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Federal investigation fails to find definitive cause of Conception dive boat fire

NTSB/J. Dingham
Photo taken prior to the fire of devices plugged in to charge at the port side aft corner of the salon on the Conception.

Over a year after 34 people died in a fiery boat disaster in the Channel Islands, an official federal investigation is now complete. But the probe didn’t pinpoint definitively what started the fire aboard the Conception dive boat.

“Some people may walk away and say, ‘well, I wish I knew what the ignition source was,’ but the focus should be on conditions were present that allowed the fire to go undetected and to grow to a point where it prevented an evacuation,” said Jennifer Homendy of the National Transportation Safety Board (NTSB). “Those are the safety issues that we need to be focused on.”

NTSB staff investigators did narrow down the area of the boat where the fire started—the rear area of the salon on the main deck, and that a malfunction of the boat's electrical system or charging batteries is likely the source of ignition. That whole area of the boat was completely destroyed in the blaze, so investigators had little physical evidence to work with.

"The charging of batteries is known to be a risk that can lead to accidental fires, when a malfunction of either the charger or the battery occurs causing the batteries to go into thermal runaway," said NTSB fire and explosives investigator Joseph Panagiotou. "On a previous voyage of the Vision [Conception's sister ship, also owned and operated by Truth Aquatics, Inc.], this in fact occurred, but due to the presence of passengers in the salon, the fire was immediately discovered and extinguished."

While malfunctioning lithium-ion batteries are strongly implicated, investigators could not conclusively rule out "improper disposal of smoking materials," i.e., cigarettes or cigars placed in a flammable wastebasket just outside the salon.

In a four-hour hearing Tuesday, the NTSB board and staff combed through the investigation into why the 2019 Conception fire was so deadly.

“What we have here is a fire that goes undetected because of an unenforceable regulation to have a roving nightwatchman to back up an inadequate smoke alarm system,” said NTSB vice chair Bruce Landsberg. “On top of that, we have a very difficult—or perhaps almost impossible—to use emergency escape system that exits to nearly the same area as the primary exit. What could possibly go wrong?”

The entire board agreed if there would have been a roving watchperson on the Conception that night, as required under current regulations, it’s likely the fire would have been discovered earlier. But that regulation is very hard to enforce.

“Coast guard records show that since 1991, no owner operator or charter has been issued a citation or been fined for failure to post a roving patrol,” said Andrew Ehlers of the NTSB.

The NTSB places blame for the Conception disaster squarely on the owner of the company Truth Aquatics, Inc. which operated the Conception and two other dive boats, saying that there was no leadership in terms of ensuring that safety protocols were followed.

“Regardless of being a reputable operator in the dive boat industry, staff found several unsafe practices on the company's vessels,” said NTSB’s Carrie Bell. “And it was clear that the crew had been deviating from required safe practices for some time.

The agency’s findings include a number of recommendations aimed at preventing future deaths on commercial passenger vessels, and says it’s the U.S. Coast Guard’s responsibility for strengthening and enforcing regulations.

The Coast Guard has recently indicated it intends to pass new rulesmaking domestic passenger vessel owners and operators to develop and implement what’s called a SMS, or safety management system. A move, says NTSB board chair Robert Sumwalt, that is long overdue.

“Congress mandated [requiring small vessels to develop an SMS] 10 years ago, the NTSB recommended it eight years ago,” Sumwalt said. “It's past time to act.”

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