Last updated on December 2, 2020, including follow-up actions by the U.S. Coast Guard.
On Labor Day in September 2019, off the coast of California, a fire aboard the MV Conception, a 75-foot (23-meter) scuba diving liveaboard, broke out during the night, killing 33 passengers and one crew member. The captain and four crew members barely escaped.
On October 20, 2020, the National Transportation Safety Board (NTSB) reviewed and voted on their investigation’s findings, the fire’s probable cause, and recommendations that could potentially prevent such maritime accidents in the future.
We are especially interested in lessons learned. It’s an accident we can’t ignore. It came with the largest loss of life in a maritime incident in US history, since a turret explosion aboard a U.S. Navy battleship in 1989.
NTSB investigators condemned the company and captain for a litany of issues including failing to train the crew on emergency procedures, a lack of safety oversight by the company, and the omission by the captain to post a roving night watchman aboard the vessel. Criminal charges appear to be imminent against the captain, Jerry Boylan.
December 2020 update: The captain was indicted on federal manslaughter charges for “misconduct, negligence and inattention” by failing to train his crew, conduct fire drills, and have a roving night watchman on the Conception when fire broke.
For the NTSB, the perceived 30-year safety record of the boat’s owner, Truth Aquatics, was nothing more than a record of good luck.
NTSB board member Jennifer Homendy was especially appalled by the lack of safety management and declared: “I hate the term accident in this case because, in my opinion, it is not an accident if you fail to operate your company safely.”
“I hate the term accident in this case because, in my opinion, it is not an accident if you fail to operate your company safely.” ~Jennifer Homendy, NTSB Board Member
“Clean up your act,” NTSB Chairman Robert Sumwalt said, referring to Truth Aquatics Inc, the owners of the Conception.
The NTSB board was equally harshed toward the U.S. Coast Guard for insufficient rules related to smoke detectors and emergency escape management, a lack of inspection process to determine if roving watchmen are really used as required by law, and for not acting on recommendations made years ago in regard to safety management systems (SMS).
The NTSB proceedings lasted almost 4 hours.
As we were listening to the live proceedings, we noted numerous operational observations pertinent to all scuba diving operations, not only liveaboards. For instance, ‘normalization of deviance’ is a key topic we need to review, discuss, and take action on. In a forthcoming article, we will discuss implications for your dive business. Subscribe at the bottom of this article to be kept in the loop.
But first, let’s present the NTSB’s findings, probable clause, and recommendations.
Although the precise cause of the fire could not be confirmed, the ‘charging station’ with numerous power bars, smartphones, and other rechargeable devices is highly suspect. That being said, the actual physical cause of the fire (ignition source) was not the main issue to be discussed, here.
NTSB’s main focus was on understanding why none of the passengers could be evacuated. There can always be a fire, for numerous reasons. What the NTSB board members wanted to ensure is that, in future incidents, passengers and crew can be alerted and evacuated in a timely and efficient fashion. In the mind of the NTSB board members, achieving such a goal is tightly linked to a Safety Management System (SMS)— whether you have one, whether you use it, and whether it is audited to ensure it is working as intended.
The official NTSB report will not be available for quite some time. For now, the information available is from the October 20, 2020, NTSB virtual meeting. Here is what we gathered and summarized for you, from the public proceedings.
NTSB’s 18 Findings From Their Investigation Into the Conception Dive Boat Fire In California in September 2019
- Weather and sea conditions were not factors in the accident.
- The use of alcohol or other tested-for drugs by the Conception deck crew was not a factor in the accident.
- The origin of the fire on the Conception was likely inside the aft portion of the salon.
- Although a definitive ignition source cannot be determined, the most likely ignition sources include the electrical distribution system of the vessel, unattended batteries being charged, improperly discarded smoking materials, or another undetermined ignition source.
- The exact timing of the ignition cannot be determined.
- Most of the victims were awake, but could not escape the bunkroom before all were overcome by inhalation.
- The fire in the salon on the main deck would have been well-developed before the smoke activated the smoke detectors in the bunkroom.
- Although the arrangement of detectors onboard 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 this maritime accident.
- Interconnected smoke detectors in all accommodation spaces on Subchapter T and Subchapter K vessels would increase the chance that fires will be detected early enough to allow for successful firefighting and the evacuation of passengers and crew.
- The absence of the required roving patrol on the Conception delayed detection and allowed for the growth of the fire, precluded firefighting and evacuate efforts, and directly lead to the high number of fatalities in the accident.
