Category Archives: Marine Safety

A New Year’s Resolution We All Can Make: Prioritize Safety

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the safety of our transportation system in 2022.

The NTSB recognizes the need for improvements in all modes of transportation–on the roads, rails, waterways, pipelines, and in the sky. Our 2021–2022 NTSB Most Wanted List of Transportation Safety Improvements (MWL), released in April this year, highlights the transportation safety improvements we believe are needed now to prevent accidents and crashes, reduce injuries, and save lives. We use the list to focus our advocacy efforts and to serve as an important call to action. We ask lawmakers, industry, advocacy, community organizations, and the traveling public to act and champion safety.

As a fellow safety advocate, I ask you to join me in a New Year’s resolution: I pledge to do my part to make transportation safer for all.

To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:

  1. Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations
  1. Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs
  1. Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes
  1. Protect Vulnerable Road Users through a Safe System Approach 
  1. Prevent Alcohol- and Other Drug-Impaired Driving
  1. Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles
  1. Eliminate Distracted Driving
  1. Improve Passenger and Fishing Vessel Safety
  1. Improve Pipeline Leak Detection and Mitigation
  1. Improve Rail Worker Safety

Achieving these improvements is possible; otherwise, they wouldn’t be on our list. The NTSB MWL includes tangible changes and solutions that will, undoubtedly, save lives. But it’s only words on a list if no action is taken. Unlike Times Square on New Year’s Eve, we cannot drop the ball on improvements to transportation safety. The clock is ticking, and the countdown has begun—we can’t afford to waste any more time. Make the resolution to do your part to make transportation safer for all!

In closing, I’d like to thank the transportation safety stakeholders, industry, lawmakers, and advocates we have worked with in 2021 and we look forward to working together in 2022 and beyond.

Two-years Later: Conception Tragedy Still a Reminder that More Should Be Done to Improve Passenger Vessel Safety

By Chair Jennifer Homendy

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.

Preaccident photograph of the Conception (Source: http://www.seawaysboats.net)

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.

Small passenger vessel Conception at sunrise prior to sinking (Source: VCFD)

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.

I Lived My Dream: Looking Back on 15 years at NTSB

By Chairman Robert L. Sumwalt

I guess it all started on an overcast day in 1973, when I found myself on the scene of a fatal aviation crash for the first time. I had heard of the crash on my car radio, and, as a curious 17‑year-old, I decided to find the crash location. Once there, I saw the remains of a twin-engine airplane lodged in the bases of the surrounding pine trees. Seeing that accident scene sparked an acute interest within me for accident investigation. In college, I spent copious amounts of time in the government documents library reading NTSB aircraft accident reports. It was then, in the mid-1970s, that I began to dream of becoming an NTSB Board member. Today, as I wrap up 15 years with the agency, serving as Board member, vice chairman, and chairman, I can look back and say I have truly lived that dream.   

Photo of ‘The State’ newspaper article on the 1973 plane crash

I was sworn in as the 37th member of the NTSB in August 2006. Seven days later, I found myself on the scene of another aviation disaster. Comair flight 5191, a regional jet operated as a Delta Connection, crashed just off the departure end of a runway in Lexington, Kentucky. Forty-nine lives were lost that morning after the pilots inexplicitly attempted to take off on a short, closed, unlighted runway. The investigation found that the pilots’ casual attitude during preflight and during the brief taxi, including their engaging in nonpertinent conversation, enabled the crew’s errors. Quite simply, the crew wasn’t paying attention and lost positional awareness. As a result, we issued and reiterated several recommendations to prevent that same type of accident. Today, flights are safer because airline pilots use enhanced procedures to ensure they are aligned with the proper runway before departure, and pilots have electronic maps that provide real-time position information during taxi.

Since the Comair crash, I’ve been on the NTSB Go-Team and served as the Board member on scene for 35 transportation accidents and crashes, and I’ve been involved in the deliberation and determination of probable cause of over 250 accidents and crashes. I’ve met with grieving family members and friends of victims on the worst day of their lives. Through these interactions, the one thing that really stands out to me is just how precious life really is. I’ve often said that we are here to give a voice to those who don’t have a voice—the victims of transportation accidents and their families. I take great solace knowing our work really does make a difference and keeps others from enduring similar tragedies.

