Channel Islands Harbor Patrol

and Ventura County Fire Department.

Engine 54 embarked (also called Boat 5 by

some witnesses and in AIS data)

Fire suppression 0455

Retriever II Commercial towing vessel - TowBoatUS

Ventura Harbor

Towing support and

victim recovery

0502

Boat 3 Patrol boat - Santa Barbara Harbor Patrol Fire suppression 0518

Boat 1 Patrol boat - Ventura City Harbor Patrol

with VCFD Engine 26 embarked

Ferried foam to the

scene

N/A -

mechanical

failure

Narwhal

(WPB 87335)

Coast Guard Patrol Boat homeported in

Corona del Mar

Assumed OSC on

arrival

0841

CG 6014 MH-60 helicopter - Coast Guard Air Station

San Diego

Search and rescue 0940

1.4 Injuries

Of the 39 persons on board the Conception at the time of the accident, 33 were passengers,

and 6 were crewmembers. Passenger ages ranged from 16 to 62 years, with a median age of

41 years old. There were 13 male and 20 female passengers (two were female minors under the

age of 18 years); all 33 passengers perished in the fire. The second deckhand, a 26-year-old female,

also perished in the fire.

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The first galley hand suffered a closed fracture of the left tibia. The second galley hand

bruised his right foot when jumping from the top deck, only realizing that he was injured when he

boarded the Grape Escape.

Table 4. Injuries sustained in the Conception accident.

Type of Injury Crew Passengers Total

Fatal 1 33 34

Serious 1 0 1

Minor 1 0 1

None 3 0 3

The Santa Barbara Sheriff’s Office, Coroner’s Bureau conducted an examination of the

victims recovered, and a coroner’s report was completed for each of the 34 victims. The Sheriff-

Coroner conducted external examinations on each of the decedents but elected not to conduct

internal examinations. The Santa Barbara Coroner’s Bureau stated more complete autopsies were

not performed because the cause of death was easily determined by a body examination and

toxicology tests and there were witnesses to the event.

According to the coroner’s reports, the cause of death in every case was smoke inhalation.

Additionally, in two cases, carbon monoxide was found to be contributory.

Carbon monoxide is

a product of incomplete combustion and is a central nervous system depressant. Carbon monoxide

also binds readily with hemoglobin and displaces oxygen in the blood.

External examinations conducted by the Sheriff-Coroner, as confirmed by recovery divers’

video, documented 27 decedents as being fully or partially clothed. One female passenger was

wearing a jacket, while another had plastic reading glasses entangled in her hair. The coroner

reports also documented that 14 people were wearing some sort of footwear, including the second

deckhand, who had sandals on both of her feet. Three other cadaver bags included footwear, though

not worn at the time of arrival ashore, and one contained a backpack. One passenger had a hiking

boot on one foot and a sandal the other, and a phone in his hand. None of the victims were found

with any type of smart or dive computer watch, which could have provided a timeline of the

victims’ activity as well as information regarding the victims’ vital signs.

At least four phones were recovered with the victims and at least five in the wreckage, all

with no visible signs of heat damage. These were taken into possession by the FBI for examination

to recover any relevant information, such as pictures and video of the vessel or any attempt to

place phone calls or send messages at the time of the fire. At the time of publication of this report,

The NTSB uses the International Civil Aviation Organization injury criteria in all of its accident reports,

regardless of transportation mode. A serious injury is a non-fatal injury that requires hospitalization for more than

48 hours, commencing within 7 days from the date the injury was received; results in a fracture of any bone; causes

severe hemorrhages, nerve, muscle, or tendon damage; involves any internal organ; or involves second- or third-

degree burns, or any burn affecting more than 5 percent of the body surface.

Toxicology testing on the Conception victims indicated carbon monoxide saturation levels between 39 and 75

percent, with a median 62 percent. The highest levels were reported as greater than 75 percent. According to National

Fire Protection Association guidance, carbon monoxide levels of 40 percent or higher indicate that victims “likely to

have died from CO [carbon monoxide] alone or in combination with other factors…or may simply have been

incapacitated sufficiently by CO poisoning to be unable the flee the fire.” National Fire Protection Association, NFPA

921 Guide for Fire and Explosion Investigation, 2017, Quincy, Massachusetts, 2016, page 263.

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one phone had been examined and the obtained information reviewed by the NTSB (see

Appendix A for more details of the investigation).

Cell phone records for the captain, first galley hand, and second deckhand were analyzed

by the NTSB, and none of the cell phone records indicated any user-initiated activity during the

time of or after the accident.

1.5 Vessel Information

1.5.1 Applicable Regulations

Title 46 Code of Federal Regulations (CFR) Subchapter T governs the construction,

outfitting, and operation of small passenger vessels, like the Conception, that are under 100 gross

tons and carry 150 or fewer passengers or have overnight accommodations for 49 or fewer

passengers. The current regulations under this subchapter were significantly updated in 1996, and

vessels constructed after 1996 are required to comply with all of the current regulations. Vessels

constructed before 1996 (known as “existing vessels”) are required to comply with portions of the

current regulations, including those pertaining to inspections and certification, vessel control and

other systems and equipment, and operations. For regulations relating to construction and

arrangement, lifesaving equipment, some fire protection equipment, machinery installation, and

electrical installation, vessels that existed prior to 1996 are subject to those portions of Subchapter

T regulations that were in force at the time the vessel was built, with certain exceptions. When

referring to the post-1996 regulations, Coast Guard inspectors use the term “New Subchapter T”

or, more simply, “New T” regulations, and when referring to the pre-1996 regulations, they use the

term “Old Subchapter T” or “Old T.” As a vessel built in 1981, the Conception was considered an

existing vessel and therefore subject to portions of both the pre- and post-1996 regulations. In this

report, “New T regulations (all vessels)” and “Old T regulations (existing vessels)” will be used to

differentiate between the two sets of regulations as they applied to the accident vessel.

1.5.2 Main Engines and Propulsion

The Conception was propelled by two 550-hp, 2-stroke, Detroit Diesel engines. The

turbo-charged, 92 series, V-8 engines drew combustion air from the engine room, which was

ventilated from ducting leading out to the main deck. The engines were bolted to Twin Disc MG-

514C Series marine transmissions that acted as both reduction and reversing gears. The

transmissions coupled directly to 3-inch stainless steel shafts. The shafts exited the hull of the

vessel through bronze compression packing glands and connected to two four-bladed propellers.

The propellers, along with two stainless steel spaded rudders, provided maneuvering. An electric

motor-driven hydraulic pump in the vessel’s engine room powered control valves and actuators

attached to the rudder posts.

At the time of the fire, the Conception was at anchor, and neither main engine was

operating.

1.5.3 Electrical Generation and Distribution

Generator. The Conception had a single Northern Lights MP55C generator package

located in the aft port corner of the engine room. While the vessel was away from the dock, the

generator package supplied the vessel with 120/208-volt, alternating current (AC), 3-phase

electrical power. The generator package consisted of an 83-hp John Deere diesel engine prime

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mover, coupled to a Newage 55-kilowatt generator. At the time of the accident, the generator

package was running and providing the vessel with electricity.

The generator’s engine had been replaced with a new model in September 2018 due to

wear. In the months prior to the accident, the new engine would reportedly overheat if put under

high electrical demand. If the flat-top stove in the galley was being used at the same time that

scuba tanks were being filled with nitrox, the generator’s engine would overheat and eventually

shut down. As a result, a standard procedure was established for the deck crew to coordinate with

the galley crew so that galley equipment was not operated while scuba tanks were being filled with

nitrox.

Figure 13. The salvaged hull of the Conception, looking from aft to forward, with recovered engine room

and lazarette equipment placed in their original installed location (with the exception of the water heater,

which was located on the starboard side).

Electrical Distribution. The vessel’s grounded, 3-phase AC electrical distribution system

consisted of a neutral lead and three conductors. While the vessel was docked, a shoreside power

connection could be used in lieu of the generator to provide the vessel with single-phase power.

Thermal circuit breakers provided overcurrent protection. Original vessel electrical schematics

indicated that the rating for these breakers varied with application. For the larger 3-phase, 208-volt

equipment, each phase was protected with either a 30- or 60-amp breaker. The smaller 120-volt,

single-phase equipment and lighting was protected by 15- and 20-amp breakers.

Original wiring schematics showed that the Conception had both 12-volt and 24-volt direct

current (DC) voltage systems. The wheelhouse had a 12-volt battery system that was set up to be

trickle-charged from the vessel’s service 120-volt AC system. The battery and charger were located

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under the console in the wheelhouse. The plans indicated that the 12-volt system was set up to

power navigation lights, radio equipment, and selected lighting in the engine room, lazarette,

bunkroom, anchor room, and restrooms. The propulsion engines’ starters and shifting actuators

operated on 24 volts, while the propulsion engines’ controls and the vessel’s diesel generator starter

and control systems operated on 12 volts. The batteries used for both main engines and generator

set were located on the forward workbench in the engine room. Battery chargers were set up for

respective voltages and located on the forward bulkhead. Aboard the Conception, normal charging

of the main engine batteries was accomplished via the ship’s service 120-volt system. The main

engines’ attached alternators had their drive belts manually removed and were only used in a stand-

by capacity. In contrast, the generator set’s alternator was used and charged its batteries while the

generator was running.

In August of 2000, Coast Guard inspectors issued a deficiency for the vessel having

non-approved wiring in some of its AC electrical system. The Conception was required by Old T

(existing vessel) regulations to use stranded or braided conductor core wire. Instead, the wiring

being used was flexible “service” wire, commonly referred to in industry as SO, SJO, or STO

wiring. It was similar in type to that used in commercially sold extension cords. Both Old T and

New T regulations prohibited the use of this wire in the way it was being used aboard the

Conception. This wiring had been installed by the boat builder and approved by Coast Guard

inspectors in 1981 during the original construction of the vessel. Truth Aquatics appealed the Coast

Guard’s decision and requested a waiver to the Coast Guard’s requirements but was denied. In

2002, all non-approved wiring was replaced with approved wiring, and, following a Coast Guard

inspection, the vessel was deemed to be in compliance and the deficiency cleared.

Emergency Lighting. The

Conception had emergency lighting

in the bunkroom. It was mounted

near the main stairs going up to the

galley/salon at the top of the

forward bulkhead of the bunkroom,

and was designed to automatically

activate, in the event of the loss of

the vessel’s service supply power,

to provide lighting along the escape

path to the main deck from

accommodation spaces below. The

emergency lighting was powered

from the ship’s service 120-volt AC

system, and if this source was lost,

batteries internal to the unit would

supply power for lighting.

Replacement of Electrical

Components.

Throughout the 39-year operation of the Conception, many electrical components

had been changed with “replacement in kind” alternatives, such as circuit breakers and receptacle

Figure 14. Bunkroom emergency lighting on board the similar

vessel Vision. The lighting was of the same make and in a

similar location as was on board the Conception. Also note the

public address system speaker to the right of the lights.

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outlets.

Subpart G of New T regulations (all vessels) specifies that if a repair or alteration is not

a replacement in kind, the owner or managing operator must submit to the local Coast Guard unit

drawings, sketches, or written specifications describing the details of the proposed alteration. The

Coast Guard would then initiate a plan review to determine if the repair or alteration was safe and

within regulations. Most reviews are handled locally at the Coast Guard sector or detachment level.

If the repair or alteration is deemed “major” by the Officer in Charge, Marine Inspection (OCMI)

at the sector, then the plan review is elevated to the Coast Guard’s Marine Safety Center in

Washington, D.C. At the Marine Safety Center, professional engineers, naval architects, and/or

subject matter experts conduct the plan review and issue recommendations, interpretations, or

guidance to the respective OCMI.

Crewmembers reported to investigators that in the weeks prior to the accident, two of the

vessel’s deckhands changed out the overhead

florescent lighting fixtures in the salon with new

LED light fixtures. Plans detailing the modification

were not submitted to the local Coast Guard Marine

Safety Detachment (MSD), and the Coast Guard was

not notified of this change. Truth Aquatics last

submitted plans for review in 2000 for the

installation of a galley hood heat detection sensor,

which was required by New T regulations (all

vessels). The plans were approved by the OCMI at

Coast Guard Sector Los Angeles/Long Beach.

1.5.4 Air Conditioning System and

Ventilation

The heating, ventilation, and air conditioning

system on board the Conception consisted of a

combination of supply and exhaust fans, natural

ventilation, and an air conditioner in the bunkroom.

According to a former crewmember, the only heater

on board was a small plug-in space heater located in

the wheelhouse. The crewmember stated that this

heater was used occasionally during the winter

months but usually was not used during the summer

season.

The engine room used both natural

ventilation and two forced-draft fans to supply air for

cooling and engine combustion consumption.

Outside supply air was ducted into the engine room

from openings on the aft main deck. In the event of

an engine room fire, these ducts could be closed

manually by dampers, with the shutoffs located on

the main deck port- and starboard-side across from

According to 46 CFR 136, replacement in kind refers to the “replacement of equipment or components that

have the same technical specifications as the original item and provide the same service. If the replacement item

upgrades the system in any way, the change is not replacement in kind.”

Figure 15. The starboard-side main deck of

Conception, looking aft from forward of the

galley. Arrows indicate the location of the

bunkroom ventilation intake and exhaust

ducts. Note the sliding windows. (Source:

R. White)

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the engine room hatch. On the night of the fire, the ducting in the engine room was not closed by

the crew.

Another ventilation fan was positioned in the bulkhead that connected the engine room to

the lazarette. The fan could be run to supply additional air to the engine room (pulled through the

lazarette), or in reverse to supply warm engine room air exhausting to the lazarette, where scuba

diving suits were hung to dry. Investigators were unable to determine in which direction the fan

was operated on the night of the accident. According to the owner, it was normal procedure when

at anchor at night to have the fan in reverse operation.

The galley flat-top and twin burner stove had a mechanical extraction fan directly above

the stove, which was used while cooking to expel fumes via a duct directly outside to the port

forward main deck.

The salon used natural ventilation via the three sliding windows on each side of the salon

and the outward-opening window at the forward galley area. Crewmembers stated that, at the time

of the accident, the aft port and starboard sliding windows in the salon were open several inches

for ventilation and the forward, outward-opening galley window was closed. The aft salon doors

were also open for ventilation, as they always were while the boat was at sea with passengers on

board. These doors were only closed when the boat was docked, not being used, and with no one

on board.

The wheelhouse and crew

staterooms on the upper deck of the

Conception also relied on natural

ventilation through windows, the

wheelhouse wing doors, and the door to the

sun deck. At the time of the accident, it was

reported by the crew that the sun deck door

was open, the port and starboard

wheelhouse wing doors were shut, and the

positions of the stateroom windows were

unknown.

The bunkroom regularly used a

combination of circulation fans and an air

conditioning unit. The supply fan, located

at the forward end of the space, drew air

through ducting that originated 12 inches

above the main deck. The ducting attached

to air plenum boxes that were about 6–

10 inches off the main deck. These boxes

were located on both the port and starboard

sides, just below the forwardmost side salon

windows. Two exhaust fans, one located on

each side of the aft area of the bunkroom,

expelled air from the space to the main

deck. The ducting for these fans led to

identical plenum boxes, which were located

aft of the intake plenum boxes.

Figure 16. Port side of the Conception’s bunkroom

looking aft, with inset of grille/diffuser. (Source:

M. Ryan; Inset: S. Landis)

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The air conditioning unit, which was the primary means of cooling and ventilation for the

bunkroom, was located under the bunkroom deck boards, just port of midship, underneath bunks

30U, 31M, and 32L (see figure 5 for the bunkroom layout) in the vessel’s bilge area. The unit was

sized for the space and was estimated to be 4–5 tons. The direct expansion package unit consisted

of an evaporator coil, blower fan, compressor, and seawater-cooled condenser. The system was

designed to pull air from the space through a diffuser and filter element, located at the forward end

of the space, directly at the bottom of the stairs. The blower fan would draw ambient air across the

evaporator coil and discharge the cool conditioned air through a network of flexible insulated

distribution ductwork located in the bilge. This ductwork connected to permanent ducts and

passageways built into the framework of the bunkroom. Each bunk was fitted with a grille/diffuser

that could be opened or closed dependent on need. Similar grille/diffusers and ductwork were

positioned on the overhead between the rows of bunks on both the port and starboard sides.

A month prior to the accident, a technician had been called to the vessel to repair a leak on

the condenser tubing, which required some soldering to fix. Since the repair, the unit had been

operating as expected.

It was standard practice for the vessel’s crew to only operate the air conditioner through

the night when the passengers were sleeping. A crewmember would turn the unit on and off by

means of a circuit breaker located in the circuit breaker panel at the top of the stairs leading down

to the shower room. At the time of the accident, the air conditioning system was in operation; a

crewmember stated that he closed the breaker to the air conditioner before going to bed.

The air conditioning unit was recovered still in place in the wreckage and was examined

by investigators. There were no signs of mechanical failure to the components of the unit. The air

conditioning system was not connected to the vessel’s emergency power. None of the surviving

crewmembers turned off the air conditioning system at the time the fire was discovered. The unit

would have operated until the Conception’s main power was lost (although there was no means to

confirm that this occurred).

1.5.5 Auxiliary Systems

Bilge and Fire Main Systems. The bilge and fire main systems were interconnected on

board the Conception. The fire pump or bilge pump could be used to pump out the vessel’s bilges.

According to the crew, during normal operations, when bilges were not being actively pumped,

the fire main was lined up in a ready state, with the bilge crossover valves shut. Located on the

port side forward in the engine room, the fire pump was driven by a 208-volt electric motor.

The 1.5-inch diameter Jabsco bilge pump was driven off the starboard main engine. Bilge

level sensors were positioned below the deck in the engine room, bunkroom, lazarette, shower

room, and forward of the collision bulkhead. If a high-liquid level in a space was reached, the

sensor would be activated, and an alarm would sound in the wheelhouse to notify the operator. A

series of 1.5-inch piping connected the bilge spaces to the pumps, which were normally lined up

to pump overboard.