- The U.S. Coast Guard does not have an effective means of verifying compliance with roving patrol requirements for small passenger vessels.
- The Conception 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.
- Subchapter T (Old and New) regulations are not adequate because they allow for primary and secondary means of escape to exit into the same space, which could result in those paths being blocked by a single hazard.
- Although designed in accordance with the applicable regulations, the effectiveness of the Conception’s bunkroom escape hatch as a means of escape was diminished by the location of bunks immediately under the hatch.
- The emergency response by the Coast Guard and municipal responders to the accident was appropriate but was unable to prevent the loss of life given the already rapid growth of the fire at the time of the detection and the location of the Conception.
- Truth Aquatics provided ineffective safety oversight of its vessels’ operations, which jeopardized the safety of crew members and passengers.
- Had a safety management system (SMS) been implemented, Truth Aquatics could have identified unsafe practices and fire risks on Conception and taken corrective action before the accident occurred.
- Implementing safety management systems on all domestic passenger vessels would further enhance operators' ability to achieve a higher standard of safety.
Probable Cause of The Conception Liveaboard Maritime Disaster
The National Transportation Safety Board (NTSB) determined that the probable cause of the accident on board the small passenger vessel Conception was the failure of Truth Aquatics 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 exits lead to a compartment engulfed by fire, thereby preventing escape.
“The probable cause of the accident on board the small passenger vessel Conception was the failure of Truth Aquatics to provide effective oversight of its vessel and crew member operations.” ~NTSB Proceedings, October 20, 2020
NTSB Recommendations From Their Investigation Into the Conception Scuba Diving Boat Fire In California in September 2019
During the public proceedings of Tuesday, October 20, 2020, the National Transportation Safety Board (NTSB) made the following ten new safety recommendations and, in addition, made a statement to reiterate one previous recommendation.
The first seven NTSB recommendations were to the U.S. Coast Guard, all of which are related to title 46 of the Code of Federal Regulation (CFR), subchapter T, for small passenger vessels under 100 gross tons which applies to the Conception. There’s also a recommendation for Subchapter K which pertains to small passenger vessels carrying more than 150 passengers or with overnight accommodations for more than 49 passengers.
- 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.
- 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.
- Revise Title 46 Code of Federal Regulations Subchapter T and Subchapter K to require all vessels with overnight accommodations including vessels constructed prior to 1996, have interconnected smoke detectors, such that when one detector alarms, the remaining detectors also sound the alarm.
- 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.
- 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.
- 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.
- 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
In addition, the NTSB formulated two recommendations to three organizations: the Passenger Vessel Association (PVA), the Sportfishing Association of California (SAC), and the National Association of Charterboat Operators (NACO). Strangely enough, it is as if the dive industry association, DEMA, doesn’t exist!
- 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 sound an alarm.
- 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.
In addition, there is one recommendation to the owners of the Conception, Truth Aquatics, which is the tenth new recommendation.
- Implement a safety management system for your fleet to improve safety practices and minimize risk.
Finally, the NTSB reiterated an old recommendation to the U.S. Coast Guard which is Safety Recommendation M-12–3.
- Require all operators of US-flag passenger vessels to implement SMS (Safety Management System), 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.
The NTSB does not have enforcement powers. It must submit its recommendations to bodies like the Federal Aviation Administration (FAA) or the U.S. Coast Guard, which have repeatedly rejected some of the board’s recommendations after other disasters.
A Missing Recommendation on Lithium-Ion Batteries
What appears to be missing in these NTSB recommendations is anything related to lithium-ion batteries.
Eight days after the Conception fire, the U.S. Coast Guard issued a Marine Safety Information Bulletin recommending to “reduce potential fire hazards and consider limiting the unsupervised charging of lithium-ion batteries and extensive use of power strips and extension cords.”
A month later, the U.S. Coast Guard was addressing the installation of lithium-ion batteries used for propulsion or electrical power on commercial vessels.
Yet, the NTSB didn’t address this issue, probably because they could not confirm that the charging of lithium-ion batteries was the ignition source of the fire aboard the Conception.
Addendum: A Follow-Up by the U.S. Coast Guard on Lithium-ion Batteries
In a policy letter issued on October 29, 2020, the U.S. Coast Guard has instructed its inspectors to “determine how portable Li-ion batteries are used onboard an SPV and assess if the storage, charging, or use of these batteries creates potentially hazardous conditions”.
