SANTA BARBARA, Calif. - The National Transportation Safety Board (NTSB) has strongly criticized the owner of the Conception dive boat for ongoing inadequate safety procedures prior to the fatal fire on September 2, 2019, and the lack of a roving night deck patrol which could have seen the first flames.
The NTSB's four-hour long public zoom hearing wrapped up by 2:00 p.m. Tuesday afternoon.
The extensive report by investigators is based on interviews with surviving crew members who were on board the vessel where the 34 deaths occurred. One of the victims was a crew member, the remaining were passengers. All were inside the boat's tight bunk quarters and sleeping when the fire broke out.
Investigators said they were not able to speak with all the survivors due to legal action and potential criminal charges.
NTSB board members also said some of the documents they needed for the investigation were not available until February of this year.
NTSB discusses findings of Conception disaster investigation
The vessel is owned by Truth Aquatics out of Santa Barbara, based at SeaLanding. It was a frequently used boat for divers worldwide seeking to explore the Santa Barbara Channel, specifically around the Channel Islands.
The Conception had been in service since 1981 and was part of a three boat fleet that included the Truth and the Vision; both remain docked and temporarily out of service.
The NTSB explained the layout of the dive boat, where the crew and passengers slept, and delved into safety protocols. Some of Conception's safety policies and practices were disputed in various interviews.
There was a spiral staircase that led from the sleeping area to an upper deck and, a one-person escape hatch above a top bunk that opened to the same upper deck.
During the year-long investigation, it was discovered that an employee was in the area where the fire broke out about 2:30 a.m. Within a half hour, that same area became engulfed in flames and billowing black smoke, blocking both escape routes for the passengers below.
NTSB investigators revealed that most if not all of the passengers were likely awakened and trapped by the smoke and flames. Some of the bodies were recovered from the burnt wreckage with their shoes on, indicating they had tried to get up and get out of the bunk area.
A deck hand is supposed to be awake all night according to the U.S. Coast Guard, however, NTSB investigators say that mandate was not followed that night. The Coast Guard was also unable to produce enforcement information on how often they did night inspections or cited vessel operators dating back to 1991.
The commission said the requirement for a roving watchman dates back more than 100 years.
Having a crew member sleeping in the same room as the divers did not fulfill the requirement, according to one commission member.
Photo taken during accident voyage of devices plugged in to charge at the port side aft corner of the salon on the Conception (source: J. Dignam). pic.twitter.com/GZeg5FxdfF— NTSB_Newsroom (@NTSB_Newsroom) October 20, 2020
The actual cause of the fire was not determined, however, based on interviews with survivors and past customers, the area of concern was an electronic gear charging station in the aft area of the common salon. Investigators showed pictures they obtained of power strips, batteries and other forms of electronics routinely plugged in and charging throughout that site.
One crew member had said in an early interview with investigators that he saw sparks from an outlet when he plugged in an electronic device prior to the fire. During Tuesday's hearing it was revealed that no further questioning could be done with that particular crew member due to a lawsuit.
It was also revealed that a small fire once broke out in a battery charging area on the sister Vision vessel. NTSB board members said two passengers spotted the flames and quickly put them out. No follow up action from that fire or fire prevention documentation was found during the investigation.
The report also stated that the smoke detectors on board were not working in one unified system. Although they passed inspection, they were not adequate. Detectors in the sleeping area were below the level of the smoke from the fire and were not capable of going off as an early detection for an upper deck fire.
The report indicated that all crew members were cleared through urine samples for (major) drugs and alcohol. Investigators did say there was not a test for over-the-counter medication that might enhance sleep. The conclusion was that drugs and alcohol were not likely contributors to the fire.
Inspections of the Conception and its sister vessel, Vision, in recent years determined that only "minor" safety issues were found, according to the Coast Guard.
Numerous findings and recommendations were made by the board in a unanimous vote. They include escape methods on vessels that do no lead to the same location, a safety management system, and changes by the Coast Guard to increase its enforcement to ensure vessels have a roving person on deck at night.
They also called for an integrated fire alarm system that alerts all areas of the vessel when one goes off.
The commissioners concluded that simple "hardware store" style fire alarms placed in a few other areas of the boat would have likely made a difference in the early detection of the catastrophic tragedy.