Diesel Fuel Tanks. The Conception had two steel 800-gallon diesel fuel tanks that stored

fuel for the vessel’s two main engines and electric generator. At the time of the fire, the vessel was

carrying about 1,400 gallons of fuel. The tanks were constructed of steel and located alongside the

hull on the port and starboard sides of the forward engine room. Held in place by wooden frames,

their outboard side was shaped to match to the side of the vessel. Filling and venting of the tanks

were accomplished via steel pipes running up to the aft main deck. To secure fuel from the tanks

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to the engines in an emergency, two handwheels (located in the port and starboard main deck

restrooms) were connected to the main supply valves through linkages. Operating fuel supply to

the main engines and generator was through their respective engine-driven fuel pump and a

network of both copper piping and fuel-rated synthetic hose.

Water and Sewage. Fresh water on board the Conception was stored in four polyethylene

tanks located on the forward bulkhead of the lazarette. The total freshwater storage capacity in

these four tanks was 1,200 gallons.

The vessel’s three pressure saltwater toilets drained to a plywood and fiberglass sewage

holding tank in the engine room. The tank, which was situated midships along the forward

bulkhead, was covered with a workbench. The bench functioned not only as a workspace but also

as a platform for the 12- and 24-volt marine engine-starting batteries. Once full, the sewage tank

could be drained overboard after the vessel was under way and at least 3 miles away from shore.

Additionally, the vessel had several auxiliary freshwater and saltwater pumps, located in

the engine room and lazarette. These pumps were used for washing down the deck, cleaning scuba

diving equipment, and other onboard tasks.

Air Compressors. To fill scuba air bottles, the Conception used three breathing air

compressors, which operated off 3-phase, 208-volt alternating current. All three compressors were

used solely for filling air bottles. They were operated manually by the crew and could be used

independently or in conjunction with each other depending on demand and purpose. The two

primary Ingersoll-Rand air compressors were in the aft starboard corner of the engine room. The

third compressor was part of a nitrox generator unit, positioned in the forward starboard corner of

the lazarette. According to crewmembers interviewed, none of the air compressors were in use at

the time of the accident.

Winches. The Conception had two winches on board. The bow capstan winch was powered

by a 208-volt, 5-hp, 3-phase electric motor. It was used to haul the vessel’s bow anchors and heave

mooring lines as needed. The stern electric hydraulic winch system was powered by a similar 1-hp

motor and was primarily used to hoist and lower the vessel’s swim platform, which acted as a

cradle for the vessel’s rigid hull inflatable skiff. Neither of these winches were wired to the vessel’s

emergency power, nor were they in use prior to the fire.

1.5.6 Galley Equipment

The galley consisted of a two-burner cooktop, flat-top griddle, double oven, microwave,

coffee pot, and refrigerator. Midships in the salon aft of the galley was a fountain soda dispenser,

ice maker, and a large refrigerated cooler. On the open main deck aft of the salon doors, there was

a barbeque grill. All equipment was electric. As a precaution, at night, the flat-top griddle and two-

burner cooktop were secured via the breaker panel located at the top of the stairs leading to the

shower room. On the night of the accident, the second galley hand stated that he turned off this

equipment by opening the respective circuit breakers. The first deckhand stated that, at the time of

the accident, the refrigerators were the only galley equipment running. Above the flat-top griddle

was a fixed-temperature heat detector, which had been replaced on February 23, 2016. The siren

was set to alarm at 135°F and would sound locally in the galley when activated.

1.5.7 Maintenance and Repair

Most of the maintenance on board was conducted by the crew under the direction of the

captain. Crewmembers told investigators that some equipment on board the vessel, such as the

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main engines, generator, and air compressors, were maintained regularly under the direction of the

captain. Crewmembers also said that equipment maintenance was recorded, and running logs were

kept for equipment and rounds made. All records and logs were kept on board and were lost in the

fire.

Conception crewmembers told investigators that they conducted maintenance and engine

room rounds and documented them in a log, which showed a general maintenance checklist for

much of the vessel’s engine room equipment. Similar logs were found aboard the Vision, a Truth

Aquatics vessel similar in size and type to the Conception. The Vision’s round sheets showed

routine daily engine room checks, and the vessel’s logs documented equipment maintenance

history, which reflected the maintenance instructions. Maintenance completed by the Vision’s crew

consisted of oil changes, coolant flushing, filter changes, zinc renewal, pump rebuild, and belt

replacement.

Figure 17. Engine Room Check Log used on the Truth Aquatics vessel Vision (Source: Truth Aquatics).

The owner of the Conception stated that if the captain deemed that the maintenance was

outside the capability of the vessel’s crew, the captain would schedule an outside contractor to

come on board and carry out the work and/or repair.

1.5.8 Certification, Inspections, and Examinations

The Conception was required to have a valid Certificate of Inspection (COI) issued by the

Coast Guard. As stated in the New T regulations (all vessels), the COI:

describes the vessel, the route(s) that it may travel, the minimum manning

requirements, the survival and rescue craft carried, the minimum fire extinguishing

equipment and lifejackets required to be carried, the maximum number of

passengers and total persons that may be carried, the number of passengers the

vessel may carry in overnight accommodation spaces, the name of the owner and

managing operator,…and such other conditions of operations as may be determined

by the cognizant [Coast Guard OCMI].

A COI is issued by the Coast Guard and is valid for 5 years for vessels traveling on domestic

routes. Prior to renewal at the end of 5 years, the vessel must be inspected to ensure that it is in

satisfactory condition, fit for the service intended, and complies with regulations. The inspection

includes examination and testing of the vessel’s structure, machinery, and equipment, and may

include fire, abandon ship, or man overboard drills. The OCMI may require the vessel to get under

way for the inspection.

The Conception had a valid COI issued on November 19, 2014. Per the COI, the vessel

was required to be manned by a credentialed master and mate, as well as two uncredentialed

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deckhands.

The vessel could carry up to 99 passengers but was limited to 46 passengers for

overnight accommodations. The COI listed the Conception’s hull material as “wood.”

A vessel carrying a COI valid for 5 years must also be inspected annually. The scope of the

annual inspection is the same as the inspection for certification but in less detail, unless the Coast

Guard inspector finds deficiencies or determines that a major change has occurred since the last

inspection. If the vessel passes the annual inspection, the inspector endorses the COI. If a vessel

does not pass an inspection, the attending marine inspector may place operational controls on the

vessel, such as an order requiring a correction “prior to carriage of passengers,” until deficiencies

are rectified to the satisfaction of the marine inspector.

In addition to certifications and annual inspections, vessels that operate on domestic routes

and are exposed to salt water more than 3 months per year are required to undergo a drydock hull

examination and an internal structure examination every 2 years.

To aid in the conduct of these inspections, the Coast Guard issued inspectors the T-Boat

Inspection Book, CG-840 TI, which contains checklists for each of the areas normally covered

during an inspection. The CG-840-TI was not required to be used or retained by inspectors and

was last updated in 2011. Coast Guard sector commands and MSDs may also have supplemental

or compressed checklists for inspections. MSD Santa Barbara, a sub-unit of Sector Los

Angeles/Long Beach that was responsible for conducting the regulatorily mandated inspections of

the Conception, had a “Small Passenger Vessel – T” checklist that was last updated in 2014.

MSD Santa Barbara conducted the 5-year COI renewal inspections, annual inspections,

and biannual drydock hull and internal structural examinations on the Conception. The detachment

had two officers assigned as inspectors, and, according to the Coast Guard, the inspectors were

appropriately qualified for the inspection of small passenger vessels under Subchapter T. The MSD

Supervisor, the officer overall responsible for all activities at the detachment, was also a qualified

inspector. According to the Supervisor, there were about 74 domestic vessels under the MSD’s

area of responsibility, most of which were small passenger vessels regulated under Subchapter T.

During the 2014 inspection for certification, subsequent annual inspections, and biannual

hull and structural inspections aboard the Conception, minor discrepancies were reported, and the

vessel owner corrected the discrepancies either immediately upon discovery or soon thereafter.

One “prior to carriage of passengers” operational control was issued in February 2016 because the

operator could not prove that the fire pump was operational. The operational control was removed

the day after it was issued when the inspector witnessed the proper operation of the pump. There

were no discrepancies reported in the annual inspection conducted in February 2019. The last

Coast Guard drydock inspection took place in February 2019, in conjunction with the annual

inspection. There were no discrepancies noted during the examination. For all inspections from

2014 onward, the inspection for certification and subsequent annual inspections were conducted

by the same MSD Santa Barbara inspector. All hull and structural examinations from 2015 onward

were also conducted by the same MSD Santa Barbara inspector.

For voyages of less than 12 hours, the crew requirement was reduced to a credentialed master and two

uncredentialed deckhands.

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In eyewitness photos and videos of the Conception, large polyethylene trash cans can be

seen throughout the interior and exterior areas of the vessel, including the bunkroom. The trash

cans were manufactured by Rubbermaid from 2016 onward. Neither the Old T nor the New T

regulations allow for these types of trash cans to be used in passenger bunkrooms and instead

require that trash cans be constructed of non-combustible materials. New T regulations extend the

prohibition on combustible trash cans to all compartments, but only apply to existing (Old T)

vessels when the trash cans are replaced. Throughout the inspection history of the Conception,

there were no remarks or deficiencies related to the waste receptacles on board.

Figure 18. Left: Photo from a previous voyage of stairway to the upper deck and restrooms of the

Conception. Note the regular stowage of a polyethylene trash can under the stairway aft of the salon. Right:

Still image from a 2019 video taken of the stairway on board the Conception with shelving installed. (Source:

M. Ryan [left], R. Clevenger [right])

1.6 Accident Damage

Evidence was recovered from the accident site, including equipment and small parts of the

hull, and brought ashore, where it was photographed and catalogued by the FBI Evidence

Response Team. The wreckage was recovered on September 12 and transported by barge to the

NBVC–Port Hueneme on September 13. The Coast Guard; Bureau of Alcohol, Tobacco, Firearms

and Explosives (ATF); FBI; and Santa Barbara Fire Department inspected the wreck. All debris

and personal effects recovered from the seafloor were also brought to the wreckage site for

examination.

On September 25–27, the NTSB examined the wreckage and debris recovered from the

seafloor and surface. The wreckage and debris were laid out by the ATF and FBI in a secure parking

lot into three sections consisting of the main hull with the below deck spaces, the main deck, and

the upper deck (figure 19). There were also bags full of items that had been floating in the water

and/or collected from the seabed. The ATF and FBI, with Coast Guard assistance, placed the

recovered items and portions of structure that could be identified in their corresponding places for

each of the three sections of the wreckage representing the three decks. Identifiable engine room

machinery and equipment, such as the generator and sewage tank, were placed back in their

original position in the engine room within the hull. For the main deck and upper deck portions,

an outline was made on tarpaulin underlays, and the items and structure were placed within the

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outlines in the areas where they belonged. Very little structural material remained from the upper

deck and the main deck.

Figure 19. Conception wreckage layout at Port Hueneme. (Source: FBI Evidence Response Team)

The hull of the Conception, where the below-deck compartments had been located,

represented the bulk of the remaining structure. The transverse bulkheads were severely fire

damaged, eliminating the separation of the below-deck compartments between the anchor room,

shower room, bunkroom, engine room, and lazarette from forward to aft. The entire interior of the

below-deck space was charred. Overall, the interior of the below-deck compartments had burned

all the way down to the floor in the bunkroom and shower room and had consumed the floor,

exposing the longitudinal frames, in both the engine room and lazarette (figure 20).

Figure 20. Below-deck areas of the Conception. The solid white lines mark the approximate boundaries of

each compartment. (Source: FBI Evidence Response Team)

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Portside portions of the hull exterior had burned down to a few inches from the waterline.

The areas with fire damage closest to the waterline corresponded with the locations of the lazarette

compartment and the passenger bunkroom. On the bow portion of the hull exterior, the fire burned

down to the level of the main deck rub rails. On the starboard side of the hull exterior, as on the

port side, the areas with fire damage closest to the waterline corresponded to the lazarette and

passenger bunkroom areas. Overall, the area of lowest burn-through of the hull on the starboard

side of the passenger bunkroom was larger than the area of lowest burn-through on the port side.

The structure and items recovered belonging to the main deck of the vessel consisted

mostly of a few pieces of partially charred deck material and the noncombustible remains of the

galley and salon equipment (figure 21). The decking material that remained belonged to the three

restrooms on the main deck and small portions of the port and starboard walkways that were

adjacent to them.

Figure 21. Wreckage belonging to the main deck of the Conception. Solid yellow lines indicate the enclosed

spaces on the deck. The blue box marks the location of the stairway to the sun deck. (Source: FBI Evidence

Response Team)

No recognizable structural components remained from the upper deck, which included the

sun deck, crew staterooms, and wheelhouse; some larger items that remained from this deck were

the metal frame of the helm wheel, a piece of a life float, and the batteries for the vessel’s radios.

Upon examination of the wreckage, investigators found silhouette evidence markings

resembling the outline of persons or objects of non-uniform shape (e.g., duffel bags) in the

bunkroom at the bottom of the main stairs leading to the salon, on the port side forward lower

double bunk, and adjacent vertical and horizontal bunk frames at bunks 17L and 19L (figure 22).

The air conditioning intake louver at the bottom of the main stairs had an observable silhouette

and traces of human tissue on it.

In a fire, when one object is covered by another, it creates a protected area, or silhouette, of that object on the

material below.

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Figure 22. Postaccident photo of the bunkroom looking from the starboard aisle forward and to port.

1.7 Operations

1.7.1 Charter Company

The accident charterer, Worldwide Diving Adventures, had been in business for about

50 years. The organizer and leader of the chartered trip, also one of the charter company owners,

was a passenger on board the Conception at the time of the accident. According to Truth Aquatics’

owner, the group leader had been “coming out with us for probably 30 years,” and many of the

group’s participants were regular customers. Per the charter agreement, Worldwide Dive

Adventures was not responsible for the operation of the Conception or its equipment, which was

handled by the crew employed by Truth Aquatics.

1.7.2 Company Information

Owner and Operator. Truth Aquatics, a small, family-run company based in Santa

Barbara, operated a fleet of three dive vessels, the Conception, the Truth, and the Vision. The

business was founded in 1974, and the current owner became a partner in the company in 1979

before eventually assuming full ownership. Ownership of the three vessels was under a trust set

up by the owner of Truth Aquatics. In addition to six crewmembers assigned to each vessel, Truth

Aquatics employed a shore staff of about ten people to handle logistics, scheduling, and the overall

operation of the company.

Current and former employees described the Truth Aquatics’ owner as being “very

involved” in the operation. According to the company’s website, the owner had personally

overseen the construction of the Conception and the Vision. He held a valid Coast Guard merchant

mariner credential as a master of self-propelled vessels (not including auxiliary sail) of less than

100 gross register tons upon near coastal waters and occasionally captained the company’s vessels.

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The company was a member of the Sportfishing Association of California, an industry advocacy

and advisory group.

According to the company owner and former captains of Truth Aquatics vessels, the

captains of the Conception, Vision, and Truth were given broad authority over the operations of

their vessels, to include the hiring, training, and dismissal of crewmembers; the conduct of routine

maintenance; and the establishment and enforcement of vessel operating procedures. The owner

stated that there were no company-wide operating procedures or crew work/rest policies; these

were left to the qualified captains of each vessel to establish and manage.

Truth Aquatics was generally well regarded among regulators, current and former

employees, customers, and other dive boat operators in Southern California. According to the

Assistant Chief, Inspection Division, Coast Guard Sector Los Angeles/Long Beach, Truth Aquatics

and the company owner “had a good reputation for being good operators. They were always more

than willing to engage in conversation about vessel operations…We’ve always had a good

relationship with Truth Aquatics.” A customer who had made several trips on Truth Aquatics

vessels stated that the company was “considered to be the top [dive boat] outfitter,” and a former

captain of the Vision described the vessels as “the safest boats on the coast...No expenses were

spared.”

Company Fleet. The Truth, built in 1974, was a 64.5-foot-long, 78-gross-ton small

passenger vessel, also inspected under Old T regulations. It had a fiberglass-over-wood hull and

was smaller and arranged differently than the Conception.

The Vision, built in 1985, was an 80-foot-long, 98-gross-ton small passenger vessel similar

in size and layout to the Conception and inspected under the same criteria. After the accident,

NTSB investigators visited the Vision to inspect construction material, general arrangement,

firefighting and lifesaving equipment, means of escape, and egress arrangements. The salon and

galley compartment was similarly arranged with the salon area in the aft portion and the galley

forward. The passenger bunkroom, which had the same capacity (45 passengers and 1 crew), was

also similarly arranged and outfitted with bunkbeds along the centerline and bunkbeds along aisles

on the port and starboard sides. As on board the Conception, egress from the passenger bunkroom

was available from the main staircase near the galley and from an emergency exit hatch above one

of the aft bunks. Both exits from the passenger bunkroom led to the salon compartment.

The Vision’s bunkroom ventilation system was similar to the system on board the

Conception. Located in the bunkroom bilge was a six-ton, direct-expansion air conditioning unit,

which drew air from within the space through a grille located at the bottom of the stairs and

discharged air-conditioned air through a system of ducts to individual bunks and to the

passageways on the port and starboard sides of the bunkroom. A single supply fan, rated for 595

cubic feet per minute (cfm), was used to distribute fresh outside air to the bunkroom. Two 480-

cfm exhaust fans, one located on each side of the bunkroom, were used to expel air from the space.

With passengers on board, the Vision, like the Conception, operated the bunkroom supply and

exhaust fans continuously and used the bunkroom air conditioning unit at night or as needed.