Looking back, I believe there are two things that allow the NTSB to truly be one of the “Best Places to Work in the Federal Government,” as ranked by the Partnership for Public Service: the agency’s mission, and our people.

First, the agency’s mission: Congress charged the NTSB with investigating transportation accidents and crashes, determining their cause, and issuing safety recommendations to prevent similar accidents and crashes, reduce injuries, and save lives. It’s an important calling—taking something tragic and learning from it so others don’t have to endure such a tragedy. Since the NTSB was formed in 1967, we have investigated over 150,000 aviation accidents, along with thousands of highway, marine, rail, pipeline, and hazardous materials accidents and incidents. In that period, we’ve issued over 15,000 safety recommendations, the majority of which have been successfully implemented.  

Our people: Even with a respectable mission, you’re nothing without great people. Fortunately, this is where the NTSB really takes the cake. We’re able to attract and retain dedicated, bright employees who love their work. We actively promote diversity and inclusion, and my hope is that the agency will continue to expand this effort. Our investigators’ passion and determination to find the truth is uplifting. Even throughout the pandemic, although working remotely, NTSB employees found ways to continue delivering our high-quality products. For example, before the pandemic, we had never conducted virtual Board meetings, where we deliberate accident findings, determine the probable cause, and adopt safety recommendations. Even with the challenges of 2020, our employees figured a way to get it done. We held 12 virtual Board meetings in a year, which compares favorably to a normal year of in-person meetings. Although I’ve always had high expectations of the NTSB workforce, I can honestly say that, considering the challenges we all faced during the pandemic, NTSB employees surpassed all expectations.

There are several other qualities that allow the NTSB to be a highly respected federal agency. One of our core values is transparency; we are open and honest with the public about our work. We realize that, when a transportation disaster occurs, the public needs to be assured that the government is conducting an open, competent, and thorough investigation. Therefore, we deliver fact-based information as we learn it. We don’t speculate—just the facts, ma’am. All NTSB Board meetings and hearings are open to the public (literally in person when not in pandemic times, and always via webcast). We post all our accident reports and publications on our website, along with the docket for each accident, which provides reams of background information such as interviews, photos, and technical information that may not be in the final accident report.

When I was sworn in for my first term at the agency in 2006, I told the audience something I had read: “Public service is one of the highest callings in the land. You have the opportunity to make a positive impact on families, communities, states, and sometimes the world.”

I followed up by saying, “I truly believe this statement applies so well to the work of the NTSB. When my term expires, I hope we can look back and say, ‘you know, we—Board members, professional staff, industry, labor, government—we all worked together, and we did make a positive impact.”

Indeed, looking back, I truly believe we have made a difference.

I will very much miss working with the incredibly dedicated men and women of the NTSB. It will be hard to stop referring to the NTSB as “we.” Although I will no longer be part of it, the NTSB will always be part of me. For that privilege, I am forever proud and grateful. I have lived my dream.

Episode 39: Marine Safety

May 22-28, 2021, has been designated as National Safe Boating Week, which kicks off a yearlong campaign promoting the importance of wearing a life jacket.

In this episode of Behind-the-Scene @ NTSB, we talk with Morgan Turrell, Director, NTSB Office of Marine Safety, about the 2021-2022 Most Wanted List safety item Improve Passenger and Fishing Vessel Safety, the NTSB Safer Seas Digest and recent marine investigations. Morgan also shares boating safety tips, including the importance of wearing a life jacket, as we approach the Memorial Day Holiday weekend.  

Behind-the-Scene @NTSB podcast Marine Safety episode

The NTSB Safer Seas Digest mentioned in this episode is available on the Safer Seas Digest 2019 Lessons Learned from Marine Accident Investigations web page.

The full report for the investigation into the fire aboard the small passenger vessel Conception is available on our web site.

For information about the upcoming NTSB Board meeting on the 2019 sinking of the fishing vessel Scandies Rose read the media advisory.