The policy letter specifies, among other things, that:
- Charging stations should be single outlet use without linking or combining together multiple power strips or extension cords (“daisy chains”).
- Lithium-powered devices and batteries should be removed from the charger once they are fully charged.
This new U.S. Coast Guard policy has implications for all scuba diving liveaboard. For instance, the second bullet above means that you cannot let your scuba diving clients charge their batteries overnight since nobody would be there to disconnect them once they are fully charged.
Furthermore, the U.S. Coast Guard recommends that during the safety briefing, passengers be “advised of safe charging locations and any Li-ion battery restrictions on board. This may include procedures for passengers to immediately stow portable batteries upon embarkation in designated locations and for the crew to verify that batteries brought on board meet an applicable UL standard.”
With this new lithium-ion battery policy, the U.S. Coast Guard is also instructing its inspectors to verify that the “crew understands how to extinguish small Li-ion battery fires, which may include purchasing, installing, and training the crew on the use of ABC dry chemical extinguishers, Class D fire extinguishers (for lithium-metal), or dirt or sand as a smothering agent based on the manufacturer’s guidance.”
If you are operating a scuba diving liveaboard, you have work to do!
Details of the Conception Scuba Diving Liveaboard Accident in September 2019 in California
This is a summary of the information we gathered from the live proceedings of an NTSB meeting on October 20, 2020.
About The Conception Boat
The 75-foot (23-meter) Conception liveaboard scuba diving boat was delivered in 1981. The vessel was purpose-built to take recreational scuba divers on day and overnight trips to dive sites around the Channel Islands. The Channel Islands are an eight-island archipelago located in the Pacific Ocean, off the coast of California, near Los Angeles.
The Conception was constructed of fiberglass with an upper deck, lower deck, and main deck. The Conception was certified as a small passenger vessel and could operate with the capacity of 99 passengers during day trips, or 46 passengers on overnight dive trips.
The Conception was operated by Truth Aquatics Inc in Santa Barbara, California. The owners of Truth Aquatics are Glen and Dana Fritzler. They have 2 other vessels: The Truth and The Vision. All 3 vessels, including the defunct Conception, are still displayed on Truth Aquatics’ chartering website.
The upper deck of the Conception consisted of the wheelhouse, which had 2 crew bunks. After the wheelhouse were 2 crew staterooms. Five of the 6 crew members were sleeping in these areas at the time of the accident.
The main deck of the Conception consisted of an enclosed salon that had tables, chairs, food service counters, and benches. At the forward part of the salon was the galley which consisted of electrical cooking and refrigerators.
The main entrance to the bunkroom for paid passengers was through foldable doors. These doors were always kept open when there were passengers on board.
Below-deck consisted of 13 double bunks and 1 single bunk. One crew member was assigned a bunk in the room. The escape hatch shown in yellow was located at the centerline of the foremost aft of the center bunks. The smoke detector was located in each aisle of the bunkroom. Aft was the engine room.
About The Conception Accident
The accident took place while the vessel was at anchor in Platts Harbor around 3 AM local time on September 2, 2019. Platts Harbor is located on the north side of Santa Cruz at 21.3 nautical miles.
Weather conditions were reported to be favorable with little to no winds and smooth sea conditions.
On the evening of September 1, after completing a night dive all passengers and crew went to sleep.
A crew member did some work on the main galley and noticed the time as being 2:35 AM.
Some time after 3:00 AM, a crew member heard a noise, got up, exited the stateroom, looked aft, and saw a glow emanating from below the sun deck. That crew member alerted the other crew that there was a fire on board. The crew found the salon to be engulfed in flames.
Crew members attempted to open the forward galley window but were not able to do so. The crew prepared and launched the skiff.
A call was made from the skiff to the coast guard that was informed the Conception was fully engulfed to the main deck.
About The Rescue Operation
The U.S Coast Guard launched rescue boats and helicopters.
At 4:17 AM, the first coast guard response boat arrived on the scene. At 4:55, firefighting efforts commenced from the harbor patrol boats. At 6:45, after water reached the burning main engine, the Conception sank.
None of the 34 occupants from the bunkroom survived — 33 passengers and one crew member.
The Conception sank in about 61 feet of water, about 20 yards from the shoreline, in an inverted position.
The following day, scuba divers from police and federal agencies began the recovery of victims and debris from the seafloor and the hull.
10 days after the Conception sank, the vessel’s hull and debris were recovered and transported by barge to the Ventura naval base for examination.