According to the organization’s website, “The Sportfishing Association of California (SAC) was founded in

1972 by industry leaders speaking out on behalf of their interests. SAC works with several agencies and stakeholders,

including the California Department of Fish and Wildlife, United States Coast Guard, Navy, National Marine Fisheries

Service, Federal Communications Commission, Congress, California Legislature, and the Mexican Government. SAC

employees serve on multiple advisory panels in the state and federal arena, and represent industry interests on a variety

of topics.” Sportfishing Association of California, www.californiasportfishing.org/about

, accessed on April 28, 2020.

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Although the passenger bunkroom had smoke detectors, the salon and galley did not. The interior

furnishings of the Vision’s salon were generally the same type and material as those that had been

in the Conception. The furnishings consisted of wooden tables, plastic chairs, seat cushions and

various surfaces sheathed with fiberglass-reinforced plastic (FRP) laminate. These furnishings

were not required to be fire-resistant.

Investigators examined the Vision’s salon for potential ignition sources. There were cable

runs located behind the seatback of the bench-type seating and receptacle drops just under the

seatbacks. The electrical cable runs were not enclosed in protective conduit, were often not

supported, and did not have the appearance of a professional installation. Similar installations were

also observed in the bunkroom (figure 23).

Figure 23. Power cable for lighting routed through ventilation grille in the Vision’s bunkroom.

1.7.3 Company Loss Control Program

In the 1980s, the International Maritime Organization (IMO) developed the International

Safety Management Code (ISM Code), the purpose of which is “to provide an international

standard for the safe management and operation of ships and for pollution prevention.”

The ISM Code, along with 33 CFR part 96 and Title 46 US Code Section 3203 that

implement the code for US and other applicable vessels, requires that vessel operators implement

a safety management system (SMS). The SMS defines the roles and responsibilities of all

personnel, outlines safe practices in vessel operation and navigation, and establishes safeguards

against identified risks. According to US law, an SMS must contain the following elements:

1. a safety and environmental protection policy;

IMO, “ISM Code and Guideline of Implementation of the ISM Code,”

http://www.imo.org/en/OurWork/HumanElement/SafetyManagement/Pages/ISMCode.aspx

, accessed April 6, 2020.

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2. instructions and procedures to ensure safe operation of those vessels and protection of

the environment in compliance with international and United States law;

3. defined levels of authority and lines of communications between, and among, personnel

on shore and on the vessel;

4. procedures for reporting accidents and nonconformities with this chapter;

5. procedures for preparing for and responding to emergency situations; and

6. procedures for internal audits and management reviews of the system.

Truth Aquatics did not have an SMS for its vessels, nor was it required to. Current

regulations for SMSs do not apply to small passenger vessels operating on domestic routes.

However, the Coast Guard Authorization Act of 2010 authorized the Secretary of the Department

of Homeland Security (DHS, in which the Coast Guard operates) to “prescribe regulations which

establish a safety management system” for all small passenger vessel operators, including

domestic. To date, the Coast Guard has not issued the regulations authorized in the 2010 law;

however, the service has signaled its intent to start the development process in the federal

government’s Spring 2020 Unified Agenda of Regulatory and Deregulatory Action.

Additionally,

in February 2020, the Coast Guard issued a Marine Safety Information Bulletin (MSIB)

encouraging operators to voluntarily implement SMSs and providing references for developing

these systems.

Although Truth Aquatics did not have an SMS, paperwork that was presented to new

employees when they were hired by the company included a Loss Control Program, which

included some elements common to an SMS.

The first element of the program document, titled

“Purpose, Duties, Responsibilities and Administration,” provided an overall safety policy for the

company. The policy included the following:

The health and safety of employees and passengers on Truth Aquatics’ property is

of critical concern. We strive to attain a high level of safety in all activities and

comply with all health and safety laws applicable to our operations. The company

expects that every employee will accept the responsibility for loss prevention and

reduction.

Captains of each vessel will be directly responsible for maintaining safe working

conditions and practices and for the safety of passengers and crewmen under their

supervision. They will direct the program to each of their crewmembers in the form

of instruction and control. Any safety deficiencies should be brought to the attention

of the captain.

All employees have a safety responsibility to themselves, their fellow crewmen,

and to the company. Their performance must reflect this mutually beneficial

Office of Management and Budget (OMB), “Spring 2020 Unified Agenda of Regulatory and Deregulatory Action,

Department of Homeland Security Agency Rule List,” 2020, https://www.reginfo.gov/public/do/eAgendaMain

(a) An MSIB is a Coast Guard publication that provides a brief, concise, and timely notice of changes in the

maritime transportation system, usually to provide guidance to industry on how to comply with new requirements

and/or address evolving operational hazards. MSIBs are announced through various press and social media outlets

and are available online at

https://www.dco.uscg.mil/Featured-Content/Mariners/Marine-Safety-Information-

Bulletins-MSIB/. (b) Coast Guard, Resources for Voluntarily Establishing a Safety Management System, MSIB 03-

20, Washington DC: Department of Homeland Security, 2020.

Loss control is an insurance industry term for a program to manage risk and reduce losses.

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obligation through active support of the safety and loss control program and

compliance with established safety practices and procedures. The captains will

provide training and instruction to help meet these responsibilities.

Follow-on sections of the document included instructions for the conduct of inspections

for safety hazards, accident investigation and reporting requirements, and guidance for annual

safety meetings between vessel captains, management, and the owner.

The fifth element of the program, “Training,” stated the following:

Truth Aquatics will provide adequate training to all employees so that they can

perform their assigned tasks. Training programs shall be performed by captains on

an as-needed basis. Records shall be kept of meeting agendas and attendance.

Management shall maintain these records in the [company’s shoreside] office and

they will be made available to all employees.

Annual CPR training classes will be held at appropriate times and all crewmembers

are encouraged to attend.

The final element of the Loss Control Program, “Emergency Procedures,” contained a list

of nine emergencies, including fires, flooding, and abandon ship, with step-by-step instructions for

crew responses to each emergency. The section lead paragraph stated, “This list is required to be

reviewed by all participants.” The first procedure on the list was firefighting and consisted of the

following instructions:

• Shut off all engines, generators and ventilation systems, unless they are needed to

maneuver the vessel.

• Recover and evacuate anyone injured.

• Locate the fire and evaluate the extent of the fire.

• Cut off air supply to fire – close items such as hatches, ports, doors, ventilators, louvers,

and shut off power ventilation system (blowers).

• Cut off electrical system supplying affected compartment if possible.

• If safe, immediately use portable fire extinguishers at base of flames for flammable liquid

or grease fires, or water for fires in ordinary combustible materials. Do not use water on

electrical fires.

• If fire is in machinery spaces, shut off fuel supply and ventilation, and activate fixed

extinguishing system.

• Maneuver vessel to minimize effect of wind on fire.

• If unable to control fire, immediately notify the Coast Guard and other craft in the vicinity

by radiotelephone (VHF).

• Move passengers away from fire, have them put on lifejackets, and if necessary, prepare

to abandon ship [emphasis in original].

The employee handbook stated, “The Loss Control Program manual is designed for the

safety of all employees. You are responsible for reading this manual and are required to sign and

date that you have read and understand it.” The second captain, first galley hand, and an alternate

second captain who had been on Conception during the previous voyage stated that they had

received a copy of the Loss Control Program, as well as an employee handbook and other

documents, after being hired by Truth Aquatics. The second captain and alternate second captain

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(who had been hired in August 2019) stated that they had received the documents in an email with

attachments.

The alternate second captain stated that he had reviewed the program document, but that

no one verified that he had read it or understood the policies and procedures before he got under

way on the Conception. The first galley hand stated that he did not receive the new employment

documents until just prior to the accident voyage, his fifth or sixth voyage on the vessel. He stated

that he wrote down the headings of the emergency procedures listed in the Loss Control Program

and asked the captain to discuss the procedures on the day before the accident. The first galley

hand stated that the captain’s response was, “When we have time.” He further said that during the

accident, “I didn’t know what the procedures were supposed to be.”

1.7.4 Watchstanding

Truth Aquatics’ owner stated that there were no company-wide policies or procedures

regarding watchstanding on board its vessels; watches were at the discretion of the captain of each

dive boat. Conception crewmembers and former crewmembers interviewed by investigators stated

that there was no formal watch rotation for the vessel.

Navigation Watches.

Per New T regulations (all vessels), “the movement of vessel shall

be under the direction and control of the master or a licensed mate at all times.” (The terms

“licensed” as used in this section of Subchapter T is equivalent to “credentialled” as used in this

report and other portions of 46 CFR.) The captain of the Conception was the principal operator of

the vessel’s controls, and during the accident voyage the credentialled second captain also took the

helm for brief periods.

In an interview with law enforcement officials, the first deckhand stated that, on previous

voyages, the deckhands would also be assigned helm watches at night. When a deckhand had the

watch, all other crewmembers were asleep, including the captain and second captain. He said that

the captain would “strategically pick the legs that the deckhands would take so that we’re not going

to be crossing the channel, or intercepting islands, or basically anything like that.” The deckhands

were instructed to monitor the radar, the VHF radio, and the electronic charting system and to wake

up the captain if the engines made unusual noises or if other vessels came within 2 miles of the

Conception. (There is no requirement in New or Old T to maintain a wheelhouse watch while a

vessel is at anchor.)

Roving Patrols. The requirement to keep a watch at night while passengers are embarked

on a vessel has been codified in US law since 1871. Per the current statute (46 United States Code

[USC] Section 8102), “the owner, operator, or charterer of a vessel carrying passengers during the

nighttime shall keep a suitable number of watchmen in the vicinity of cabins or staterooms and on

each deck to guard against and give alarm in case of fire or other danger.” An owner, operator, or

charterer who fails to comply with this law is subject to a civil penalty of $1,000. In interpreting

the statute for small passenger vessels under New T regulations (all vessels), the Coast Guard

requires that a “suitable number of watchmen patrol throughout the vessel during the nighttime,

whether or not the vessel is underway, to guard against, and give alarm in case of, a fire, man

overboard, or other dangerous situation.”

As a result, a provision was included in the “Route Permitted And Conditions of Operation”

section of the Conception’s COI stating that “a member of the vessel’s crew shall be designated by

the master as a roving patrol at all times, whether or not the vessel is underway, when the

passenger’s [sic] bunks are occupied.” NTSB investigators reviewed COIs from other small

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passenger vessels with overnight accommodations, and all of the certificates had a similar

statement regarding the requirement for a roving patrol, both under way and not under way.

When the Conception was not under way, whether moored in harbor in Santa Barbara or

anchored around the Channel Islands, there was no designated roving patrol while passengers were

aboard, according to crewmembers and former crewmembers. When passengers boarded the vessel

the night before an early departure, it was common for there to be no crew on board until hours

after the passengers had arrived. While on a dive trip and at anchor, no watch was set at night, and

all crewmembers normally slept after the day’s activities had ended until the next morning.

The NTSB interviewed captains and crewmembers from other Truth Aquatics vessels, and

all stated that the practices on their vessels were the same as those on the Conception. A captain of

the Vision stated, “We’d prep the boat the day before, and then leave the boat open for the

passengers to board…all of the deck crew would arrive a half hour before our scheduled

departure.” No watches were set while in port or at anchor. The Vision captain stated that he

believed that having one of the crew sleep in the bunkroom “somehow fulfilled” the roving patrol

requirement. He said that he had followed the practice that was shown to him when he began

working for Truth Aquatics, and he thought “the boat’s been operating this way for so long

successfully after so many inspections that it must be fine.” Referring to the roving patrol

requirement, a former captain of the Truth told Los Angeles Times reporters, “It’s a regulation, but

it wasn’t really followed.”

After the accident, NTSB staff visited other dive boats operating in Southern California

waters to gather information about industry-wide practices. During informal discussions with

investigators, the owners and operators of all vessels that were visited stated that crewmembers

were aboard the vessel and night watches were conducted when passengers were embarked.

However, procedures for the conduct of night watches varied from boat to boat, ranging from

active roving patrols to stationary watches located in the wheelhouse or salon.

When asked by NTSB investigators, Coast Guard representatives stated that during

inspections for certification and annual inspections, inspectors have no practical way of verifying

that operators were complying with the requirement for a roving patrol on small passenger vessels

with overnight passengers. A Coast Guard senior marine inspector stated, “The master of the vessel

is responsible for operating the vessel within the parameters on the certificate. But there’s no way

during an inspection to know, because the inspection is conducted dockside, and even if you took

the vessel out to do drills, it wouldn’t be with passengers.” Neither the CG-840 TI inspection book

nor MSD Santa Barbara’s “Small Passenger Vessel – T” checklist included a line item for verifying

that a roving patrol was being conducted. Coast Guard records show that, nationwide since 1991,

no citations have been issued and no fines have been levied for failure to post a night watch or

roving patrol.

1.8 Survival Factors

The 33 passengers on board the Conception at the time of the accident were all United

States citizens from various states across the country. Passenger ages ranged from 16 to 62 years

old.

Puente, Mark, Richard Winton, Leila Miller, “Before Conception boat fire, captains say Coast Guard safety

rule was ignored,” The Los Angeles Times, December 30, 2019.

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1.8.1 Station Bill

Per New T regulations (all vessels), the Conception had a station bill—an official list of

each crewmember’s assigned duties and watch station—which outlined instructions to the crew in

case of emergency situations involving man overboard, fire at sea, and rough weather or crossing

hazardous bars. The station bill for the Conception was not found in the wreckage; however, the

two other vessels in the Truth Aquatics fleet, the Vision and Truth, had the same station bill as the

Conception.

For onboard fires, the station bill required the second captain to cut off air supply to the

fire and close hatches, ports, doors, and ventilation dampers, while the first deckhand was to use

portable fire extinguishers to extinguish the fire. The second deckhand was tasked to shut off the

fuel supply and ventilation to the engine room and discharge the system for any fire in machinery

space. The captain’s task was to minimize the effect of wind on the fire and to immediately notify

the Coast Guard and other boats in the vicinity if the fire was unable to be controlled. The second

captain was also responsible for moving passengers away from the fire, having them don

lifejackets, and, if necessary, have them prepare to abandon ship. There were no specific

emergency duties assigned to the first or second galley hands. Additional procedures were

discussed in Truth Aquatics Loss Control Program.

Figure 24. Fire at sea emergency instructions/station bill from the Vision.

Although the station bill was required to be posted by regulation, none of the crewmembers

on the Conception at the time of the accident were aware of any posted station bill. The first galley

hand was unfamiliar with the concept of a station bill when asked by investigators. The second

captain stated that he understood that his role in a fire emergency was to start the fire pump and/or

launch the skiff.

The Conception was fitted with a fixed installation public address (PA) system that could

be used to alert passengers and crew of an emergency from the wheelhouse, with speakers on the

bow, stern, and in the bunkroom. Regulations required the fixed PA system to be audible during

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normal operating conditions in passenger accommodation spaces and all other spaces normally

manned by crewmembers.

Although there was a speaker for the PA system in the bunkroom, it

was reported to have been disconnected so that passengers who were sleeping would not be

interrupted by routine announcements. There were no pre-accident records from the Coast Guard

showing whether the PA system on board the Conception was checked during inspections or any

deficiencies noted. During an inspection after the accident, the Coast Guard found that the PA

system on board the Vision was disconnected in the passenger bunkroom, and inspectors issued a

deficiency requiring it to be rectified.

1.8.2 Passenger Manifest and Accountability

New T regulations (all vessels) require the owner, charterer, managing operator, or master

of a vessel to “keep a correct list of the names of all persons that embark on and disembark from

a vessel…where passengers are carried overnight.” The list “must be communicated verbally or in

writing ashore at the vessel’s normal berthing location or with a representative of the owner or

managing operator of the vessel.”

On the Conception, a handwritten crew and passenger list was kept on board the vessel,

and a copy of the list for the accident voyage was found in the company office ashore. Passengers

were required to write their own names on the list after boarding, and some of the names appeared

to be signatures, making them difficult to read. The list had the names of 32 passengers; the name

of 1 passenger was missing (the owner of Truth Aquatics was able to provide an up-to-date list of

passengers after the accident). No emergency contact information was required to be given by any

of the passengers.

1.8.3 Safety Briefing

Passenger safety orientations are required on small passenger vessels by New T regulations

(all vessels). The regulations require that the orientation be conducted “before getting underway

on a voyage or as soon as practicable thereafter.” Among several required topics, the orientation

must include a briefing on the location of emergency exits and a demonstration of life jacket

donning or instructions that passengers may contact a crewmember for a demonstration. The

regulations also required that passengers “shall be requested to don life jackets and go to the

appropriate embarkation station during the safety orientation for vessels on a voyage of over

24 hours.”

Crewmembers told investigators that the 15–20-minute safety briefing on the Conception

was conducted by the crew following a standard bullet-point script. For trips that began late at

night or early in the morning, such as the accident voyage, the safety briefing was normally

conducted following breakfast, after the vessel had anchored at the first dive site. All passengers

were required to attend. Former passengers confirmed that during the briefing, the location of the

bunkroom escape hatch was discussed, as the briefer normally stood directly aft of the hatch in the

salon during the presentation. Passengers were informed but not shown where the hatch was

located in the bunkroom. According to current and former crewmembers, the briefer did not

demonstrate donning of lifejackets. During interviews with investigators, current and former

According to 46 CFR 175.400, accommodation spaces include those spaces used as a public space, dining

room or mess room, lounge or café; overnight accommodation space; or washroom or toilet space. On board the

Conception, the accommodation spaces included the salon, bunkroom, and shower room.

NTSB Marine Accident Report

crewmembers on other Truth Aquatics vessels confirmed that the safety orientation procedures on

their vessels were the same or similar to the procedures on the Conception.

On the evening of August 30, passengers boarded the vessel and went to their assigned

bunks to sleep. The Conception got under way from Santa Barbara about 0404 on August 31.