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Improving Passenger and Fishing Vessel Safety

By Chairman Robert L. Sumwalt

May 22–28 is National Safe Boating Week, calling to mind well known campaigns against boating while intoxicated, distracted operations, and promoting proper use of life jackets on watercraft. But the present NTSB Most Wanted List puts a special emphasis on a lesser-known issue: the safety of passenger vessels and commercial fishing vessels.

It’s critical to watch out for your own safety and that of your guests on board personal watercraft, but when you step aboard a passenger vessel or go to work on a fishing vessel, somebody else is responsible for the whole range of safety concerns, from having appropriate fire-detection devices to well-maintained lifesaving equipment. We’re working to ensure that marine operators have your safety in mind, in part, by asking the country’s marine transportation regulating authority, the US Coast Guard, to implement our safety recommendations.

Passenger Vessels

Passenger vessels range in size from small charter vessels, such as dive boats and amphibious passenger vessels (DUKW boats or “duck boats”) to large cruise ships operating in international waters. The number of passengers and crew on these types of vessels varies.

Fires can pose a catastrophic threat to passenger vessels, as we saw in the 2019 Conception dive boat accident off the coast of California, in which 34 people died. Our investigations have revealed that crew training and safety regulations for these vessels vary, increasing the risk to passengers and crew. We have investigated 74 fire-related marine accidents since 2010.

To prevent needless deaths and mitigate injuries, passenger vessels should:

  • have safety management systems,
  • use voyage data recorders, and
  • provide adequate fire-detection, extinguishing systems, and available emergency egress options.

Operators should ensure their crews have enhanced training that includes practicing fire drills and learning firefighting techniques. We also need to see existing requirements for roving patrols enforced to ensure passengers are being transported safely.

Additionally, amphibious passenger vehicle operators should instruct passengers that seat belts must not be worn while the vessel/vehicle is operated in the water. Each passenger should visually check to ensure they have unbuckled their belt when the vessel enters the water.

Commercial Fishing

The commercial fishing industry, which remains largely uninspected, is another marine sector of concern. Fishing consistently tops the list of most deadly occupations due, in large part, to challenging work environments, such as poor weather and rough waters. These conditions threaten vessel stability and integrity, which, as we’ve seen in our investigations, can lead to catastrophic results. More than 800 people have died on fishing vessels in the past two decades.

We need new standards to address—and periodically reassess—intact stability, subdivision, and watertight integrity in commercial fishing vessels up to 79 feet long. Many fishing crews aren’t trained in stability management techniques or emergency response, and we have found that many vessels do not have proper life-saving equipment, such as flotation devices and operational search-and-rescue locator devices.

Back on the Water

As more and more people get vaccinated against COVID-19, many Americans are considering travel again, including on personal craft, passenger, and fishing vessels. The NTSB will continue to investigate accidents such as allisions, groundings, sinkings, and vessel fires in which people are injured or lose their lives, vessels are damaged or destroyed, or there is a threat to the environment. These cases are rare, and we hope to make them rarer, but as traffic on our waterways begins to return to pre-pandemic levels, the likelihood of an accident increases.

The dedicated men and women of the US Coast Guard work to improve safety on both passenger and fishing vessels by implementing recommendations that come out of our investigations and studies. We continue to urge the US Coast Guard to act on our passenger and fishing vessel recommendations to make these marine sectors as safe as possible for crews and passengers.

Learn more

Improve Passenger and Fishing Vessel Safety

National Safe Boating Week

Fire Aboard Small Passenger Vessel Conception
Santa Barbara, CA | September 2019


Sinking of Amphibious Passenger Vessel Stretch Duck 7
Branson, MO | July 2018


Capsizing and sinking of fishing vessel Destination
George’s Island, AK | February 2017


Fire aboard Roll-on/Roll-off Passenger Vessel Caribbean Fantasy
Atlantic Ocean, 2 Miles Northwest of San Juan, Puerto Rico | August 2016


Capsizing and sinking of fishing vessel Christopher’s Joy
Southwest Pass, LA | September 2014