No Night Watch Doomed the ‘Conception’

Final Accident Report in Santa Barbara Dive-Boat Tragedy Lays Blame on Lack of Procedure

‘Conception’ and its skiff | Credit: Courtesy of NTSB/Truth Aquatics

The National Transportation Safety Board strongly criticized the safety procedures onboard the Conception and the regulations that allowed such inadequate standards, in its final report released on October 20. It also indicated criminal charges were coming from the U.S. Attorney’s Office in the tragedy that claimed 34 lives off the coast of Santa Cruz Island on Labor Day weekend in 2019.

The report details a deadly chain of circumstances including the long-standing lack of a night watch aboard the ship, an escape hatch that led to the fiery salon, and no smoke detectors in the salon to sound the alarm earlier. These factors contributed to the 34 deaths since the victims, most of whom were awake below deck when the fire broke out, were unable to escape, ultimately succumbing to smoke that smothered them.

“The absence of the required roving patrol on the Conception delayed detection and allowed for the growth of the fire, precluded firefighting and evacuation efforts, and directly led to the high number of fatalities in the accident,” the report stated.

Blamed were both shipowner Truth Aquatics’ lack of oversight of the vessel and crew operations and also the lack of a Coast Guard requirement for more smoke detectors and the daytime Coast Guard inspections that had no means to verify compliance on a nighttime patrol.

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Though the Conception had two escape exits from the bunkroom area, they both came out in the galley. In hindsight, an escape to the outer deck would have allowed the passengers to escape, the report noted.

NTSB investigators put the blame for the 34 deaths squarely on Truth Aquatics. The shipowner had lacked crew training, emergency drills, and the roving night patrol for some time, the report stated. “If the company had been actively involved in ensuring the safe practices required by regulations were enforced … it is likely this accident would not have happened.”

Many of the investigators’ questions went unanswered, according to the report. Both the crew and the owner deferred many questions to the Conception‘s captain, Jerry Boylan, who had operated the ship for decades. Out of deference to a criminal investigation by the U.S. Attorney’s Office, the NTSB waived those questions. As well, documents, records, security cameras, and such items as smoke detectors were seized by the U.S. Attorney Office and were not available to the NTSB, the report stated. 

The report ruled out sea conditions and alcohol and drug use by the crew as factors in the incident. The fire’s origin was thought to be in the aft portion of the salon, but the report could only guess at the most likely source of ignition — the Conception‘s electrical system, unattended batteries being charged, improperly discarded smoking materials, or “other” factors. 

As part of its mission to prevent similar disasters in the future, the NTSB report ended with recommendations for changes to federal regulations for small passenger ships: smoke detectors in all accommodation spaces, connected smoke detectors that all sound if one sounds, a protocol to ensure a roving patrol takes place, and requirement of an unobstructed secondary escape outlet.

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