Sometime after 0830 that morning, after the Conception anchored at the initial diving site, the first

deckhand completed the safety orientation in the salon. The first deckhand stated that he briefed

passengers on the location of lifejackets, extinguishers, and escape routes but was interrupted when

a passenger fainted. According to crewmembers’ accounts of the safety brief on the accident

voyage, the passengers on the Conception were not requested to don lifejackets or muster at the

embarkation station. After the passenger was revived and his vital signs checked, the remainder of

the safety brief was conducted by the captain, who, according to the deckhand, provided “an

abridged version” of the dive safety section of the brief.

As an alternative to the safety orientation announcements, New T regulations (all vessels)

permitted the use of a card or pamphlet, delivered to each passenger before getting under way, with

the information that would have been provided in a safety briefing. If using the pamphlet, an

abbreviated announcement must be made prior to getting under way. A “Welcome Aboard” card

was available in the Conception salon, containing general information that would “serve as your

pre-departure safety briefing,” as well as the location of lifesaving equipment. Placards in each

bunk provided lifejacket donning instructions. During interviews, surviving crewmembers did not

report that an announcement was made prior to getting under way for the accident voyage.

Figure 25. Truth Aquatics “Welcome Aboard” information specific to pre-departure safety briefing. (Source:

Truth Aquatics)

In the months prior to the accident, Truth Aquatics was finalizing the production of a vessel

and safety orientation video that was intended to be shown on board both the Vision and

Conception, which were similar in layout. The video had been completed by the contractor tasked

with production but was not yet in place on board each vessel. The safety orientation video showed

how to don a lifejacket, the locations of the muster area and of lifesaving appliances, instructions

for a man overboard, and the locations of the emergency escape hatch from the bunk room and

salon.

1.8.4 Smoke Detectors and Firefighting Equipment

According to the Coast Guard, the Conception was in compliance with the applicable

regulations pertaining to fire safety for this class of vessel.

Smoke Detectors. New T regulations (all vessels) specified that “each overnight

accommodation space on a vessel with overnight accommodations for passengers must be fitted

with an independent modular smoke detection and alarm unit.” The smoke detection and alarm

system was further required to:

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(1) Meet UL 217 (incorporated by reference, see 46 CFR 175.600) and be listed as a ‘Single

Station Smoke detector—Also suitable for use in Recreational Vehicles,’ or other standard

specified by the Commandant;

(2) Contain an independent power source; and

(3) Alarm on low power.

Neither Old T nor New T

regulations required the salon and galley

compartment to have smoke detectors

installed. Heat detectors were installed in

the engine room and galley. The smoke

and heat detectors were not

interconnected to other alarms or a

central operating station in the

wheelhouse. In the engine room, the heat

detector, if activated, would initiate the

carbon dioxide fixed fire-extinguishing

system for the engine room. The galley

detector was not connected to the range

hood fan or any damper, nor was it

required to be.

As required by 46 CFR

181.405(c), which applied retroactively to

existing vessels with an overnight

accommodation space, the bunkroom area contained two independent modular smoke detectors,

installed in the overhead on the port and starboard aisles between the bunks. Investigators were

informed by the vessel owner that the smoke detectors in the bunkroom were hardwired into the

vessel’s electrical system, with a 9-volt battery backup. The smoke detectors were not

interconnected to other alarms or a centralized system in the wheelhouse. Based on photos and

video, the smoke detectors appeared to be common consumer-type smoke detectors, as specified

in the regulations. The smoke detectors in the bunkroom were the only ones required to be on

board. There were no additional smoke detectors installed on board.

(a) UL 217 is an industry standard describing the basic requirements and minimum performance characteristics

of single and multiple station smoke detectors used in ordinary indoor locations. (b) In contrast, the regulations in

46 CFR Subchapter K, applicable to larger US-flagged passenger vessels, require accommodation, control, and service

spaces to have a “smoke actuated fire detection system” and “a manual alarm system.”

Figure 26. Photo of the galley of the Conception taken

from the forward centerline window. (Source: NTSB

eyewitness submission)

NTSB Marine Accident Report

Figure 27. Interior view of Conception bunkroom. (Source: Truth Aquatics; annotated by NTSB)

There were no requirements related to the testing and inspection of smoke detectors. The

owner was aware that the bunkroom smoke detectors functioned properly less than a month before

the accident voyage, when a contractor soldering on the air conditioning unit activated them. The

owner told investigators that after the smoke detectors activated, the captain of the Conception

“unplugged” them while the soldering was ongoing. When the work was completed, the smoke

detectors were plugged back in, “fresh” batteries were added, and the detectors were tested. When

asked whether there were routine inspections or testing of the smoke detectors on the Conception,

the owner stated the captain was responsible for any inspections or testing.

At the time of the accident, the second galley hand stated that he did not hear any alarms,

nor did he smell smoke from his bunk aft of the wheelhouse. The first deckhand, whose bunk was

also in the wheelhouse, said that he heard a faint alarm when he was awakened. He did not

recognize the alarm and described it as “coming from the dash [in the wheelhouse]…barely a little

chirp.” He further noted that when he looked, he did not notice anything flashing on the console

in the wheelhouse.

Fixed Fire-Extinguishing Systems. New T regulations included fixed fire-extinguishing

requirements for a number of spaces, including most engine rooms. Existing wooden vessels, such

as the Conception, were required to comply with the new regulations by March 1999.

In accordance with the New T regulations (all vessels), the engine room was equipped with

an approved fixed fire-extinguishing system. Two 75-pound fixed cylinders charged with carbon

dioxide could be activated automatically via heat sensors located above the main engines or

remotely at a pull station positioned on the port side of the aft main deck. Once activated, the

system would flood the engine room with carbon dioxide. The carbon dioxide bottles were located

on the forward bulkhead in the lazarette, starboard side. The fire-extinguishing system and

ventilation dampers for the engine room were not activated manually on the night of the fire.

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A third-party inspection of the engine room fixed fire-fighting system and extinguishers

was competed in February 2019, and no outstanding deficiencies were noted.

The Conception’s galley had a flat griddle for which regulations prescribed a fixed fire-

extinguishing system. Due to the short 14-inch ducting that led directly outside, in 2000, the Coast

Guard granted a waiver for the system contingent on the company providing an additional B-II

extinguisher (10-pound dry chemical) in the galley, installing a heat detector, and implementing a

maintenance program “to ensure the existing galley and ventilation equipment is kept free from

any build-up of grease.” The second galley hand told investigators it was his duty to clean the

grease trap.

According to the owner, the captains for each vessel in the fleet were responsible for all

maintenance on board the vessel and all maintenance records were kept on each vessel.

Firefighting Equipment. The Conception used a combination of fire extinguishers, a fire

pump, and a fire axe to meet the fire equipment carriage regulations. There was no additional fire

equipment on board in excess of the requirements.

In total, there were six fire extinguishers on board the Conception. According to the COI,

five of them were type B-II and one was type B-I (2-pound dry chemical). On the main deck, one

fire extinguisher was mounted in the galley by the coffee pot, and one was mounted port side aft

in the salon. In the bunkroom, there was a fire extinguisher mounted on a bulkhead across from

the main stairs by the changing room. There was one fire extinguisher in the engine room, one in

the lazarette, and one in the wheelhouse dash at the console.

An electrically driven fire pump in the engine room provided firefighting water to hoses at

two fire stations located on the main deck on either side, outboard of the salon. Each fire station

contained 50 feet of 1.5-inch fire hose. The fire pump could be activated from two locations:

locally at the motor controller and remotely from the vessel’s port fire station. Crewmembers on

board at the time of the accident stated that the fire pump was tested daily to ensure performance

and maintain the pump’s readiness.

On September 1, the day before the fire, the sewage holding tank had overflowed into the

port bilge, and the first deckhand attempted to use the bilge pump to clean up. The bilge pump was

inoperable, so the deckhand lined up the fire pump to finish cleaning. He told investigators that

after the clean-up, before leaving the engine room, he lined up the fire pump so that it was ready

for use. The fire hoses were tested annually during Coast Guard inspections.

A single fire axe, as required by regulations, was stowed on the aft bulkhead of the

wheelhouse.

The Coast Guard documented a total of 31 deficiencies on the Conception from 2009-2019,

4 of which were related to fire protection, including the fire pump, galley heat detector, hose, and

wheelhouse extinguisher, all of which were rectified to the Coast Guard’s satisfaction.

1.8.5 Means of Escape and Egress

When the Conception was constructed and underwent sea trials in 1981, the Coast Guard

“Sea Trials; T new construction and conversion” inspection form required the attending Coast

Guard inspector to “physically use each emergency escape on board.” The inspection item was

checked as completed on the form. The inspector wrote on the signed form that the sea trials were

satisfactory.

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As an existing vessel, the Conception was required to meet the Old T standards for means

of escape and emergency egress, which required that “not less than two avenues of escape from

all general areas accessible to the passengers or where the crew may be quartered or normally

employed, so located that if one is not available the other may be.” The New T regulations in

46 CFR 177.15-1, which did not apply to the Conception, further require the means of escape to

be sufficient for rapid evacuation in an emergency for the number of persons served. Investigators

were unable to find a quantitative definition of the word “rapid.” Although there was no specific

minimum dimension guidance in either Old or New T regulations regarding means of escape,

New T regulations state the “dimensions of the means of escape must be such as to allow for easy

movement of persons wearing lifejackets and that there must be no protrusions that could cause

injury, ensnare clothing, or damage lifejackets.”

From the Conception’s bunkroom, there were

two means of escape, both leading to the salon above: (1)

the spiral stairs forward in the bunkroom (figure 28), and

(2) the escape hatch installed centerline at the aft end of

the bunkroom (figure 29). The hatch, marked with a

two-inch plastic sign, was accessible from either aisle by

climbing a wooden ladder, located in the corner where

the aftermost middle and aft athwartship tiers of bunks

were, onto the upper bunk; crawling to the centerline;

and then pushing the plywood escape hatch up and out

of the way. The hatch opened below the centerline

countertop in the salon. Investigators measured the

Vision’s escape hatch, which, according to the owner,

was similar to the Conception’s escape hatch. The

opening dimensions were approximately 22 inches by 22

inches through the main deck, with the aft-facing vertical

opening having a clearance of about 35 inches from the main deck to the countertop above, or 28

inches from the top of the 7-inch main deck coaming. The two means of escape were at opposite

ends of the bunkroom (so as to minimize the possibility of one incident blocking both escapes)

and did not pass through a watertight door, thereby fulfilling the regulations applicable to the

Conception. In the available documentation and inspection history of the vessel, no deficiencies

or modifications were found related to the emergency escape hatch or the bunk ladders to the hatch.

Figure 29. The Conception bunkroom escape hatch from above in the salon (left) and in the bunkroom

from the port side (right). (Source: R. Clevenger [left]; Truth Aquatics [right], annotated by NTSB)

Figure 28. Staircase from the main

deck galley/salon leading down to the

bunkroom on the Conception. (Source:

NTSB eyewitness submission)

NTSB Marine Accident Report

The salon compartment of the Conception had three means of escape—the main doors aft

in the salon, the forwardmost sliding window on the port side, and the middle sliding window on

the starboard side of the salon. If closed, the windows latched and could not be opened from the

exterior walkways.

1.8.6 Lifesaving Appliances

Figure 30. Locations of firefighting equipment, lifesaving appliances, and evacuation plan for the

Conception at the time of the accident (compiled from the investigation and drawn by the NTSB).

The primary lifesaving appliances aboard the Conception included 6 various-sized life

floats, with an aggregate capacity of 104, or 100 percent of the people allowed on board. All

lifesaving appliances were located either on the upper deck or on top of the wheelhouse.

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Per its COI, the vessel was required to carry Type I offshore lifejackets for 103 adults and

11 children. All Type I lifejackets were stowed on the upper deck in boxes with float-free covers.

According to the station bill on the Conception, the second captain was responsible for ensuring

passengers donned their lifejackets in an emergency.

The crew was unable to retrieve any lifesaving equipment before abandoning ship, and all

equipment was consumed in the fire. Investigators were not able to examine the Conception’s

lifesaving equipment; only pieces survived the fire. The largest piece recovered was a corner of a

life float.

The Conception was also required

to have a rescue boat. The skiff served as

the vessel’s designated rescue boat. The

16-foot Caribe UB15 rigid-hull

inflatable, equipped with a 40-hp Honda

4-stroke outboard engine, was capable of

carrying up to 8 people. The skiff was

primarily used to support diving

operations but was also intended to be

used to retrieve persons overboard. It was

stowed on the raised swim platform at the

stern when not in use.

The Conception had a Category I

float-free Emergency Position Indicating

Radio Beacon (EPIRB), which was

mounted on the upper deck bulwark on

the starboard side, near the top of stairs to

the main deck. The surviving crew of the

Conception did not retrieve or manually

activate the EPIRB, and the EPIRB was destroyed in the fire; there were no signals received by

the Coast Guard.

Medical equipment, including a first aid kit, oxygen, and an automated external

defibrillator were stowed under the wheelhouse console. The Conception also had flares that were

reported to be located in the wheelhouse. None of this equipment was retrieved or used in the

accident.

1.8.7 Emergency Drills

New T regulations (all vessels) require the master of a small passenger vessel to “conduct

sufficient drills to make sure that all crew members are familiar with their duties” in the event of

a man overboard, an emergency necessitating abandoning ship, or a fire. The regulations do not

specify the frequency that the drills must be conducted but state that the drills shall include a muster

of the passengers and reporting of the crew to assigned stations and preparation for assigned duties.

Man-overboard and abandon ship drills must include checking that life preservers are properly

donned and instruction in the automatic or manual deployment of survival craft. Fire drills must

include a demonstration of assigned duties by the crew and instruction in the use of fire alarms,

extinguishers, and any other firefighting equipment on board. Required drills must be logged and

include the date of the drill and a general description of the drill scenario or training topics.

Figure 31. Postaccident photo of the Conception skiff.

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According to the Truth Aquatics owner, logs for drills and other training activities on the

Conception were kept on the vessel. No logbooks were found after the accident—the wheelhouse

where the logs were stored was destroyed by the fire. During a 2017 Coast Guard annual inspection

of the Conception, inspectors noted that the drill log was not up to date. The inspectors cleared the

discrepancy once underway drills were completed and logged. No other discrepancies with logs or

the conduct of drills were noted by inspectors in the 5 years prior to the accident.

The second captain, first deckhand, and second galley hand told investigators that they had

not participated in a fire drill aboard the Conception. The first deckhand stated that he had never

pulled out a fire hose on the vessel and had “never done a dry run on anything, with the exception

of during the Coast Guard inspections.” He stated that he had participated in one fire drill on

another Truth Aquatics vessel during a Coast Guard inspection, and the drill log for the Truth

reflected his participation in a drill during an April 2019 inspection of that vessel. A former first

galley hand stated that the crew had pulled out fire hoses during a training session while she was

on the Conception. Other former crewmembers told investigators that they had never participated

in a fire drill.

1.9 Personnel Information

By regulation, the Conception was required to have four crew, with two being credentialled

mariners. The vessel normally operated with six crew, including a captain and second captain, two

deckhands, and two galley hands. During overnight voyages, the second captain and first deckhand

slept in the wheelhouse bunks, the galley hands slept in the two-bunk stateroom, and the captain

slept in the single-bunk stateroom. The second deckhand slept below in the passenger bunkroom.

1.9.1 Crew Recruitment and Training

Current and former crewmembers interviewed by NTSB investigators described the hiring

and training process for employees on board Truth Aquatics vessels. A prospective employee was

first invited to participate in a voyage without pay. During this voyage, the prospective employee

was provided the opportunity to interact with and work alongside the crew, and the captain

evaluated the person to determine whether they would be a “good fit.” Upon completion of the

unpaid voyage and a negative drug test, a suitable candidate was offered a job if there was an

opening on the vessel. Once hired, the new employee began work immediately in their assigned

position. Current and former crewmembers stated that there was no formal training (company-wide

or aboard the vessel) for new employees prior to getting under way as a paid employee. All training

was on-the-job instruction by the vessel’s crew.

New T regulations (all vessels) require the owner, operator, or master of a small passenger

vessel to “instruct each crew member, upon first being employed and prior to getting underway

for the first time on a particular vessel and at least once every three months, as to the duties that

the crew member is expected to perform in an emergency including, but not limited to, the

emergency instructions listed on the emergency instruction placard.” For small passenger vessels,

the emergency instruction placard must include the actions to be taken in the event of fire, heavy

weather, or man overboard. Training of crewmembers must be logged or otherwise recorded.

Conception crewmembers stated that, with the exception of first aid and cardiopulmonary

resuscitation (CPR) training, the captain conducted training with new employees individually,

showing the new employee where various equipment was located, how to align the fire pump, and

other normal operating and emergency procedures. Experienced crewmembers also conducted

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informal training with the new employees. Training was conducted when time allowed during

normal commercial operations of the vessel. For first aid and CPR, Truth Aquatics provided

training to company employees annually.

Coast Guard inspectors told investigators that they validated compliance with periodic

training regulations by reviewing the required training logs and evaluating proficiency during drills

conducted at inspections. Coast Guard records show that, nationwide since 1991, fourteen small

passenger vessel owners, operators, or charterers have been cited for failure to conduct or properly

record crew training in accordance with regulations. Truth Aquatics was not among the cited

operators.

1.9.2 Crew Licensing and Certification

Captain. The 65-year-old captain of the Conception held a valid merchant mariner

credential as a master of self-propelled vessels (not including auxiliary sail) of less than 100 gross

year hiatus in the late 1990s), starting as a deckhand and then rising to captain in 1985 once he had

obtained his 100-ton master’s credential. According to Truth Aquatics and Coast Guard documents,

he had captained all three of the company’s vessels, but was primarily assigned to the Conception

throughout his 3 decades of employment.

The captain was in overall charge of the vessel. Crewmembers, both current and former,

told investigators that the captain was the primary operator of the helm and engine controls, turning

over to the second captain or first deckhand for two-hour periods when transiting at night, or for

short periods during the day for breaks.

