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Lessons learnt.
Are there some lessons to be learnt from this type of incident on a small vessel for South African maritime legislation, or are our local safety requirements adequate to address these issues?

Executive Summary

​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 crew members were asleep in their bunks in the crew berthing on the upper deck, and 1 crew member and all 33 passengers were asleep in the bunkroom below. A crew member 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 crew member alerted the four other crew members sleeping on the upper deck.

The captain was able to radio a quick distress message to the Coast Guard. Crew members jumped down to the main deck and attempted to access the salon to assist the passengers and crew member in a bunkroom below the main deck but were blocked by fire and overwhelmed by thick smoke. The five surviving crew members jumped overboard. Two crew members 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 crew members in the water. The crew transferred to a recreational vessel anchored nearby where the captain continued to radio for help, while two crew members 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 crew member 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 crew member 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.

Recommendations

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.1 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 crew member 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
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.