Three years ago, I launched with the NTSB Go Team to Santa Barbara, California, to investigate the deadliest U.S. marine accident in decades.
On September 2, 2019, the Conception dive boat caught fire in the early morning hours, burned to the waterline, and sank less than 100 feet from shore. Tragically, the 34 people asleep below deck in the bunkroom — 33 passengers and one crewmember — were trapped. None of them survived.
The Conception tragedy was my first marine investigation as an NTSB Board member. As I have previously shared, I am forever changed by the time we spent on scene—especially my time speaking with the victims’ families.
Unfortunately, they are not alone. Including the Conception, the NTSB has investigated seven passenger vessel accidents since 1999 that have claimed a total of 86 lives.
Eighty-six lives lost unnecessarily. Eighty-six people who’ve left behind bereaved families and friends.
Enough is enough.
It’s time for meaningful action to improve passenger vessel safety — and it starts with the U.S. Coast Guard (USCG).
Our Marine Safety Partner
The USCG is NTSB’s closest marine safety partner. Our relationship is an outstanding example of government collaboration focused on saving lives and improving safety.
It is no exaggeration to say that we could not carry out our marine safety mandate without the USCG. Every accident we investigate is supported in a variety of ways by the dedicated men and women of the USCG, and my sincere thanks goes out to every one of them.
Many NTSB marine safety recommendations are directed to the USCG because, as the industry’s regulator, they are best positioned to improve safety.
Improving passenger and fishing vessel safety is on the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL).
Lessons from Tragedy
There are currently 21 open NTSB recommendations to the USCG focused on improving passenger vessel safety. “Open” status means the recipient of our safety recommendation has not, in the Board’s estimation, sufficiently addressed the safety risk.
That’s 21 unacted-upon opportunities to prevent further passenger vessel tragedies, like the Conception.
Every day that an NTSB recommendation lingers as “open” is unacceptable. But, sometimes, we must measure inaction on our recommendations not in days, weeks, months, or even years. That’s the case with several NTSB recommendations to the USCG.
Here are some of the safety gaps the USCG needs to address — all of which are on the MWL.
The Conception is a heartbreaking example of the need for rigorous fire safety standards for small passenger vessels.
We determined the probable cause of the accident was the failure of the operator, Truth Aquatics, to provide effective oversight of its vessel and crewmember operations. The lack of both oversight and adherence to certain safety requirements allowed the fire to grow undetected.
We also found that the lack of a USCG regulatory requirement for smoke detection in all accommodation spaces and inadequate emergency escape arrangements from the vessel’s bunkroom contributed to the undetected growth of the fire and the high loss of life.
As a result of our investigation, we issued 7 new safety recommendations to the USCG and reiterated a prior recommendation calling on the USCG to require safety management systems (SMS) on U.S.‑flag passenger vessels.
The Conception disaster was so compelling that Congress felt our safety recommendations needed to be codified into law. Legislators mandated the USCG implement our recommendations in the Elijah E. Cummings Coast Guard Authorization Act of 2020 as part of the National Defense Authorization Act.
The USCG took an important step to carry out this congressional mandate by issuing an interim rule, most of which took effect in March of this year. We look forward to the final rule implementing our recommendations.
Until then, our recommendations from the Conception investigation remain open.
Safety Management Systems
The second safety issue involves SMS: a comprehensive, documented system to enhance safety. They’re so effective that the NTSB has recommended SMSs in all modes of transportation.
For nearly two decades, we’ve called for SMS on passenger vessels. This call to action is on the MWL, which is our single most important tool to increase awareness of important needed safety improvements.
The first time we issued a marine SMS recommendation was due to the October 15, 2003, ferry accident involving the Andrew J. Barberi. The vessel struck a maintenance pier at the Staten Island Ferry terminal, killing 11 passengers and injuring 70 others. We issued a recommendation to the USCG to “seek legislative authority to require all U.S.-flag ferry operators to implement SMS.”
Congress granted the necessary authority in 2010 — but the Coast Guard still didn’t act.
We then investigated a second accident involving the Andrew J. Barberi. This time, the ferry struck the St. George terminal on May 8, 2010, resulting in three serious injuries and 47 minor injuries.
Between the 2003 and 2010 accidents, the New York City Department of Transportation Ferry Division had implemented an SMS. Based on differences between crew actions in the two accidents, we concluded that the SMS benefitted passenger safety.
But the USCG still didn’t act on our SMS recommendation.
Several more accidents followed — in all of these, we determined an SMS would have either prevented the accident or reduced the number of deaths and injuries:
- In 2013, the Seastreak Wall Street hit a pier in Manhattan, seriously injuring four passengers; 75 passengers and one deckhand sustained minor injuries.
- In 2018, a fire aboard the small passenger vessel Island Lady killed one passenger and injured 14 others.
- In 2019, the Conception tragedy claimed 34 lives.
The USCG initiated steps in January 2021 to implement our SMS recommendation by publishing an Advanced Notice of Proposed Rulemaking (ANPRM). In the ANPRM, the Coast Guard discussed that the NTSB “has identified issues associated with failed safety management and oversight as the probable cause or a contributing factor in some of the most serious casualties involving U.S. passenger vessels.”
That was over 18 months ago. We’ve been calling for such a requirement for almost 20 years. We will persist for as long as it takes.
I look forward to working with Admiral Linda Fagan in her new role as Commandant and call on the USCG to prioritize the rulemaking in the weeks and months ahead.
The Work Ahead
When it comes to safety, time is of the essence. That’s why we fight so hard for NTSB recommendations: to improve passenger vessel safety and save lives.
On the third anniversary of the Conception disaster, I’m calling on the USCG to act on the 21 open NTSB passenger vessel recommendations.
Doing so can’t undo past tragedy — but it can prevent similar suffering for other families.
I can think of no better way to honor the memory of the 34 Conception victims, whose loved ones we hold in our hearts today.