Second Captain. The 28-year-old second captain held a valid merchant mariner

credential, issued on March 19, 2019, as a master of self-propelled vessels (not including auxiliary

sail) of less than 100 gross register tons upon near coastal waters. He told investigators that he had

been hired by Truth Aquatics in late June or early July 2019 and that this was his first job as a

credentialed mariner. Prior to this position, he had worked as a deckhand on several boats operating

off the Southern California coast and the Channel Islands from 2017 to 2019.

The second captain stated that, as a new crewmember, his duties were primarily deck

related, including working with the deckhands to anchor the vessel, launch and recover the skiff,

and conduct general cleaning. He said that on the accident voyage, the captain had allowed him to

spend more time at the controls in the wheelhouse so that he could gain experience with

maneuvering the vessel.

First Deckhand. The 28-year-old first deckhand had been employed by Truth Aquatics on

board the Conception since November 2018. He did not hold, nor was he required to hold, a

merchant mariner credential. He told investigators that he held an American Sailing Association

certification for bareboat cruising, and, for the 3 years prior to being hired by Truth Aquatics, he

had worked aboard a 70-foot sailing vessel that conducted 2-hour passenger cruises in Monterey

Bay, California.

The first deckhand’s duties included line and anchor chain handling, monitoring

engineering equipment and diving compressors, filling scuba diving tanks, monitoring and

assisting divers, operating the skiff, minor maintenance, pumping bilges, general cleaning, and

occasional turns at the helm.

NTSB Marine Accident Report

Second Deckhand. The 26-year-old second deckhand, who died in the fire, had been

working on the Conception for about a week when the accident occurred. It was her second voyage

aboard the vessel. She did not hold, nor was she required to hold, a merchant mariner credential.

Prior to joining the Conception crew, she had worked for a couple months as a galley hand on

another Truth Aquatics vessel.

The second deckhand’s duties were similar to the first deckhand. According to other

crewmembers, she was being trained on the various duties of the position during the previous and

accident voyages. She was also designated as the safety diver, requiring her to stand by with a

wetsuit on while divers were in the water. As such, she held certifications for advanced open water

diving.

First Galley hand. The 34-year-old first galley hand had been working on the Conception

for about 3 weeks before the accident. He had no prior experience working on vessels; he did not

hold, nor was he required to hold, a merchant mariner credential. The first galley hand had worked

in the hospitality industry for about 11 years before being hired by Truth Aquatics. During an

interview with law enforcement officials, he stated that he had made about five to six voyages on

the Conception, the first two under the supervision of the first galley hand whom he eventually

replaced.

The first galley hand’s duties included purchasing food and stores for each voyage,

developing the menu and preparing food, and supervising the second galley hand.

Second Galley hand. The 58-year-old second galley hand had worked on the Conception

since October 2017. He did not hold, nor was he required to hold, a merchant mariner credential.

He stated that, prior to being hired by Truth Aquatics, he had worked in the restaurant industry for

about 30 years.

The duties of the second galley hand included food preparation, making coffee, washing

dishes and silverware, and general cleaning in the galley and salon.

1.9.3 Toxicological Testing

Company drug and alcohol testing program. As required by regulation, Truth Aquatics

had a workplace pre-employment and random drug and alcohol testing program. During annual

inspections by the Coast Guard, inspectors were required to verify that the company’s program

was in place and being properly followed.

According to Truth Aquatics’ Employee Education Program for the Drug and Alcohol Free

Workplace, a document that was provided to employees when they were hired, employees were

“prohibited from unlawful manufacture, distribution, dispensing, possession of, or use of a

controlled substances without authority on Truth Aquatics, Inc.’s premises.” Further, the document

stated that “The presence of any detectable amount of any illegal drug in an employee while

performing Truth Aquatics, Inc.’s business or while on Truth Aquatics, Inc.’s premises is

prohibited.” Surviving crewmembers told investigators that there was a strict no-alcohol/no-drugs

policy for employees while on board the Conception, but passengers were permitted to bring

aboard and consume alcohol.

Postaccident toxicological testing. Just after 0800 on the accident date, upon the arrival

ashore at Channel Islands Harbor, the second captain, first deckhand, and the second galley hand

were administered required postaccident breathalyzer tests for alcohol. The captain was tested

NTSB Marine Accident Report

when he arrived at the harbor about 45 minutes later. All tests results were negative. The first galley

hand was not tested prior to being transported to the hospital.

On the day after the accident, all surviving crewmembers underwent required postaccident

urine drug testing.

The first galley hand tested positive for marijuana metabolites. He told law

enforcement officials that he had smoked marijuana a few days before the accident voyage but not

during the voyage. The urine results for the captain, second captain, and first deckhand tested

negative for drugs; the second galley hand tested negative dilute.

Toxicology testing was performed during the autopsy of the deceased second deckhand.

Results were negative for alcohol and other tested-for drugs.

1.10 Waterway Information

Platts Harbor is a rounded inlet surrounded by cliffs and steep hillsides on the north side of

Santa Cruz Island that provides a partially protected anchorage for small vessels. The harbor lies

on the Pacific Ocean within the Santa Barbara Channel, a 20-mile-wide waterway formed by the

California Coast and the Channel Islands, including Santa Cruz. Water depths in Platts Harbor

range from 20 to 54 feet at mean lower low water, with a tidal range of about 5.5 feet on the

morning of the accident.

The charted seabed type is rocky.

1.11 Meteorological Information

The accident occurred during nighttime hours, with civil twilight beginning at 0608 and

sunrise at 0633. At 0310, a remote weather observation site about 4 miles southeast of the accident

site on Santa Cruz Island recorded an outside air temperature of 64.6°F and a wind speed of

6.4 knots, with gusts up to 9.6 knots from the east. The nearest marine data buoy from the National

Data Buoy Center (buoy number 46053), located about 13 miles north-northwest from the accident

site, recorded a water temperature of 64°F. At the anchorage in Platts Harbor, the deckhand from

the Conception recalled that from the skiff, “there was no swell and no current really that I noticed

at all.” According to the second galley hand, “the wind was light.” According to the owner of the

Grape Escape, there was “absolutely no wind” or fog.

1.12 Postaccident Actions

Shortly after the fire on the Conception, the Coast Guard issued an MSIB addressing

passenger vessel compliance and operational readiness for small passenger vessels, MSIB 008-19.

The MSIB recommended owners, operators, and masters of passenger vessels complete a review

of the overall condition of the passenger accommodation spaces for unsafe practices and other

Urine drug testing is limited to identifying urinary metabolites of cocaine, codeine, morphine, heroin,

phencyclidine (PCP), amphetamine, methamphetamine, methylenedioxymethamphetamine (MDMA),

methylenedioxyamphetamine (MDA), methylenedioxyethylamphetamine (MDEA), tetrahydrocannabinol (THC),

oxycodone, oxymorphone, hydrocodone, and hydromorphone.

A negative dilute sample can occur when the donor consumes a large quantity of fluids before providing the

urine specimen. The urine results for the second galley hand were labeled negative dilute; both creatinine and specific

gravity were out of range. No follow-up urine testing under direct observation was performed.

Mean lower low water is the average of the lower low water height of each tidal day observed over the National

Tidal Datum Epoch.

NTSB Marine Accident Report

hazardous arrangements, and “reduce potential fire hazards and consider limiting the unsupervised

charging of lithium-ion batteries and extensive use of power strips and extension cords.”

The Coast Guard initiated a Concentrated Inspection Campaign for all Subchapter T-

inspected vessels with overnight accommodation for passengers.

On October 2 and November

1, 2019, the Coast Guard inspected the Truth Aquatics vessel Vision while it was not in operation

and noted a total of 40 deficiencies. By comparison, during the previous annual inspection, carried

out on April 2019, there were no deficiencies noted by the attending Coast Guard marine inspector.

The concentrated inspection was conducted independent of the required regulatory inspections for

certification and focused on firefighting, fire protection, means of escape systems, and crew

proficiency/knowledge regarding the elements of firefighting, fire protection, and means of escape

that rely on human intervention to successfully operate.

Among the deficiencies documented aboard Vision was a requirement to provide a means

of escape from the shower room that leads to an area that does not contain any source of fire (such

as a galley stove). In the bunkroom, deficiencies were issued for an inoperable public address

system speaker and for having a trash container without metal covering. The Coast Guard noted

that the double bunks did not allow for free and unobstructed escape for the inside occupant as per

the regulations. This bunk arrangement deficiency had never been cited during the previous 40-

year history of the vessel. The Coast Guard also issued a “prior to carriage of passengers” order

for the grease extraction hood, which was missing a heat detector (removed and taken as evidence

by federal law enforcement during a search warrant served at the Truth Aquatics office and the

Truth and Vision September 8–10, 2019), had a build-up of grease, and was missing a maintenance

plan.

After the fire on the Conception, Truth Aquatics voluntarily began modifications to the

Vision and the Truth to improve safety aboard its two remaining vessels and address the

deficiencies found during the Coast Guard’s inspections. The owner stated that, on each vessel, an

integrated fire-detection system with manual call points was being installed, as well as an

electronics-charging cabinet. The cabinet was equipped with self-closing doors and a fire-

suppression system that vented to the exterior and was integrated with the fire-detection system. A

relay for the fire detection system was designed to shut down all ventilation if smoke is sensed in

any compartment on board each vessel. Additionally, the owner stated that the company was in the

process of implementing a logging requirement for roving patrols. Fire escape ladders were

procured for both wheelhouse wing stations, as well as Lipo-Safe bags for use while charging

handheld VHF radios.

Further, to improve the bunkroom egress on the Vision, watertight hatches

leading from the bunkroom to the exterior walkways were installed on both the port and starboard

side of the vessel, with ladders to assist with egress through the hatch (figure 32).

According to Coast Guard data, 383 vessels with overnight accommodations were inspected during the

campaign, including 357 vessels under Subchapter T and 26 vessels under Subchapter K.

A Lipo-Safe bag is used for the charging and stowage of batteries. The bag has an inner lining made from a

woven fire-retardant fiberglass material, which helps contain and reduce the risk of fires spreading outside the bag.

NTSB Marine Accident Report

Figure 32. Modifications made to the Vision after the accident on the Conception. Left: Ladders at the

forward end on each side of the bunkroom lead directly to the weather deck. Right: Flush-mounted

watertight hatches were installed in the deck, outboard of the galley. (Source: Truth Aquatics)

Because the Coast Guard considered the Vision’s new egress to be a major modification,

the new and existing emergency escapes were subject to New T regulations, even though the Vision

was considered an existing vessel. New T regulations are more specific regarding emergency exit

pathways, and as such, the owner of the Vision was required to submit the plans to the Coast Guard

for approval. At the time of this report, the owner’s fire-detection system plans are also under

review by the Coast Guard.

1.13 Similar Small Passenger Vessel Accidents and Related NTSB

Safety Recommendations Previously Issued

1.13.1 Passenger Ferry Andrew J. Barberi – 2003

On October 15, 2003, the ferry Andrew J. Barberi struck a maintenance pier at the Staten

Island Ferry terminal in Staten Island, New York. Fifteen crewmembers and an estimated

fifteen-hundred passengers were on board. Eleven passengers died as a result of the accident, and

seventy were injured. The NTSB determined that the probable cause of the accident was in part

due to the failure of the New York City Department of Transportation to implement and oversee

safe, effective operating procedures for its ferries. As a result of the investigation, the NTSB issued

Safety Recommendation M-05-6 to the Coast Guard to “seek legislative authority to require all

U.S.-flag ferry operators to implement [safety management systems] SMS, and once obtained,

require all U.S.-flag ferry operators to do so.”

The Coast Guard Authorization Act of 2010 authorized the Coast Guard to require the

implementation of SMS on domestic passenger vessels, including domestic ferries, which satisfied

the first part of Safety Recommendation M-05-6 (seek legislative authority to require all US-flag

ferry operators to implement SMS).

NTSB Marine Accident Report

1.13.2 Passenger Ferry Andrew J. Barberi – 2010

On May 8, 2010, the Andrew J. Barberi was involved in a second accident when it struck

a terminal structure at the St. George terminal in Staten Island, New York, after a loss of propulsion

control. Eighteen crewmembers, two New York City police officers, two concessionaires, and two-

hundred and forty-four passengers were on board. As a result of the accident, three passengers

sustained serious injuries; forty-seven passengers, crew, and others reported minor injuries. The

NTSB determined that the probable cause of this accident was a solenoid failure, which caused a

loss of propulsion control of one of the vessel’s two cycloidal propellers. In its report, the NTSB

noted that the New York City Department of Transportation had voluntarily implemented an SMS

after the 2003 accident involving the vessel, which was evident in the response to the 2010 accident

when personnel carried out their designated emergency procedures in a timely and effective

manner. The NTSB expressed concern, however, that SMSs were still not required on US

passenger vessels in domestic service. As a result, the NTSB superseded Safety

Recommendation M-05-6 with Safety Recommendation M-12-3, which recommended that the

Coast Guard require all operators of US-flag passenger vessels to implement SMSs, taking into

account the characteristics, methods of operation, and nature of service of these vessels, and, with

respect to ferries, the sizes of the ferry systems within which the vessels operate.

1.13.3 Seastreak Wall Street – 2013

The Seastreak Wall Street, a high-speed passenger ferry serving commuters traveling

between New Jersey and New York City, struck a Manhattan pier at about 12 knots on

January 9, 2013. Of the 331 people on board, 79 passengers and 1 crewmember were injured, 4 of

them seriously. The NTSB determined that the probable cause of the accident was the captain’s

loss of vessel control because he was unaware that the propulsion system was in backup mode. In

addition, his usual method of transferring control from one bridge station to another during the

approach to the pier did not allow sufficient time and distance to react to the loss of vessel control.

Contributing to the accident, in part, was the operator’s ineffective oversight of vessel operations.

In the report, the NTSB stated that it “continues to highlight the need for unambiguous, detailed

operating procedures and believes they are prerequisite to managing a safe transportation system”

and recommended that the operator implement an SMS. The report noted that regulations had yet

to be implemented requiring SMSs for small passenger vessels, and thus the NTSB classified

Safety Recommendation M-12-3 “Open-Unacceptable Response.”

1.13.4 Island Lady – 2018

On January 14, 2018, a fire broke out in an unmanned space on the small passenger vessel

Island Lady near Port Richey, Florida, during a scheduled transit to a casino boat located about

9 miles offshore in the Gulf of Mexico. Fifty-three people were on board the Island Lady. After

the captain beached the vessel, all crewmembers, employees, and passengers evacuated it by

entering the water and wading/crawling ashore. Fifteen people were injured; one passenger died

in the hospital several hours after the fire. The NTSB determined that the probable cause of the

accident was the operator’s ineffective preventive maintenance program and insufficient guidance

regarding the response to engine high-temperature conditions. In the report, the NTSB found that

a requirement for an SMS would likely have ensured greater adherence to completing crew training

drills, appropriate responses to emergencies such as alarms and fires, and failsafe record-keeping

of training and maintenance-related documents. Therefore, the NTSB reiterated Safety

Recommendation M-12-3.

NTSB Marine Accident Report

In the report on the Island Lady accident, the NTSB concluded that had the vessel been

outfitted with fire detectors in the lazarette, the fire and its location would have been identified

earlier, proving the opportunity for a swifter response. The NTSB issued Safety Recommendation

M-18-13 to the Coast Guard to “require fire detection systems in unmanned spaces with machinery

or other potential heat sources on board small passenger vessels.” The Coast Guard responded in

October 2020, and the recommendation is currently classified “Open—Response Received.”

1.13.5 Vision – 2018

A small fire involving the charging of a lithium-ion battery took place on board the Truth

Aquatics small passenger vessel Vision about a year before the fire aboard the Conception. On

October 8, 2018, between 0415 and 0430 in the morning, a passenger, who was awake and in the

galley, heard a “hissing” noise and then a loud “bang” that came from the bookshelf located at the

aft starboard side of the salon (the Conception did not have a bookshelf in the same area). Another

passenger, who was returning to the bunkroom after using the restroom on the aft deck, also heard

the noise, which drew his attention to a fire on the bookshelf. He stated that the fire looked like a

“torch” flame, and a battery charger (which was charging two lithium-ion batteries) was emitting

smoke. The passenger in the galley grabbed a dry chemical extinguisher from the galley, and both

passengers went to the battery charger. The passenger without the fire extinguisher unplugged the

charger, grabbed the unburnt end of the charger, brought it out to the main deck, and threw it in to

the rinse bin located under the stairs to the sun deck. The passenger with the fire extinguisher stated

he discharged one “shot” on the bookshelf after the battery charger had been removed to extinguish

the smoldering paper books on the shelf. He then grabbed a sponge and wetted the bookshelf and

items on it to prevent reignition.

Afterward, the passenger went to the

wheelhouse and informed the captain, who in

turn examined the batteries and charger in the

rinse bin. The batteries and charger were

removed from the rinse bin and thrown

overboard. One of the passengers

interviewed stated there was soot residue and

scorch marks on the books and the shelf.

The two batteries that caught fire

were for an underwater diving light, and,

according to the owner, the batteries had

been removed from the light and were

connected to a separate charger and plugged

into a power strip on the bookshelf. The

lithium-ion batteries were each 3.7 volts and

capable of 5,000 milliamp hours.

According to the captain on the Vision at the time, who was filling in as a relief captain, he

photographed the charger and sent the photo to another captain in the Truth Aquatics fleet. Upon

returning from the trip, he informed the owner of Truth Aquatics as well as the captain that took

the Vision on its next trip.

The owner of Truth Aquatics stated he was only made aware of the small fire on the Vision

after the accident on the Conception. The owner noted that at the end of each trip, each captain

was required to complete a “Trip Payment Report,” which required multiple handwritten entries

Figure 33. Photograph taken of the battery charger

that caught fire on the Vision (with the batteries

removed).

