Deadly shipboard fire prompts NTSB to call for networked smoke detectors, verification of crew ‘roving patrols’ and implementation of safety management systems on small US passenger vessels
In the wake of one of the deadliest shipboard fires in Californian maritime history, the US National Transportation Safety Board (NTSB) is calling for major safety improvements aboard small passenger vessels, including the implementation of safety management systems (SMS).
Fire on board 22.8-m recreational dive boat Conception in the early morning hours of 2 September 2019 while it was anchored in Platt Harbour off Santa Cruz Island, 21 nautical miles off Santa Barbara, California, resulted in the death of all 33 passengers and one crewmember.
All died of smoke inhalation after being trapped in the berthing area while a fire raged on the deck above. Both exits from the passenger berthing area led to the fire- and smoke-filled enclosed area above. Five other crewmembers who were asleep in their bunks in their berthing on the upper deck escaped harm. Loss of Conception was estimated at US$1.4M.
One of the key findings in NTSB’s investigation into the incident was the lack of ‘roving patrols’ by the crew to check on the safety of the sleeping passengers and crew. NTSB investigators found the absence of such patrols – required by regulations – on Conception likely delayed the initial detection of the fire, allowed it to grow, precluded firefighting and evacuation efforts and directly led to the high number of fatalities in the accident.
In the scope of conducting its investigation, NTSB interviewed owners and operators of other recreational dive boats operating in southern California. Those informal discussions revealed that while those roving patrols were assigned whenever passengers were aboard, the procedures for them varied greatly.
In discussions with investigators, US Coast Guard inspectors revealed they could not verify compliance with the roving patrol requirement, since inspections were not conducted during overnight voyages with passengers embarked.
As a result of its findings, NTSB recommended the US Coast Guard develop and implement an inspection programme to verify roving patrols were being conducted on small passenger vessels.
Commenting on the accident, NTSB chairman Robert L Sumwalt said the vessel “may have passed all Coast Guard inspections, but that did not make it safe. Our new recommendations will make these vessels safer, but there is no rule change that can replace human vigilance.”
Interconnected smoke detector system
NTSB called for all USCG Subchapter T-certified vessels similar to Conception with overnight accommodation to be required to have interconnected smoke detectors in all passenger areas. USCG Subchapter T vessels like Conception are under 100 gt and have overnight accommodation for 49 or fewer passengers. NTSB recommended interconnected smoke detectors should also apply to larger Subchapter K vessels, which carry 150 passengers or more or have accommodation for more than 49 passengers.
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. Conception was equipped with two modular smoke detectors in the bunkroom—one mounted on the overhead of each of the port and starboard aisles. But 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 utilised as a fire detector for the entire salon. Additionally, all detectors aboard the vessel only sounded locally. Although 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.
“The vessel may have passed all Coast Guard inspections, but that did not make it safe”
NTSB also reiterated its call for small passenger vessels to be required to implement an SMS to improve the safety culture of small vessel owners and operators.
Not a regulatory body, the NTSB can only make recommendations regarding vessel safety.
NTSB blames owner
During a virtual board meeting in October, NTSB placed the blame for the accident on vessel owner Truth Aquatics, saying it failed 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.”
NTSB added “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.”
While the burning and sinking of Conception made it difficult to pinpoint the exact cause of the fire, NTSB investigators indicated the fire originated near the back deck of the vessel’s salon – where passengers plugged in their chargers for their phones, cameras and other lithium battery-containing devices.
A fire ignited on a sister vessel, Vision, by cellphone chargers plugged into an outlet on the boat but was quickly detected and extinguished, according to a report in The Washington Post.
One of the recommendations in a Marine Safety Information Bulletin (MSIB 008-19) issued by the US Coast Guard following the accident was for small passenger vessel owners to “reduce potential fire hazards and consider limiting the unsupervised charging of lithium-ion batteries and extensive use of power strips and extension cords.”
The MSIB advised small passenger vessel owners to review the routes and conditions listed on the vessel’s Certificate of Inspection (COI) including the number of passengers and overnight passengers permitted. The notice said crewmembers should also be aware of and clearly understand their obligations including any additional requirements detailed on the COI.
This pertains to reviewing all emergency duties and responsibilities with the crew and any other crewmember in a safety-sensitive position to ensure they comprehend and can comply with their obligations in an emergency to include the passenger safety orientation. Ensure emergency escapes are clearly identified, functional, and remain clear of objects that may impede egress.
Review the vessel logbook and ensure records of crew training, emergency drills, and equipment maintenance are logged and current. Additionally, it is recommended that the master complete log entries to demonstrate to the Coast Guard that the vessel is operating in compliance with routes and conditions found on the COI.
Owners are required to ensure firefighting and lifesaving equipment is on board and operational.
They must also review the overall condition of the passenger accommodation spaces and any other space that is readily available to passengers during the voyage for unsafe practices or other hazardous arrangements.