NTSB: More Action Needed on the Lessons From the Conception Fire

Courtesy Santa Barbara County Fire Department

Published Sep 1, 2022 10:29 PM by The Maritime Executive

In its post-accident investigation into the deadly Conception dive boat fire, the NTSB issued 11 recommendations for safety improvements aboard passenger vessels. Now, three years after the fire, NTSB says that not enough has been done to address its safety concerns - and it notes that the law requires the U.S. Coast Guard to act on its recommendations. 

In the early hours of Sept. 2, 2019, the Conception caught fire while at anchor off Santa Cruz island. No roving fire watch had been posted, and 34 people who were asleep belowdecks were killed. The vessel burned to the waterline and sank. 

Following the investigation, the NTSB issued seven recommendations to the U.S. Coast Guard and two to small passenger vessel associations. The NTSB also repeated its decade-old recommendation for the Coast Guard to require all passenger vessels to have a safety management system - the same way that tugs and towboats have to have an SMS under Subchapter M. NTSB has looked into three other passenger-vessel accidents since 2005 in which it believes an SMS would have made a difference.

“Three years ago, I made a promise to the victims’ families that I would vigorously work to ensure the safety recommendations we issued would be implemented,” said NTSB Chair Jennifer Homendy. “While I am encouraged by the progress that has been made, more work needs to be done. NTSB will continue to push until these recommendations are fully implemented.”

Of the three industry groups with members operating small passenger vessels with overnight accommodations, only the Passenger Vessel Association has taken sufficient action to satisfy the NTSB recommendations, the agency said. Two others in the charterboat sector have not yet responded. 

At the Coast Guard regulatory level, a new SMS requirement for small passenger vessels - which NTSB has recommended since 2005 - is now in motion. New Coast Guard regulations are being developed for six other NTSB recommendations as well, but none have yet reached the implementation stage, according to NTSB's tracking

The NTSB noted that Elijah E. Cummings Coast Guard Authorization Act of 2020 requires that the Coast Guard carry out all of the NTSB recommendations issued or reiterated in connection with the Conception investigation.

“We appreciate Congress addressing these safety issues in legislation, and for the cooperation and partnership of the Coast Guard,” said Chair Homendy. “But this shouldn’t have taken an act of Congress to improve safety. Passenger vessel owners and operators should act now to ensure no one else loses a loved one in another tragedy on our waterways.”

With or without regulatory requirements, NTSB recommends that overnight passenger vessel operators:

  • Install smoke detectors in all accommodation spaces and ensure they are interconnected.
  • Ensure that the two emergency escape paths out of a berthing area do not lead to the same space, which can be blocked by a single hazard.
  • Adhere to the terms of their vessel's COI, including a requirement for a roving watchstander. 
  • Keep escape routes unobstructed.
  • Implement a safety management system.