NTSB Marine Accident Report

related to the voyage conducted, including the number of people on board, the amount of fuel used,

and the number of engine running hours. At the bottom of the form, there was a “special comments

about the trip section” where the captain on duty was required to enter any notable incidents that

occurred during the trip, including “any accident, bad weather, notable rescues or incidents.”

Investigators reviewed the completed form for the October 7–10 trip for the Vision and found no

entries made in this section.

There was no report to the Coast Guard of this incident, nor was there any requirement to

do so, since the size of the fire did not meet the monetary damage threshold stated on the marine

casualty reporting form (CG-2692), nor did it require treatment of injury beyond first aid or loss

of life.

1.13.6 Red Sea Aggressor – 2019

On November 1, 2019, two months after the Conception accident, another dive vessel with

overnight accommodations caught fire and sank. Just after midnight, the Egyptian-flagged, 120-

foot, 247-gross-ton passenger, fiberglass-over-wood vessel Red Sea Aggressor (formerly named

the Suzanna 1) caught fire while at a mooring off the coast of Port Ghalib, Egypt, with 19

passengers and a reported 12 crewmembers on board. All on board, except for one passenger, were

able to abandon the Red Sea Aggressor. The passengers in the water were picked up by the crew

in the vessel’s dinghy and brought to a dive vessel moored nearby. The passenger who did not

escape, a female adult US citizen, was last seen in the lower deck accommodation space and was

never found. She is presumed dead. The Red Sea Aggressor remained on fire until it sank.

Passengers told investigators that they understood that there was a vessel-wide

interconnected smoke detector system. Although the Red Sea Aggressor had fire detectors in the

salon area—where the fire was suspected to have started—and in each of the staterooms, the

passengers and crew sleeping below did not hear any alarms.

Surviving passengers told investigators that they were informed there was a crewmember

on watch during sleeping hours; however, none of the crew and passengers sleeping below deck

were alerted to the fire by a crewmember. Surviving passengers stated they were either awakened

by the smell of smoke or by other passengers.

Similar to the Conception fire, the primary egress stairs to the main salon were blocked by

smoke and fire. The below-deck passengers and crew escaped via an escape hatch that exited to a

crew berthing area and up a ladder that led to the deck above, into a space separate from the primary

stairway egress route. The passenger that opened the escape hatch, which was in his stateroom,

recalled it was blocked on the other side by a mattress on which a crewmember was sleeping. The

crewmember was awakened, and the mattress removed, allowing them to escape.

Because US citizens were on board the vessel, and the fatality was a US citizen, the Coast

Guard conducted an investigation related to the circumstances of the fire and subsequent sinking

of the vessel by conducting interviews of witnesses and the surviving passengers. The NTSB was

invited by the Coast Guard Office of Investigations and Casualty Analysis to participate in the

investigation into the circumstances into the fire and subsequent sinking of the vessel. NTSB

investigators were unable to interview the crew or management at Aggressor Adventures, the US-

based company operating the Red Sea Aggressor, since they refused to be interviewed by the Coast

Guard.

NTSB Marine Accident Report

2 Analysis

2.1 General

The analysis first identifies factors that can be eliminated as causal to the fire aboard the

Conception. The following issues are discussed next:

• Origins and potential sources of the fire

• Cause of death

• Fire detection

• Roving patrol

• Means of escape

• Search-and-rescue efforts

• Oversight

2.2 Exclusions

2.2.1 Weather

At the time the fire broke out on the Conception, weather and sea conditions were calm

and did not contribute to the fire or hamper the crew’s attempted rescue efforts of the passengers

and crewmember in the bunkroom. While conditions of reduced visibility were experienced by

vessels responding to the accident, the weather and sea conditions did not impact their efforts to

respond to the accident and fight the fire and did not have an effect on the survivability of those

on board. The NTSB concludes that weather and sea conditions were not factors in the accident.

2.2.2 Alcohol and Other Drugs

Surviving crewmembers stated that, in accordance with company policy, they had not

consumed any alcohol during the accident voyage, nor had they seen any other crewmember

consume alcohol. Following the accident, the captain, second captain, first deckhand, and second

galley hand were tested for the presence of alcohol, and all results were negative. The surviving

crewmembers were also tested for the presence of drugs, and results for the captain, second captain,

and first deckhand were negative. The results for the second galley hand were negative dilute. The

results of toxicology testing in association with the coroner’s examination of the second deckhand

were also negative for alcohol and drugs. The first galley hand was not tested for alcohol because

he was taken immediately to the hospital and treated for his injury upon arrival ashore. The first

galley hand tested positive for marijuana metabolites in his urine. Metabolites for marijuana can

remain in the body for up to 30 days, so the galley hand’s statement that he did not consume the

drug while on the Conception is plausible. The NTSB concludes that the use of alcohol or other

tested-for drugs by the Conception deck crew was not a factor in the accident.

2.3 Origins and Potential Sources of the Fire

The fire aboard the Conception burned out of control with no intervention for about 1 hour

and 41 minutes from the time of the captain’s initial distress call until firefighters arrived and began

firefighting efforts.

Due to the combustible nature of the vessel’s fiberglass-over-plywood

NTSB Marine Accident Report

construction, very little material above the main deck remained after the fire had been extinguished

by the emergency responders. Examination of the recovered wreckage and debris did not yield any

physical evidence relevant to the origin and cause of the fire.

The surviving Conception crewmembers that investigators interviewed provided a

snapshot of the state of the fire when it was first discovered. Their descriptions of the fire provide

the basis for the analysis of the probable origin area of the fire. In addition to the crew interviews,

an examination of a similar vessel in the Truth Aquatics fleet, the Vision, was performed to identify

possible types of ignition sources available in the likely origin areas. Statements from previous

passengers and crew on the Conception were also considered when evaluating the likely ignition

sources for the fire.

2.3.1 Area of Origin

None of the crewmembers interviewed by NTSB investigators reported any open flame or

heat upon waking up from their bunks on the upper deck. The second galley hand did not report

any fire on the open sun deck located aft of the accommodation and wheelhouse.

During interviews, none of the crewmembers reported that they saw flames or felt heat

coming from the anchor room located at the forward bow area below the main deck. Further,

examination of the electrically powered winch motor and ropes recovered with the wreckage

showed no signs of significant heat damage in that space.

All galley appliances on board the Conception were electrically powered. The crew

reported that the vessel’s refrigerators and freezers were the only equipment operating on the

morning of the fire. As a precaution, and to prevent any accidental activation of an unattended

burner, the vessel’s second galley hand opened the breakers for the flat-top griddle and the

cooktop’s two burners the night before the accident. The second galley hand said that the only

galley equipment running at the time of the accident were the refrigerators.

Once the fire was discovered, crewmembers reported that they attempted to access the

center galley window from the bow. The crewmembers saw smoke through the window and did

not feel significant heat, allowing them to attempt to pry it open. Considering that all galley

equipment was reported to be either de-energized or in good condition, the evidence indicates that

the fire did not originate in the main deck galley at the forward section of the salon compartment.

The fire also did not likely originate in the below-deck shower room or bunkroom. No fire

or high heat were reported in the forward part of the galley, located above the shower room, and

there was no heat, smoke, or flame sighted by a crewmember in the anchor room, which was

adjacent to and forward of the shower room. With 33 passengers in the bunkroom and smoke

detectors present, it is unlikely that an accidental fire could grow undetected in the bunkroom to

the point where it would trap the occupants and preclude escape.

While abandoning the vessel after the galley/salon and wheelhouse had been engulfed in

flames, two surviving crewmembers opened the engine room hatch and described seeing the space

filled with smoke. But neither described a presence of intense heat associated with a fire, nor did

they recall hearing the alarm produced by the release of carbon dioxide from the heat-activated

fixed fire-extinguishing system. Since the Conception was anchored with both main propulsion

engines shut down, the smoke in the engine room was likely from the established fire, which

entered the engine room via the main deck ventilation ducting.

NTSB Marine Accident Report

At night, it was normal procedure to operate the fan that was in the bulkhead between the

engine room to the lazarette to help dry wet suits hanging in the lazarette. The fan likely would

have drawn smoke in through the main deck ventilation ducting and filled the engine room and

lazarette. Given that the lazarette was aft of the engine room, and the entrance was adjacent to

where the two crewmembers had re-boarded the vessel, accessed the skiff, and passed en route to

the engine room without feeling any heat, it is not likely there was any fire in the lazarette.

The diesel generator had a history of overheating while running all three air compressors

and operating the flat cooktop in the galley. However, at the time of the fire, none of the air

compressors were operating, nor was the flat cooktop. Additionally, surviving crewmembers

reported that electrical power was being supplied by the generator during the evacuation of the

vessel, after fire had engulfed the salon. Electric lights in the engine room and lazarette were seen

to be illuminated during the evacuation of the vessel, and the aft swim platform hydraulic-electric

winch was used by the crew to lower the skiff into the water and escape the burning vessel,

indicating that the generator was functioning at the time of abandonment.

The aft portion of the salon compartment, and in particular the starboard side, was

consistently identified in the crew interviews as having the most intense fire at the time they

encountered it. When observed from the upper deck through the door to the crew berthing area,

the crewmembers described an orange glow near the stairs at the aft starboard end of the sun deck.

Approaching the stairs and looking down, the second galley hand described flames at the base of

the stairs and the starboard toilet, preventing him from using the stairs to access the main deck.

The crewmembers also described smoke coming up the sides of the sun deck on both the port and

starboard sides. Crewmembers used the port side of the sun deck and the portside wing station of

the wheelhouse to make their way down to the main deck after their initial assessment of the

conditions.

The crew described the fire as filling and effectively blocking the open doors to the aft

portion of the salon and extending outward to where the restrooms were located. Smoke and some

intermittent flames were also described as coming out the aftmost windows of the salon on the

port side of the vessel. The second galley hand, who was the first crewmember to arrive on the

main deck, was able to drop down from the port side of the sun deck. He was able to walk down

the port side of the vessel to the open doors to the salon, where he witnessed the entire area

engulfed in flames, including the escape hatch, before walking back up the port side to the bow.

The other crewmembers dropping down to the main deck after him did not feel that they could

walk down the port side of the vessel to access the stern due to the smoke and some flames that

were exiting the aftmost portside windows of the salon.

At the exterior aft of the salon, there was a large polyethylene trash can underneath the

stairs to the upper deck. Polyethylene trash cans are highly combustible and cannot contain a fire

originating from within. However, fire tends to spread vertically at a much greater rate than it does

horizontally. If the fire had started on the exterior of the salon in the area of the stairs to the upper

deck, it would be reasonable to expect that the fire would have spread vertically, igniting the stairs

above and spreading to the upper deck before it spread horizontally and into the salon

compartment. The descriptions given of the fire indicate more fire involvement internal to the

salon and around the port and starboard restrooms of the entranceway to the salon than external

and spreading up to the upper deck. The NTSB concludes that the origin of the fire on the

Conception was likely inside the aft portion of the salon.

NTSB Marine Accident Report

2.3.2 Ignition

Potential Sources. In the interior of the aft portion of the salon, the potential sources of

ignition available included the vessel’s electrical system and the electronic devices and batteries

being charged at the aftmost tables and aft bulkhead area. On the aft exterior of the salon, the

potential ignition sources would likely be limited to improperly discarded smoking materials in

the trash can.

An energized electrical system has the potential to become a source of ignition when

elements of the system age, are improperly installed, or are accidentally damaged. Crew interviews

revealed that, on occasion, electrical work, such as the replacement of lighting electrical fixtures

in the salon, was completed by crewmembers, who were not licensed electricians. Although

examination of the Conception’s electrical system was not possible, the examination of the Vision

and the similarity of the two vessels would suggest similar electrical installations and condition.

On October 2, 2019, a Coast Guard inspection found 19 electrical system deficiencies throughout

the Vision. Some of the deficiencies cited were a result of work being done at the time. Deficiencies

in the salon and galley area included corrosion, improper connectors, and signs of overload on a

power strip. Deficiencies of this type can lead to electrical system malfunctions capable of

initiating a fire.

Since the salon compartment was a critical element in the egress pathway from the

passenger bunkroom, prudent fire safety planning would suggest that risky activities (unattended

charging of batteries) and materials, such as the plastic chairs and polyethylene trash cans, that

could contribute to a fire should have been minimized in this area. This was not the case on the

Conception. Crew statements, as well as statements from previous passengers, indicated that the

overnight, unattended charging of a large number of batteries was a normal practice in the salon

compartment and was a risk that had not been considered. Each device and battery represented a

separate potential source of ignition. The passengers on the Conception were recreational divers,

so in addition to common types of electronic items, such as phones, tablets, digital cameras, and

laptops, divers also used underwater cameras, flashes, strobes, and flashlights.

Batteries (in particular, lithium-ion batteries) have a known and documented history of

initiating accidental fires. In the past, the Consumer Product Safety Commission has issued

numerous product safety recalls due to fires caused by electronic devices with defective batteries

and chargers. The NTSB has investigated accidents in which battery failures led to fires, and, based

on the history of incidents involving fires, the Federal Aviation Administration enforces

regulations on the carriage of lithium-ion batteries aboard passenger aircraft.

About a year prior

to the fire on board the Conception, a small fire involving a charging lithium-ion battery took place

on board the similar vessel Vision; a passenger was able to extinguish the fire by unplugging the

charger and throwing it in a rinse bin. However, unlike in the incident on board the Vision, the fire

aboard the Conception grew, and the vessel burned for almost four hours, thus destroying much of

the materials in the salon and aft deck area. Further, based on past accidents that the NTSB has

investigated, conclusive causal physical evidence identifying a thermal runaway of a lithium-ion

Recent NTSB investigations involving battery fires include Lithium-Ion Battery Truck Fire Following Aerial

Transport, Brampton, Ontario, Canada, June 3, 2016 (HZB-20/01

) and Auxiliary Power Unit Battery Fire Japan

Airlines Boeing 787-8, JA829J, Boston, Massachusetts, January 7, 2013 (AIR-14/01). These reports and other

information regarding investigations involving battery fires are available at www.ntsb.gov.

NTSB Marine Accident Report

battery is difficult to differentiate from a lithium-ion battery thermal runaway caused by exposure

to fire.

At the exterior of the aft portion of the salon (in the area where the stairs lead to the upper

deck), the only potential sources of ignition would include transient types, such as discarded

smoking materials. Based on the examination of the Vision and the statements from previous

passengers, there was no evidence of electrical systems or electronic devices being charged in this

area. There was, however, one large polyethylene trash can located aft of the salon underneath the

stairs to the upper deck where one could potentially discard smoking materials. Old T regulations

did not allow for the use of these trash cans in the passenger bunkroom but did not preclude their

use in any other area of the vessel. New T regulations do not allow the use of these combustible

trash cans in any areas of the vessel but do not retroactively apply to vessels built under the Old T

regulations unless they are replaced. As stated earlier, polyethylene trash cans are highly

combustible, making them susceptible to accidental fires that could be caused by the improper

disposal of smoking materials or other unforeseen sources of ignition. The NTSB concludes that

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.

Time of Ignition. Fires not involving accelerants (such as fuel) typically go through an

incipient stage following the ignition and then transition into a growth stage. The rate of the growth

stage is highly dependent on the type of materials burning and the geometry of the compartment

in which the fire is taking place. Fires inside compartments such as the Conception’s salon, which

had a low ceiling (about 7.5 feet), tend to have high growth rates due to the heat from the fire and

products of combustion accumulating at the ceiling and thermally radiating down to the unburned

materials. This radiative heating causes the materials to begin to thermally break down and emit

flammable vapors. Once this happens, the compartment fire can enter a stage called flashover

during which all the combustible materials start to become involved, and the compartment

becomes filled with flames. At this point, the compartment is deemed untenable for human

survival.

Based on the crew interviews, the fire likely reached the flashover stage around the time or

shortly after it was discovered. The crew interviews indicated that a window of approximately 30

minutes passed between the time the salon compartment was last visited to when the fire was

discovered. Sometime within that 30-minute window, an incipient fire became established and

transitioned into a fast-growing fire, followed by flashover. The construction materials of the

vessel (fiberglass over wood) were not fire-resistant and are, in fact, known to burn quite freely.

Additionally, the interior furnishings such as the wooden tables, plastic chairs, polyethylene trash

cans, seat cushions, and FRP laminates would have added to the fast-growing fire. The

compartment configuration would compound the ease of combustibility by trapping the heat and

preheating the materials not yet involved. It is not unusual under these circumstances for a fire to

reach the flashover point in a short timeframe. The unknown in this accident is the incipient stage

of the fire, which depends on the ignition source, the location of the ignition, and the first materials

to become involved. Therefore, the NTSB concludes that the exact timing of the ignition cannot

be determined.

NTSB Marine Accident Report

2.4 Cause of Death

NTSB investigators reviewed reports completed by the Santa Barbara Coroner’s Office for

all 34 decedents. Autopsies were not completed due to severe thermal injuries, obvious trauma,

and the circumstances of the accident. All deaths were attributed to smoke inhalation.

On the similar Truth Aquatics vessel Vision, NTSB investigators examined the bunkroom

ventilation equipment, which consisted of an air conditioning unit, an electric supply fan, and two

electric exhaust fans. The combined air flow capacities of the Vision’s two exhaust fans exceeded

the capacity of the single supply fan, and air was likely drawn into the bunkroom from the open

stairs leading to the galley and salon area.

The Vision’s bunkroom ventilation equipment was similar to the type and size of equipment

on board the Conception. At the time of the fire, the larger combined capacity of the operating

bunkroom exhaust fans could have drawn smoke and noxious gases from above in the salon down

into the bunkroom via the open stairwell. The air conditioning unit circulation fan, which was

operating at the time of the accident and took suction from a grille diffuser directly at the bottom

of the stairs and discharged to vents located in each bunk and to the passageways between the

bunks, would have further distributed the smoke and gas. The bunkroom ventilation system likely

continued to operate during the initial stages of fire aboard the Conception, although the exact

timing when the air conditioning unit and ventilation fans ceased operating could not be

determined. Given the ventilation imbalance and that the one open exit led to the space with the

fire, it is likely the bunkroom filled with smoke.

