Two years ago today, a preventable tragedy became one of the worst maritime events in US history.
At about 3:14 a.m. on September 2, 2019, the U.S. Coast Guard (USCG) received a distress call from the Conception, a 75-foot-long small passenger vessel operated by Truth Aquatics, Inc.
The Labor Day fire began in the early morning hours, as five crewmembers slept in their upper-deck crew berthing. Two decks below, thirty-three passengers and one crewmember slept in the bunkroom. A crewmember on the upper deck, awakened by a noise, noticed a glow from the aft main deck and alerted the remaining four crewmembers that there was a fire on board. Then the captain radioed the 3:14 a.m. distress message to the USCG before evacuating the smoke-filled wheelhouse.
Crewmembers tried to get to the bunk room through the main deck salon but were blocked by fire and smoke. Unable to reach the bunkroom, they jumped overboard. Two of them re-boarded the vessel at its stern but were once again blocked by smoke and fire. Ultimately, the five crewmembers who had been sleeping on the upper deck survived. Two were treated for injuries. But tragically, the 33 passengers and one crewmember who had been asleep below deck in the bunkroom lost their lives in the fire.
Along with a multidisciplinary NTSB team, including marine safety investigators and specialists from the NTSB Transportation Disaster Assistance (TDA) and Media Relations divisions, I launched to my first maritime investigation as a Board Member. During my time on-scene, I met with the families of those on-board the vessel and gave them the only promise we at NTSB have to give, that we would find out what caused the fire aboard the Conception, in hopes of finding ways to prevent similar suffering for other families.
Our investigators, along with the USCG, the Federal Bureau of Investigation (FBI), and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) were carefully recovering wreckage. They examined a similar vessel to help learn how it was built, and how escape might have been thwarted for so many. While we conducted our safety investigation, a parallel criminal investigation was underway.
Yet despite difficult circumstances and the limited evidence left after the fire, the NTSB was able to identify critical safety issues, determine the probable cause, and make important safety recommendations. If implemented, these recommendations will help prevent a similar tragedy from happening again.
NTSB investigators found that the Conception had no smoke detectors anywhere in the main deck salon where the fire likely started. But incredibly, there are no passenger vessel regulations requiring smoke detection in all accommodation spaces. The vessel was also required to have a roving patrol to guard against and raise alarm in case of a fire or other emergencies, but there was no evidence that such a safeguard was in place, and the USCG has difficulty enforcing such an important requirement aboard small passenger vessels.
Furthermore, small passenger vessel construction regulations for means of escape did not ensure that both escape paths from the sleeping compartment exited to different spaces. On the Conception, the only emergency routes from the passenger accommodations exited into the same space, which was fully engulfed in fire.
Finally, our investigation highlighted yet another company with ineffective safety oversight. When the Board met to deliberate the report on the tragedy on October 20, 2020, we determined that the probable cause of the fire 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 USCG 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.
The NTSB reiterated its Safety Recommendation (M-12-3) to the USCG to require all operators of U.S.-flag passenger vessels to implement safety management systems (SMS) considering 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. An SMS is an enormously powerful tool which helps a safety critical company identify hazards and mitigate risks.
Additionally, we issued seven new safety recommendations to the USCG to:
- require new and existing small passenger vessels to be equipped with smoke detectors in all accommodation spaces, which are interconnected so that when one detector alarms, the remaining detectors also alarm.
- develop and implement inspection procedures to ensure vessel operators are conducting roving patrols when required.
- require a secondary means of escape into different exits from overnight accommodations that emerge into different spaces than the primary exit, and that those routes are not obstructed.
While these regulatory changes may take time, the NTSB also recommended that industry groups such as the Passenger Vessel Association act voluntarily to install smoke detectors and improve emergency egress routes. Finally, we recommended that the company that operated the Conception implement an SMS to improve safety practices and minimize risk.
The Conception investigation report is an excellent example of the NTSB’s ability to complete investigations in a timely manner, resulting in effective common-sense safety recommendations. It is now up to the USCG and industry to make these essential changes to improve safety and prevent the horrendous loss of life we saw two years ago on Labor Day weekend. The NTSB added Improve Passenger and Fishing Vessel Safety to its Most Wanted List in 2021 and will actively advocate to ensure these safety recommendations are implemented.