An Analysis of the NTSB’s Preliminary Report on the CONCEPTION Tragedy
Originally posted on https://www.ss-pc.com/an-analysis-of-the-ntsbs-preliminary-report-on-the-conception-tragedy/
This morning, September 12, 2019, the National Transportation Safety Board (NTSB) issued its Preliminary Report regarding the major marine casualty involving the tragic, deadly fire onboard the dive boat CONCEPTION. The NTSB was named as the lead federal agency for the safety investigation and mobilized an investigation team after this incident and has joined the United States Coast Guard as well as law enforcement agencies, in investigating this tragedy.
The National Transportation Safety Board is an independent Federal agency charged by Congress with investigating significant accidents involving marine transportation. Because the CONCEPTION tragedy falls within the purview of the NTSB’s mandate, the NTSB is the investigating agency of this tragedy. During a NTSB investigation, the Board will attempt to determine the probable cause of the incident and will issues safety recommendations aimed at preventing future accidents.
The National Transportation Safety Board is engaged in an active investigation of the CONCEPTION tragedy. The NTSB has already interviewed the survivors and other witnesses, as well as having inspected similar vessels, and obtained documents from the CONCEPTION’s owners.
The National Transportation Safety Board’s preliminary report indicates that at the time of the fire, there were no crew members awake, on watch, or acting as a roaming guard onboard the vessel, as is required for the safety of the passengers. The preliminary report reveals that the five crewmembers who did not suffer fatal injuries were all asleep in the wheelhouse at the time of the fire.
The preliminary report also reveals that the design of the CONCEPTION had one stairway leading to the lower bunk room where all the passengers and one crew member were asleep, and where they all tragically lost their life. The report also indicates that while there was a safety escape hatch from the bunk room, the escape hatch did not exit to the exterior of the vessel, nor did it exit to a different area of the vessel from the stairway. As a result, there was no acceptable alternative means of escape from the bunkroom in this incident. Both exits culminated in the galley, which, according to the preliminary report, became engulfed in flames. The fire which was not detected immediately upon its ignition by the sleeping crew, nor identified by any fire suppression or vessel wide fire detection system, grew to engulf the galley, rendering both the stairway and the nearby escape hatch unusable.
The preliminary report indicates that there were only two local smoke detectors in the bunk room, but they apparently were not a part of a fire safety system, nor were they a part of a boat wide fire warning system. As a result, if or when the smoke alarms activated, the sleeping crew would not be alerted to their activation because they were local alarms, and not a part of a vessel wide system. Further, there was apparently no fire suppression system onboard, which was or could have been activated to address the fire when it was identified. There is also no indication in the preliminary report that the crew had fire extinguishers, fire hoses, or other fire safety equipment available to them, or which they attempted to use, during this incident.
The Board will likely be investigating whether the CONCEPTION was in compliance with all fire safety standards and contained all of the required safety equipment and fire suppression systems onboard. The preliminary report makes no mention of the CONCEPTION being outfitted with an automatic fire suppression system, makes no mention of fire extinguishers, and, apparently, the crew made no attempts to fight the fire before they evacuated the vessel. The Board will also be looking at the CONCEPTION’s owners, and the policies and procedures they set out, and what, if any auditing procedures they employed to ensure that their policies and procedures were being followed by the crew, with regards the crew’s watch standards, and the use, upkeep and maintenance of any fire equipment that may have been onboard.
These tragic results of this incident appear to have been preventable. While the cause of the fire will not be known until the investigation is complete, it appears that the CONCEPTION lacked adequate safety and fire systems to address a fire such as the one which occurred. Based on the information contained in the preliminary report, it appears that had the owners and crew implemented various safety systems, any fire could have been identified early, and likely in time to allow the passengers to escape the bunkroom. If there had been a vessel wide fire suppression system, or a vessel wide alarm, the crew may have been alerted to the fire in time to save the lives of the passengers. If any of the crew had been awake, standing watch, and roaming the vessel looking out for the safety of the passengers, it is likely that the fire would have been identified early enough and in time to save the passengers. If the vessel would have been equipped with an escape hatch to a different area of the vessel, away from the main stairway, the passengers likely could have escaped.
Stepp & Sullivan, PC is a maritime law firm, with extensive experience in Maritime casualties, casualties involving Coast Guard and National Transportation Safety Board investigations, Limitation Act suits, and has experience in handling thousands of serious injury and wrongful death maritime claims during the past 35 years, including claims from crewmembers, passengers, and bystanders
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