Coroner reports and diver video also documented that 13 deceased passengers were

wearing footwear, and the second deckhand had sandals on both of her feet, indicating that some

of the passengers and the second deckhand were awake and attempting to escape prior to being

overcome by smoke. In one case, the victim was wearing a sandal on one foot and a hiking boot

on another, indicating that the victim was likely in a rush. Passengers also appeared to have

prepared to escape the vessel, since two victims had cell phones, one had a flashlight, another had

a backpack, and two were wearing jackets. Silhouette areas of protection were found on unburned,

sooted wood in the forward bunkroom near the stairs to the galley and salon, indicating that some

of the passengers were not in their bunks and were laying against those sections prior to the sinking

of the Conception. The passengers who were awake would have likely awakened the other

passengers before they attempted to escape the bunkroom. Therefore, the NTSB concludes that

most of the victims were awake but could not escape the bunkroom before all were overcome by

smoke inhalation.

2.5 Fire Detection

The Conception was equipped with two modular smoke detectors in the bunkroom—one

mounted in the overhead of each aisle (port and starboard). Coast Guard regulations required no

additional smoke detectors aboard the Conception, and therefore the salon and crew quarters were

not equipped with them. Truth Aquatics’ owner told investigators the smoke detectors in the

bunkroom had hard-wired power supplies with a battery backup. Interviews with crewmembers

and the owner of Truth Aquatics indicated that the bunkroom smoke detectors were likely

operational. Contractors working on the air conditioning had inadvertently activated them about

one month prior to the accident. The captain of the Conception unplugged the detectors while the

contractor was soldering but plugged them back in and replaced the batteries and tested the

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detectors after the work was finished. Since the captain of the Conception was not able to be

interviewed, investigators were unable to determine any specifics of the detectors being placed

back in service, when he last tested them, or any routine tests and inspections the captain had for

the detectors. Aboard the Vision, however, investigators found the smoke detectors’ hard-wired

power supply disconnected, although the battery-powered detectors were functional and met the

regulations.

Smoke detectors sense products of combustion, which are hot and rise due to buoyancy,

and activate an alarm. Smoke detectors mounted to ceilings therefore will encounter the products

of combustion as early as possible. The smoke detectors in the passenger bunkroom would have

provided early warning of a fire originating in the bunkroom only. When a fire in the salon (the

compartment above the bunkroom) began to produce combustion products, those products would

have risen to the ceiling and spread out along the length of the ceiling until they reached the

bulkheads, creating a smoke layer at the ceiling that thickened and began to fill the compartment

from the top down. The buoyancy of the smoke layer would have made it difficult for sufficient

amounts of combustion products to migrate down to deck level, and even more difficult to migrate

further down into the compartment below. A fire in the salon therefore would not have activated

the smoke detectors in the bunkroom in a timely manner, allowing the fire time to grow. The NTSB

concludes that the fire in the salon on the main deck would have been well developed before the

smoke activated the smoke detectors in the bunkroom.

In accordance with New T (all vessels) regulations applicable to the Conception, the only

compartment that was required to be fitted with smoke detectors was the passenger bunkroom,

since it was the vessel’s only overnight accommodation space. More robust fire-detection systems

are required for larger US-flagged passenger vessels, such as those inspected under 46 CFR

Subchapter K. On Subchapter K vessels, accommodation, control, and service spaces are required

to have a “smoke actuated fire detection system” and “a manual alarm system.” New T regulations

(all vessels), in contrast, only require a household-type smoke detector.

A properly functioning fire-detection system with appropriately located smoke detectors is

an effective means of early warning and detection of fire. Successful escape from fires is

contingent on early warning, especially when occupants are asleep. The Conception had no smoke

detectors anywhere in the main deck salon area where crewmembers reported seeing the fire. The

nearest heat detector was well forward in the galley, a deck above the bunkroom, and was not

intended to be utilized as a smoke detector for the entire salon. The NTSB concludes that 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 in the accident.

The NTSB therefore recommends that the Coast Guard revise 46 CFR Subchapter T to require that

newly constructed vessels with overnight accommodations have smoke detectors in all

accommodation spaces. The NTSB likewise recommends that the Coast Guard revise 46 CFR

Subchapter T to require that all vessels with overnight accommodations currently in service,

including those constructed prior to 1996, have smoke detectors in all accommodation spaces.

Regulations require fire detection in engine rooms on most Subchapter T vessels, including

the Conception, which had heat detection and a fixed fire-suppression system in its engine room.

In January 2018, a fire that started in the lazarette—a space that was not required to have fire

detection—on board the Island Lady went undetected and grew out of control. After the fire was

established and spread, it eventually engulfed the vessel. In its investigation of the Island Lady

accident, the NTSB concluded that had there been a smoke detector in the lazarette, the fire and

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its location would have been identified earlier. The NTSB recommended that the Coast Guard

require fire detection systems in unmanned spaces with machinery or other potential heat sources

on board small passenger vessels.

The smoke detectors aboard the Conception only sounded locally, meaning that once a

detector was activated, it sounded only in the space it occupied (in this case, the bunkroom). None

of the surviving crew heard the vessel’s detectors sounding during the fire, since the fire likely

originated in the salon and not the bunkroom, where the smoke detectors were located.

An interconnected fire detection and alarm system would sound alarms in all spaces when

one alarm is activated; the system would incorporate all required smoke and fire detectors fitted

on board the vessel, including those in the engine room, other machinery spaces, or the lazarette.

In this accident, an interconnected system with smoke detectors in all accommodation spaces

would have sounded throughout the vessel in the salon, bunkroom, and upper deck, alerting crew

and passengers and giving the crew more time to fight the fire and assist the passengers below.

Passengers sleeping in the bunkroom would have been awakened by the alarms going off

throughout the vessel, including in the bunkroom, giving them a better chance to escape.

The circumstances of this accident make clear that interconnected smoke detectors in all

accommodation spaces would have given early warning of the fire to the passengers and crew and

likely would have allowed time for the crew to fight the fire and assist passengers in evacuating

the bunkroom. Currently, Subchapter K passenger vessels with overnight accommodations must

have smoke detectors in accommodation spaces, but detectors are not required to be

interconnected. Subchapter K vessels are typically larger than Subchapter T vessels, with more

accommodation spaces and distance between those spaces. Additionally, Subchapter K vessels are

allowed to carry more than 49 passengers overnight (or more than 150 passengers during the day).

Therefore, interconnecting detectors on both Subchapter K and Subchapter T vessels is critical,

since passengers and crew are subject to the risk of an undetected fire. The NTSB concludes that

interconnected smoke detectors in all accommodation spaces on Subchapter T and Subchapter K

vessels would increase the likelihood that fires will be detected early enough to allow for

successful firefighting and the evacuation of passengers and crew. The NTSB therefore

recommends that the Coast Guard revise 46 CFR Subchapter T and Subchapter K to require all

vessels with overnight accommodations, including vessels constructed prior to 1996, have

interconnected smoke and fire detectors such that when one detector alarms, the remaining

detectors also alarm. (The system installed on Truth Aquatics’ remaining vessels after the

Conception fire exceeds the minimum requirements recommended here.)

The NTSB believes that it is imperative that operators of similar small passenger vessels

learn about the circumstances of this accident and act without waiting for the Coast Guard to

require action to install interconnected smoke detectors in all accommodation spaces to provide

passengers and crew with early warning of fires. Therefore, the NTSB recommends to the

Passenger Vessel Association, Sportfishing Association of California, and National Association of

Charterboat Operators that, until the Coast Guard requires all passenger vessels with overnight

accommodations, including vessels constructed prior to 1996, to have smoke detectors in all

accommodation spaces, share the circumstances of the Conception accident with their members

and encourage members to voluntarily install interconnected smoke and fire detectors in all

accommodation spaces such that when one detector alarms, the remaining detectors also alarm.

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2.6 Roving Patrol

The requirement to keep a watch at night while passengers are embarked on a vessel has

been codified in US law for nearly 150 years. The law came into effect when vessels were primarily

constructed of wood and the advent of steam power had greatly increased the threat of fire. The

threat of fire has been reduced by modern engineering, fire detection, and fire extinguishing

equipment, but the law has remained largely unchanged since it was originally enacted. While the

probability of a fire is less, the consequences of a fire, particularly on a wood vessel carrying

passengers, has warranted the continuation of the legal requirement for a watch at night.

In the event that a space is not equipped with a smoke detector, or if a smoke detector fails

to activate, the only means of detecting a fire aboard the vessel is limited to discovery by a

crewmember or a passenger. The law (46 USC Section 8102) requires “a suitable number of

watchmen in the vicinity of cabins or staterooms and on each deck to guard against and give alarm

in case of fire or other danger.” For small passenger vessels subject to Subchapter T regulations,

this requirement has been interpreted by the Coast Guard to be a suitable number of watchmen

who “patrol throughout the vessel during the nighttime, whether or not the vessel is underway, to

guard against, and give alarm in case of, a fire, man overboard, or other dangerous situation.” This

interpretation is based partly on the size of vessels subject to Subchapter T allowing a single

watchman to rapidly patrol the vessel on a periodic basis.

On the Conception (and all other

Subchapter T vessels visited by the NTSB during this investigation) the requirement for watchmen

was included in the vessel’s COI, which stated “a member of the vessel’s crew shall be designated

by the master as a roving patrol at all times, whether or not the vessel is underway, when the

passenger’s bunks are occupied.”

According to surviving crewmembers, all members of the crew had gone to sleep the night

before the fire, after the Conception had anchored in Platts Harbor. No roving patrol was set. When

the second galley hand awoke, the fire was well developed and beyond the capability of the crew

to extinguish it. The crew was not able to warn passengers or aid in their escape. Had a

crewmember been awake and actively patrolling the Conception on the morning of the fire, it is

likely that they would have discovered the fire at an early stage, allowing time to fight the fire and

give warning to the passengers and crew to evacuate. The NTSB concludes that 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 purpose of the Coast Guard inspections is to ensure that vessels are complying with

applicable laws, regulations, and the terms of the vessel’s COI. The Conception was inspected as

required by New T regulations (all vessels), and in the 5 years before the accident, inspectors found

only minor discrepancies. Only one “prior to carriage of passengers” order was issued during that

time, and it was cleared within a day. The owner of Truth Aquatics believed that the company’s

fleet of three vessels was in compliance with the applicable regulations, based on satisfactory

completion of the required Coast Guard inspections and examinations.

Prior to the accident, the Conception and other Truth Aquatics vessels were regularly

operating in contravention of the regulations and the vessel’s COI, which required a roving patrol

at night and while passengers were in their bunks. Truth Aquatics encouraged passengers to board

54 Federal Register 4443-4444.

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their vessels the night before an early morning departure from their Santa Barbara dock, and

passengers had already boarded the Conception before the first crewmembers—the second captain

and galley hands—arrived between 2200 and midnight the night before the vessel got under way

for the accident voyage. After boarding the vessel and stowing their gear, the crew went to sleep.

No roving patrol was set, and there were no crewmembers awake on the vessel until the remainder

of the crew arrived about 30–40 minutes before getting under way. A captain of another Truth

Aquatics vessel stated that it was a regular practice for passengers to board his vessel the night

before an early morning departure, but the crew was not required to be aboard until 30 minutes

prior to getting under way.

Once the Conception was under way en route to Santa Cruz Island during the accident

voyage, the second captain and the deckhands went to their bunks (the galley hands had remained

in their bunks while the vessel got under way), and the captain operated the helm in the

wheelhouse. There was no roving patrol set during the early morning transit. Similarly, the

deckhand told law enforcement officials that, when he had been assigned night navigation watches

on previous voyages, he was the only crewmember awake and no other watches were set. Current

and former crewmembers on the Conception, Vision, and Truth stated that roving patrols were not

being maintained on any Truth Aquatics vessels. One captain told investigators that, although he

believed that the legal and regulatory requirements for a roving patrol were not being met, it was

the way he had been instructed when he joined the vessel. Another captain stated that the

requirement for the patrol was a regulation, “but it wasn’t really followed.”

During the investigation, NTSB staff visited other dive boats operating from Southern

California ports and harbors and spoke with their owner/operators. During informal discussions,

all owners/operators stated that night watches were assigned whenever passengers were aboard,

but the procedures for the watches varied greatly. On some of the vessels, crewmembers assigned

to the watch spent a majority of their time in a single location—either the wheelhouse or the

salon—which does not appear to meet the intent of the regulation.

When asked by investigators, Coast Guard inspectors stated that they could not verify

compliance with the roving patrol requirement, since inspections were not conducted during

overnight voyages with passengers embarked. There was no requirement for a log for the roving

patrol, and thus no records existed to verify that the patrol was being properly implemented. Coast

Guard inspection aids and checklists reviewed by the NTSB, such as those contained in the CG-840

TI inspection book and the MSD Santa Barbara “Small Passenger Vessel – T” checklist, did not

include line items to verify or discuss regulatory watchstanding requirements or the terms of the

COIs. Coast Guard records show that, since 1991, no owner, operator, or charterer has been issued

a citation or been fined for failure to post a roving patrol. The NTSB concludes that the Coast

Guard does not have an effective means of verifying compliance with roving patrol requirements

for small passenger vessels.

The NTSB recognizes that the resources necessary to conduct unannounced, overnight,

underway inspections to positively verify roving patrol watchstanding compliance may be

impractical. Therefore, other means need to be developed to verify compliance with the roving

patrol requirements. For example, at the most basic level, a log containing the time of the roving

patrol and the name and signature of the watchstander would give Coast Guard inspectors an

indication of the level of compliance when reviewed during inspections. More advanced

watchstander management systems are also commercially available and would provide greater

credibility to the compliance verification process. A review of logs or watchstander management

records during inspections would also provide inspectors the opportunity to discuss the

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requirement with owners, operators, and charterers and underscore the importance of the patrol for

the safety of passengers. Given the importance of this patrol to the safety of passengers and crew,

the NTSB recommends that the Coast Guard develop and implement a means to verify that small

passenger vessel owners, operators, and charterers are conducting roving patrols as required by 46

CFR Subchapter T.

2.7 Means of Escape

The Conception had two means of escape from the bunkroom, both of which led to the

salon. The primary access was a spiral staircase from the starboard forward part of the main deck

salon to the starboard forward corner of the bunkroom. Anyone trying to escape the bunkroom

with a fire in the aft salon would have encountered heavy smoke in the stairway and low visibility

conditions. Even if they succeeded in ascending the stairs, the main exit (open doors) from the

salon was blocked by the fire. They would have had to find their way through a fire-filled space,

with thick, dark smoke and zero visibility, to get outside through the emergency window exits.

The secondary emergency exit for the bunkroom occupants was the square escape hatch

on the centerline in the overhead. The Conception’s escape hatch was accessible from either port

or starboard aisles by climbing into one of the top aftermost inboard bunks. This emergency exit

opened into the aft part of the salon, where the fire was most intense. In fact, surviving

crewmembers reported seeing the whole area around the escape hatch ablaze before abandonment,

indicating it was not an option for escaping the bunkroom. As this accident clearly shows, having

two emergency escape paths that exit into the same space provides the opportunity for a single

hazard to block both. The NTSB concludes that the Conception bunkroom’s emergency escape

arrangements were inadequate because both means of escape led to the same space, which was

obstructed by a well-developed fire.

The Conception was designed in accordance with the Old T regulations at the time of

construction. As such, the vessel was required to have “not less than two avenues of escape from

all general areas accessible to the passengers or where the crew may be quartered or normally

employed, so located that if one is not available the other may be.” There were no additional

requirements regarding size, egress times, vertical access, or obstructions. Therefore, the

Conception’s two means of escape from the bunkroom (spiral stairs and escape hatch) leading to

the salon met the means of escape requirements in Old T regulations (existing vessels).

The New T regulations for emergency escape, which did not apply to the Conception as an

existing vessel, require an escape path to be a minimum of 32 inches wide, and the route must

facilitate easy movement of a person wearing a lifejacket. New T regulations (new vessels only)

also prohibit ladders leading to deck scuttles as a means of escape for vessels this size. The

regulations do not require that passengers and crew be able to evacuate within a specific timeframe.

Instead, New T regulations (new vessels only) require escapes of a number and dimensions

“sufficient for rapid evacuation.” Rapid evacuation is not further discussed or defined.

When considering the fire safety aspects regarding the evacuation from occupied spaces

both the exit capacity (number and size of exits) and the escape path to reach an area of refuge

must be considered. If all escape paths are compromised, then the evacuation fails. The exits and

the escape paths are equally important elements of the evacuation plan and must be given

consideration as a system. The goal is to maintain a tenable evacuation pathway so that the

occupants can make their escape. Coast Guard regulations applicable to the Conception do not

address the escape path as an element of the fire safety plan. The regulations only consider the

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exits from occupied spaces. Although the regulations require vessels to have two exits from an

occupied space, spaced as far apart as practicable, the regulations do not preclude having both exits

lead to the same compartment, as was the case in the Conception. In this circumstance, the salon

compartment was the only escape path to exterior (weather) decks. Therefore, because the fire was

located in the salon, the passengers were trapped, and the crew was not able to reach them. If an

escape hatch had exited to a space other than the salon, optimally directly to the weather deck,

some of the occupants in the bunkroom may have been able to escape.