About The Fire on the Conception Scuba Diving Liveaboard
The fire onboard the Conception burned out of control for approximately one hour and 40 minutes without intervention. After the arrival of the first responders, suppressing the fire took an additional 13 minutes. Finally, the Conception sank and became inverted on the seabed.
Due to the combustible nature of the Conception construction (fiberglass-over-plywood), very little of the main and upper deck remained after it was recovered from the seabed and staged at the Naval base in Ventura county.
There were no smoke detectors in the salon where the fire took hold and it was not required by applicable regulations. There were smoke detectors, as required by law, in the bunkroom below the salon. But since smoke rises, the smoke detectors in the bunkroom would not have been triggered until it was too late.
“It is amazing we have an unattended room with batteries charging in it, a griddle, two burners as well as a refrigerator, and we have no regulation that requires smoke detectors”, NTSB Vice-Chairman Bruce Landsberg observed.
Furthermore, the PA system speakers in the bunkroom of both the Conception and the Vision were found to have been disconnected. Therefore, even if a crew member had caught the fire earlier, it would have been difficult to notify the sleeping scuba divers.
About The Investigation
The A.T.F. and U.S. Coast Guard worked to reconstruct the Conception by laying it out in three sections representing each deck. Items and portions of the structure that could be identified were placed in their corresponding places in each of the three sections.
The NTSB examined the wreckage on September 25 and spent two days at the site. The examination of the wreckage did not reveal evidence that indicated a probable origin area or cause for the fire.
Since no physical evidence was left that could lead to the determination of the origin area and cause of the fire, the investigation relied on the interviews of the surviving crew members, and their description of the fire at the time they discovered it.
In addition to the crew interviews, the NTSB proceeded with the examination of a similar vessel in the Truth Aquatic fleet, collected statements from previous passengers about the typical operating practices on board the Conception, and took into consideration a previous incident onboard the Vision.
It is unlikely that the fire originated at the below deck bunkroom since it was a small compartment occupied with 34 persons and monitored by two smoke detector units.
About Recharging Batteries Aboard a Scuba Diving Liveaboard
The interviews of the crew members and the statements from previous passengers indicated that it was a common practice to recharge battery-powered devices overnight in the salon compartment. The area within the salon where this would take place was the aft portion of the salon.
The devices and chargers were typically placed on the aft-most tables on the port and starboard sides. Devices and chargers would also be placed over the port and starboard side of the aft portion of the salon, as shown in the photo at the top right on the slide.
The charging of batteries is known to be a risk that could lead to accidental fires when the malfunction of the battery causes it to go into a thermal runaway.
On a previous voyage of the Conception’s sister vessel, the Vision, a battery recharging issue caused a fire. A fire extinguisher was used to fight the fire and the offending battery was tossed over the side. It was apparently reported to the owner by both the passengers and the captain of the Vision but when asked about it, Fritzler denied knowledge.
About The Exits
The Conception had two means of escape from the bunkroom, both of which lead to the salon.
The main exit was via a curved stairwell while the secondary emergency exit was through a square, escape hatch positioned over a top bunk, and leading into the same area as the stairs.
Anyone trying to escape the bunkroom with the fire in the salon would have encountered smoke and low visibility. Ascending the stairs to the main door would have been blocked by the fire and heavy smoke.
The escape hatch was accessible from the port and starboard aisles by climbing into one of the top aft-most bunks. This opened into the aft part of the salon, where the fire was most intense. Survivors reported seeing the whole area around the hatch ablaze before abandonment, indicating it was not an option for escaping the bunkroom.
Both means of escape from the Conception’s bunkroom lead to the same place where a well-developed fire was raging.
The Conception was designed to meet the regulations in place at the time of the construction in 1981. As such, the vessel was required to have not less than two escape avenues from the bunkroom. There were no additional requirements regarding size, egress time, access, or obstructions.
Regulations for new vessels built since 1996, which do not apply to the Conception, require among other things the escape hatch to be at least 32 inches wide and of a dimension sufficient for rapid evacuation.
Yet, rapid evacuation is not further discussed or defined.
The regulations do not preclude having both exits lead to the same compartment, as was the case on the Conception. If the escape hatch had an exit to a space other than the salon, the passengers and crew members in the bunkroom may have been able to escape.
NTSB staff believes regulations are not adequate because they allow for primary and secondary means of escape to lead into the same space, which could result in both paths being blocked by the same hazard.