By comparison, in the similar fire aboard the Egyptian vessel Red Sea Aggressor, the

primary stairway exit was blocked by smoke and fire in the salon, but all of the surviving

passengers and crew that were sleeping below deck were able to escape through the emergency

escape hatch, which led to a different space than the primary stairs did. Aboard the Red Sea

Aggressor, the escape led to a forward crew berthing area and up a ladder through a door to the

weather deck. All but one of the passengers successfully escaped. The NTSB concludes that

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. Therefore, the NTSB recommends that the Coast Guard revise 46 CFR

Subchapter T to require newly constructed small passenger vessels with overnight

accommodations to provide a secondary means of escape into a different space than the primary

exit so that a single fire should not affect both escape paths. Similarly, the NTSB recommends that

the Coast Guard revise 46 CFR Subchapter T to require all small passenger vessels with overnight

accommodations, including those constructed prior to 1996, to provide a secondary escape path

into a different space than the primary exit so that a single fire should not affect both escape paths.

The circumstances of this accident make clear that means of escape that exited to separate

or outside spaces, such as the weather deck, may have provided the occupants in the bunkroom a

greater opportunity to escape. The NTSB believes it is imperative that operators of similar small

passenger vessels act to ensure that secondary means of escape exit to a different space than the

primary exit. The NTSB therefore recommends to the Passenger Vessel Association, Sportfishing

Association of California, and National Association of Charterboat Operators that, until the Coast

Guard requires small passenger vessels with overnight accommodations to provide a secondary

means of escape into a different space than the primary exit, share the circumstances of the

Conception accident with their members and encourage members to voluntarily do so.

Had the bunkroom escape hatch not been blocked by fire, there still may have been

difficulties evacuating a large number of people through the hatch in a timely manner. The escape

path through the hatch was impeded by the bunks below it. Passengers would have had to climb

up a bunk’s ladder and onto a bunk to reach the escape, and therefore, the approach to the hatch

did not facilitate easy movement of a person through it. The escape path would have been

challenging for anyone to navigate without practice and would have been further complicated by

low lighting and poor visibility due to smoke from the fire. Further, it would have been extremely

difficult to evacuate an injured or unconscious person through the hatch.

The Conception’s escape hatch met the requirement in the Old T regulations for a second

emergency egress pathway from the bunkroom; Old T regulations did not stipulate the size of,

egress times from, or vertical access to the hatch, or address the possibility of obstructions. The

NTSB concludes that, although designed in accordance with the applicable regulations, the

effectiveness of the Conception’s bunkroom escape hatch as a means of escape was diminished by

the location of bunks immediately under the hatch. The NTSB recommends that the Coast Guard

review the suitability of 46 CFR Subchapter T regulations regarding means of escape to ensure

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there are no obstructions to egress on small passenger vessels constructed prior to 1996 and modify

regulations accordingly.

2.8 Search-and-Rescue Efforts

The Conception’s captain was able to transmit only a quick VHF radio distress call before

being overwhelmed by smoke and forced out of the vessel’s wheelhouse. The crew did not have

the opportunity to collect and activate the EPIRB or visual distress signals prior to or after

abandoning the Conception. The Coast Guard computed the Conception’s position based on VHF

radio direction finders, and although the calculation was about 6.5 miles from the actual position

of the Conception, it would have been close enough for any search and rescue unit to see the fire,

and the position would have been updated with AIS and/or VTS information before any search and

rescue unit arrived on scene.

Coast Guard watchstanders heard the captain say he could not breathe and assumed there

was a medical emergency, not a fire, on board. Coast Guard watchstanders alerted the closest small

boat station at Coast Guard Station Channel Islands Harbor. The Station’s boats however, had no

advanced life support equipment, so the crew requested assistance from the Ventura County Fire

Department. The initial distress call was made at 0314, the call to the Station at 0323.

Once the Command Center understood that the nature of the emergency was fire from the

Grape Escape’s radio call at 0329, they relayed the information to the Station, where the first boat

was launched at 0342. A second boat got under way, with an engine company from VCFD, at 0349.

Additional resources followed. At the time of the call from the Conception’s crew on board the

Grape Escape, the fire was reported to have “fully engulfed” the Conception.

The first boats on scene were the Coast Guard’s two RB-Ms, making the 27-mile trip at

full speed in about 50 minutes. Although outfitted with portable dewatering pumps that could be

used for fighting fires, the boats were not capable of fighting a fire of this magnitude. The VCFD

engine captain and RB-M coxswains chose to search for survivors in the water and along the

shoreline, realizing their limited firefighting capability, and aware that a fire boat was en route. At

0441, the first fire boat arrived on scene. At 0508, the fire was first reported extinguished, although

it did reflash at least twice after that report. Search efforts by both surface and air assets found no

survivors.

The location of the vessel fire, 27 miles from the California mainland, and the advanced

nature of the fire at the time of reporting made for a challenging response. Further, Coast Guard

watchstanders did not understand that the emergency was a fire until 15 minutes after the initial

mayday call, which slowed the dispatch of firefighting assets. Even if they had known that the

emergency was a fire, the location of the vessel prevented a speedy response. It took about 50

minutes to travel there at full speed, and reports from the Grape Escape indicated that the vessel

was likely beyond saving at the time of the call for help. The NTSB concludes that the emergency

response to the accident was appropriate but was unable to prevent the loss of life given the rapid

growth of the fire at the time of detection and the location of the Conception.

2.9 Oversight

Truth Aquatics was a well-respected operator among regulators, current and former

crewmembers, competitors, and passengers. A Coast Guard representative stated that the company

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“had a good reputation for being good operators,” and a former captain of the Truth Aquatics dive

boat Vision described the company’s vessels as “the safest boats on the coast.” Yet, despite its

reputation, the NTSB found several unsafe practices on company vessels. NTSB investigators

sought to understand how these practices became normalized in a company that, by most accounts,

was considered to be a safe and effective operator. 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.

As previously noted, current and former Truth Aquatics employees stated that required

roving patrols were not conducted on company vessels, and although the captains and other

crewmembers were aware of the requirement for the patrol, they ignored it.

New T regulations (all vessels) require that a credentialed master or mate at all times direct

and control the movement of a vessel when under way. However, on occasion, the Conception’s

captain would assign one of the uncredentialed deckhands to helm watches at night while the vessel

was under way when all other crewmembers were asleep, including the captain and second captain.

The deckhands would be responsible for directing and controlling the vessel and were instructed

to awaken the captain if the engines made unusual noises or if the Conception came within 2 miles

of other vessels.

Regulations also require that, “prior to getting underway for the first time and at least once

every three months,” new crewmembers be instructed on the duties that the crewmember is

expected to perform during emergencies, including fire, heavy weather, or man overboard. Truth

Aquatics’ Loss Control Program document contained crew procedures for these emergencies, and

the Conception second captain and an alternate second captain, both of whom had been hired in

2019, stated that they had received and reviewed this document prior to joining the vessel.

However, the alternate second captain stated that no one verified that he had read and understood

the emergency procedures prior to getting under way. The first galley hand, who had begun

working aboard the Conception about 3 weeks before the accident, had also received the Loss

Control Program document, but not until just prior to the accident voyage—his fifth or sixth on

the vessel. He stated that he wrote down the headings to each of the emergency procedures and

asked the captain about them the day before the accident, but the captain deferred discussion to a

later time. Other current and former crewmembers stated that there was no formal training for new

employees prior to getting under way, and all training was on-the-job, as time allowed.

Regulations further required that the captain conduct sufficient fire drills to ensure that

crewmembers were familiar with their duties. The drill logs for the Conception were lost in the

fire, and thus could not be reviewed for completeness or currency. According to Coast Guard

records, the drill log was not up to date during the vessel’s 2017 Coast Guard annual inspection.

During interviews, the second captain, first deckhand, and second galley hand stated that they had

never participated in a fire drill aboard the Conception. The second captain had only been aboard

the vessel for 2 months, so it is feasible that a regularly scheduled drill had not yet been conducted.

However, the first deckhand and the second galley hand had been aboard since November 2018

and October 2017, respectively, and thus should have been aboard for a fire drill. The first

deckhand had participated in a drill aboard another Truth Aquatics vessel during a Coast Guard

inspection, but he had never pulled out a fire hose or “done a dry run on anything” on the

Conception.

A passenger safety orientation was required by regulation to be conducted on a small

passenger vessel “before getting underway on a voyage or as soon as practicable thereafter.”

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However, during voyages with early morning departures, passenger safety briefings on Truth

Aquatics’ vessels were routinely conducted hours after getting under way once the passengers had

awoken and the vessel had reached its first anchoring site. On the accident voyage, passengers

boarded prior to many of the crewmembers and before the vessel left its berth in Santa Barbara.

Between the time that the vessel got under way and when the briefing was conducted, the vessel

transited open water in darkness for several hours while passengers were sleeping. Passengers were

on board for up to 10 hours before they had been verbally briefed on critical information that might

be needed in the event of an emergency on board the vessel.

Because passengers boarded the vessel the night before departure, there was ample

opportunity to conduct the briefing before getting under way. Instead, a laminated “Welcome

Aboard” card was available on the Conception when passengers boarded, and, when combined

with the lifejacket-donning instructions posted in each bunk, the card met the requirements of the

safety pamphlet alternative to the orientation, with the exception that the location of emergency

exits was not provided. However, the pre-underway announcement required in conjunction with

the pamphlet was not conducted.

A habitual disregard for rules, policies, and procedures predisposes the crew and

passengers to an unsafe environment. Knowingly and routinely violating policies and procedures

can be characterized as normalization of deviance, which occurs when people within an

organization become so insensitive to deviant, or non-standard, practices that it no longer feels

“wrong.” This insensitivity typically occurs over time and does not become apparent until all the

critical factors line up and disaster occurs.

The pathway to normalization of deviance often starts with shortcuts. People eventually

begin to rationalize these shortcuts, particularly when negative consequences or penalties do not

appear to exist. If there are no measures or attempts to verify rules and procedures are being

followed appropriately, these rationalized shortcuts can be normalized for a long time.

Oftentimes, the shortcuts go unnoticed on a large scale, normalizing the behavior and changing

company/customer expectations and ultimately jeopardizing safety. This behavior is often related

to the environment and conditions surrounding the work (time pressures, inadequate number of

crew, insufficient crew training, prioritization of goals, or fatigue) and does not necessarily mean

that the operator or person deviating from safety standards or policies was doing so intentionally

or out of gross negligence. Additionally, each minor deviation does not necessarily result in an

immediate negative consequence; however, over time, each slight deviation has a cumulative

negative effect on safety.

A person’s or organization’s deviation may become greater as they

continue to push the limit over time because the potential negative consequence from the deviation

has not materialized.

Often, deficient behaviors and patterns are caused by varying environmental factors, which

often start at the company—not hiring enough crewmembers to adequately complete the job, hiring

crewmembers lacking the experience necessary to carry out their duties without the assistance of

other crewmembers, or not providing adequate oversight to ensure the crew is working safely and

effectively to company standards. The owner of Truth Aquatics stated that there were no

company-wide operating procedures; these were left to the captains of each vessel to establish and

Dr. Rich Gasaway, Situational Awareness Matters, “The Normalization of Deviance,”

https://www.samatters.com/the-normalization-of-deviance/

A. Lebbon & S. Sigurdsson (2017), Behavioral Perspectives on Variability in Human Behavior as Part of

Process Safety, Journal of Organizational Behavior Management, 37:3-4 261-282.

NTSB Marine Accident Report

manage. Watchstanding, crew training, and operating procedures, including hiring, training, and

dismissal of crewmembers, were the responsibility of the captains of the company’s vessels. While

this practice is not uncommon among small-scale operators, it does not absolve the company from

its responsibility to ensure the safety of its passengers and crew. Entrusting the operation of the

vessel to a single individual with little to no verification of compliance with regulations, policies,

and procedures, can lead to non-conforming conditions on a vessel. The noted lax practices were

not single incidents; they were common practice. If the company had been actively engaged in

ensuring the safe practices required by regulations were being followed, most notably the

requirement for a roving patrol, the fire would have been discovered earlier, and the consequences

of this onboard fire likely would have been greatly diminished. The NTSB concludes that Truth

Aquatics provided ineffective oversight of its vessels’ operations, which jeopardized the safety of

crewmembers and passengers.

When properly implemented, an effective tool for safety oversight is a safety management

system (SMS), which is a comprehensive, documented system to enhance safety for a company

and its vessels. Safety of operations and compliance with mandatory rules and regulations related

to the safe operations is the objective behind every action and decision by both those who oversee

procedures and those who carry them out. Regardless of the size of the company, an SMS ensures

standardized and unambiguous procedures for each crewmember during both routine and

emergency operations. Duties and responsibilities are specified, and supervisory and subordinate

chains of command delineated. An SMS also calls for the creation of plans to respond to a range

of possible emergency situations, with crewmember duties and responsibilities specified. Finally,

an SMS requires procedures for the identification and correction of non-conformities and includes

an audit process for management to ensure policies and procedures are being followed.

The Coast Guard is required by regulation to ensure that US-flagged vessels engaged in

oceangoing international service have an SMS, but there is no SMS requirement for the domestic

passenger vessel fleet. Thus, Truth Aquatics was not required to have an SMS for its vessels. The

company’s Loss Control Program contained some of the elements of an SMS. However, the

company code did not have procedures for normal operations. While the company had procedures

for identifying and correcting non-conformities, it did not have an audit process. Further, although

the program included procedures for reporting accidents, there was no requirement to develop

procedures to prevent future occurrences of accidents.

Had an SMS been in place at Truth Aquatics, it would have likely included procedures for

roving patrols that complied with regulations and a company-involved audit process for identifying

and correcting non-conformities, when they existed, with the watch requirements. Also, following

the battery fire that had occurred on the Vision about a year prior to the accident, SMS postaccident

procedures could have led the company to identify battery charging as a potential risk and take

measures to prevent such fires, as it has done in the wake of the Conception fire. The NTSB

concludes that had an SMS been implemented, Truth Aquatics could have identified unsafe

practices and fire risks on the Conception and taken corrective action before the accident occurred.

Therefore, the NTSB recommends that Truth Aquatics implement an SMS for its fleet to improve

safety practices and minimize risk.

The NTSB has long advocated for the implementation of SMSs. Following the 2010

contact of the passenger ferry Andrew J. Barberi with a terminal at Staten Island, New York, in

which 50 people were injured, the NTSB issued Safety Recommendation M-12-3 to the Coast

Guard:

NTSB Marine Accident Report

Require all operators of U.S.-flag passenger vessels to implement SMS taking into

account the characteristics, methods of operation, and nature of service of these

vessels, and, with respect to ferries, the sizes of the ferry systems within which the

vessels operate.

After the Coast Guard initially responded that it was developing appropriate regulations

for all US-flagged passenger vessels (part of Public Law 111–281), the NTSB classified Safety

Recommendation M-12-3 as “Open―Acceptable Response” in May 2013. However, in April

2014, following the investigation into the 2013 contact of the passenger vessel Sea Streak Wall

Street with a pier in Manhattan, New York, and after more than 3 years had passed since Congress

authorized the Coast Guard to mandate SMSs, the NTSB reclassified the recommendation

“Open―Unacceptable Response.”

In its most recent correspondence, dated October 18, 2016, the Coast Guard wrote that it

continued to work on developing the necessary regulations to implement the requirements for an

SMS in all passenger vessels. On February 17, 2017, the NTSB replied that it had been over 6 years

(at that time) since Congress authorized the Coast Guard to mandate SMSs, and it had been over

3 years since the Coast Guard indicated to the NTSB its intent to initiate rulemaking. Accordingly,

Safety Recommendation M-12-3 remained classified “Open—Unacceptable Response.” The

NTSB also requested that the Coast Guard expedite action to address this recommendation.

The NTSB reiterated Safety Recommendation M-12-3 again in late 2019 following the

investigation into the 2018 fire aboard the small passenger vessel Island Lady. To date, the Coast

Guard has not issued the regulations authorized in the 2010 law, although the service has indicated

an intention to develop the regulations and has issued guidance encouraging operators to

voluntarily implement SMSs.

The NTSB continues to believe that an SMS is an essential tool for enhancing safety on

board all US passenger vessels and that the Coast Guard is the appropriate authority to ensure

implementation and enforcement of such a system. In the case of the Conception and Truth

Aquatics, a Coast Guard requirement for an SMS would likely have ensured greater adherence to

watchstanding requirements, an appropriate response to a fire emergency, record keeping of

watchkeeping and training documents, and the development of risk mitigation measures. The

NTSB concludes that implementing SMS on all domestic passenger vessels would enhance

operators’ ability to achieve a higher standard of safety. Therefore, the NTSB reiterates Safety

Recommendation M-12-3.

NTSB Marine Accident Report

3 Conclusions

3.1 Findings

1. Weather and sea conditions were not factors in the accident.

2. The use of alcohol or other tested-for drugs by the Conception deck crew was not a factor in

the accident.

3. The origin of the fire on the Conception was likely inside the aft portion of the salon.

4. 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.

5. The exact timing of the ignition cannot be determined.

6. Most of the victims were awake but could not escape the bunkroom before all were overcome

by smoke inhalation.

7. The fire in the salon on the main deck would have been well developed before the smoke

activated the smoke detectors in the bunkroom.

8. 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 in the accident.

9. 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.

10. 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.

11. The US Coast Guard does not have an effective means of verifying compliance with roving

patrol requirements for small passenger vessels.

12. The Conception bunkroom’s emergency escape arrangements were inadequate because both

means of escape led to the same space, which was obstructed by a well-developed fire.

13. Subchapter T regulations (Old and New) 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.

14. Although designed in accordance with the applicable regulations, the effectiveness of the

Conception’s bunkroom escape hatch as a means of escape was diminished by the location

of bunks immediately under the hatch.

15. The emergency response by the Coast Guard and municipal responders to the accident was

appropriate but was unable to prevent the loss of life given the rapid growth of the fire at the

time of detection and location of the Conception.

NTSB Marine Accident Report

16. Truth Aquatics provided ineffective oversight of its vessels’ operations, which jeopardized

the safety of crewmembers and passengers.

17. 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.

18. Implementing safety management systems on all domestic passenger vessels would further

enhance operators’ ability to achieve a higher standard of safety.

3.2 Probable Cause