More About The Secondary Emergency Hatch Exit
Even if the bunkroom escape hatch had not been blocked by a fire there may have been difficulties evacuating a large number of people through the hatch in a timely manner.
The escape hatch is not easily accessed because of the bunk below it.
Passengers would have had to climb up a ladder onto the top bunk. Crawl, stand, and then pull themselves up through the hatch. The configuration would have been challenging for anyone to navigate without practice. And further complicated by low lighting and poor visibility.
During the proceedings, NTSB member Jennifer Homendy described how she encountered extreme difficulty when she tried to exit the bunkroom of Conception’s sister vessel, the Vision, via this emergency hatch exit.
Furthermore, it would have been extremely difficult to evacuate an injured or unconscious person through this hatch.
You can see this secondary exit in the following video of an NTSB team touring a similar vessel in the Truth Aquatics fleet.
“I don’t see how an average human with a life jacket on could get up through that hatch without being a contortionist”, board member Michael E. Graham said.
About The Cause of Death
Investigators reviewed the reports by the coroner’s office. In all cases, smoke inhalation was listed as the cause of death. It is likely the bunkroom filled with smoke.
Coroner reports and video also documented some of the passengers were wearing footwear indicating occupants were awake and attempting to escape prior to being overcome with smoke. This is quite a chilling revelation!
Those passengers who were awake would have likely awakened other passengers before they attempted to escape the bunkroom.
The NTSB staff believes most of the victims were awake, but could not escape the bunkroom before all were overcome by smoke inhalation.
About the Roving Patrol Aboard The Conception
Small passenger vessels are required to have a suitable number of watchmen. The watch is required to patrol throughout the vessel overnight whether or not the vessel is underway.
The requirement for a roving watch was underscored in the vessel certificates of inspection stating a roving patrol should be designated at all times when passengers were in their bunks.
Former captains of the Conception and other Truth Aquatics vessels, as well as owners and operators of other dive vessels in Southern California, all stated that they were familiar with this requirement.
According to survivors of the accident, all members of the Conception crew had gone to sleep the night before the fire.
No roving patrol was assigned.
When the crew awoke, the fire was well developed and beyond their capability to extinguish it. The crew was not able to warn passengers or aid in their escape.
Had a crew member been awake and patrolling the 75-foot Conception on the morning of the fire, it is likely he or she would have discovered the fire at an earlier stage, allowing time to fight the fire and give warning to passengers and crew to evacuate.
The NTSB staff believes 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 lead to the high number of fatalities in the accident.
About The Inspections of The Conception
All three Truth Aquatics vessels were inspected no less than annually by the U.S. Coast Guard to ensure compliance with applicable regulations.
In the years prior to the Conception accident, only minor discrepancies were found during inspections of these vessels.
At the same time, however, each of the company’s vessels was operating without complying with the requirement for the roving patrol.
When asked by investigators, coast guard inspectors stated they could not verify compliance with the roving patrol requirement because inspections were not conducted during overnight voyages or with passengers embarked.
No records exist to verify the roving patrol is being properly implemented. Coast guard inspection lists do not include line items to verify the implementation of the roving patrol.
No owner, operator, or charterer has been issued a citation or fine for failure to post a roving patrol.
Therefore, the NTSB staff believes that the U.S. Coast Guard does not have an effective means of verifying compliance with the roving patrol requirement for small passenger vessels.
About The Safety Management System (SMS)
When properly implemented a proper tool for safety oversight is the safety management system (SMS), which is a comprehensive, documented system to enhance safety for a company and its vessels.
Regardless of the size of the company, SMS defines the role and responsibilities of all personnel, ensures standardize and unambiguous procedures during routine and emergency operations, and establishes safeguards against identified risks.
An SMS requires procedures for identifying and correcting nonconformity and to ensure policies and procedures are being followed.
U.S. flag vessels engage in ocean-going international service are required by regulation to have an SMS but there is no SMS requirement for the domestic passenger fleet. Thus, Truth Aquatics was not required to have an SMS.
However, the company did have an industry-based insurance-related loss control program to manage risk and reduce losses.
Truth Aquatics loss control program shared some elements with a standard SMS, including emergency procedure and accident reporting requirements. However, the program did not have procedures for normal vessel operations and there was no requirement to develop policies or procedures to prevent future occurrences of accidents.
Further, while the program had procedures for identifying and correcting nonconformities it did not have an audit process for company management.
The NTSB staff believes that if an SMS had been implemented Truth Aquatics could have identified unsafe practices on the Conception and taken corrective action.
About Human Performance & Management
Regulations require that new crew members be instructed on the duties that they would be expected to perform during emergencies. The captain was responsible for ensuring that the crew members were trained in their assigned duty.
The Conception had a station containing a list of each crew member's assigned duties, including instructions, in case of emergencies.
The newest crew member on board had no understanding of that station, and according to interviews, three crew members had not been involved in a fire drill since they had been working onboard. Of those three, one had been working on the vessel for two years, one for about a year, and the other for only two months. Some former crew members say they had not participated in fire drills, while on the vessel.
Another safety-critical element is the passenger safety briefing. This is required to include the location of emergency exits, and a demonstration of life jacket dawning instructions.
On the Conception, it was common on overnight trips for no crew to be on board until hours after the passengers arrived.
A “welcome aboard” card was available to passengers in the salon, and life jacket dawning instructions were available on each bunk.
However, in-person safety briefings were not completed until the next morning after the passengers had slept on board and transited and anchored at the first dive location.
Though Truth Aquatics had a good reputation in the industry, the NTSB staff found many examples where the company and crew showed signs of complacency.
Each crew member was responsible for following the policies and procedures in the employee handbook. Yet, from crew interviews, it was clear the company was not verifying that the newest crew members understood or even read the policies and the proceedings of the company, before getting underway.
One crew member stated that he received the new employee documents just prior to the accident voyage, with which was his sixth voyage on the vessel.
No documentation of training or drills was found in the company’s personnel files.
The regulation required the vessel to always be under the control of a credentialed mariner. The captain and second captain were both credentialed mariners but it was discovered that deck hands had been assigned watches when other crew members and both captains were asleep.
In addition, as discussed above, roving patrols were not carried.
All of these deviances lead to what is called normalization of deviance.
Normalization of deviance occurs when people in the organization become so desensitized to deviancies that they feel it is no longer wrong.
This typically occurs over time.
The captain said he believed having one crew member sleeping in the bunkroom somehow fulfilled the roving patrol requirement. He said he assumed it must be fine since the boat had been operating successfully this way for so long.
Regardless of being a reputable operator in the dive boat industry, the NTSB staff found several unsafe practices on the company’s vessel and it was clear the crew had been deviating from required safe practices for some time. Some NTSB board members voiced concerns on what are the ‘real practices in the industry’ if a reputable operator is deviating so much from required safe practices.
The captains of the Truth Aquatics vessels were given broad authority over the operations of their vessels including the hiring and training of crew members, maintenance, as well as establishment and enforcement of vessel operating procedures.
The lack of a top-down commitment by the owner to be involved in the execution of his own company operations exhibits a poor overall safety culture. Instead of being involved, the owner relied on his captains to ensure the crew was adhering to the policies.
Despite the company’s vessels being moored within feet of the company office in Santa Barbara, California, the owner, Glen Fritzler, claimed he had not been on board for a long time.
Given the safety issues found, the NTSB staff believes Truth Aquatics’ safety oversight of its vessels was inadequate.
“Some NTSB board members voiced concerns on what are the ‘real practices in the industry’ if a reputable operator is deviating so much from required safe practices.”
Concluding Remarks by The NTSB Chairman
At the end of these lengthy discussions, Robert L. Sumwalt, Chairman of the NTSB, concluded the session with the following words.
“The recommendations that we’ve issued today, if implemented (‘if’ being the key word), would reduce the risk of future passenger fires going undetected and it would ensure that escape routes exit to different spaces, improving the chances of survival for passengers and crew.”
“We recommended that Truth Aquatics implement a safety management system, and we reiterated our recommendation for the U.S. Coast Guard to require SMS for all passenger vessels — an action that’s long overdue.”
“Congress mandated that 10 years ago. The NTSB recommended it eight years ago. It’s past time to act.”
A preliminary synopsis of the official report is available on the NTSB website.
There’s a lot to digest, here.
Numerous issues highlighted by the NTSB should also be reviewed in the context of dive center operations — including ‘normalization of deviance’, complacency, and lack of company oversight.
We will analyze how these issues apply to all scuba diving centers, in a forthcoming article. And we’ll discuss what our dive industry association, DEMA, should do in the face of recommendations issued by the NTSB to three other industry associations. Be sure to subscribe to stay in the loop.
You may be interested in more scuba diving industry news.