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The commercial dive boat Conception at sunrise prior to sinking, September 2, 2019. (Source: Ventura County Fire Department)

The commercial dive boat Conception at sunrise prior to sinking, September 2, 2019. (Source: Ventura County Fire Department)

NTSB Urges Coast Guard to Act on Passenger Vessel Safety Recommendation

Mike Schuler
Total Views: 4753
August 31, 2023

The National Transportation Safety Board is renewing its call for the U.S. Coast Guard to strengthen passenger vessel safety in response to 2019 fire aboard the dive boat Conception that claimed the lives of 34 people.

Now four years after the tragedy, the NTSB’s recommendation to the Coast Guard to require safety management systems (SMS) for passenger vessels remains open.

NTSB Chair Jennifer Homendy sent a letter to the Coast Guard Commandant today emphasizing the need to issue the regulations within 30 days.

“While the Coast Guard has implemented so many of our recommendations from the Conception investigation, we’ve yet to see the necessary action taken on one of the most important ones: safety management systems,” said NTSB Chair Jennifer Homendy. “We’ve been advocating for SMS on passenger vessels for nearly two decades. The public can’t afford to wait any longer.”

The Conception was anchored in Platts Harbor, off Santa Cruz Island, California, when it caught fire in the early morning of September 2, 2019, as passengers and a crew member slept below deck. The vessel burned to the waterline and sank less than 100 feet from shore.

All 33 passengers and one crewmember died of smoke inhalation after they became trapped in the berthing area while the fire raged on the deck above. Both exits from the berthing area were blocked by smoke and fire.

The NTSB concluded that had an SMS been implemented, the owner and operator of the Conception, Truth Aquatics, could have identified unsafe practices and fire risks on the Conception and taken corrective action before the casualty occurred.

As a result of the investigation, the NTSB issued 10 new safety recommendations: seven to the U.S. Coast Guard, two to associations that have members operating small passenger vessels with overnight accommodations, and one to Truth Aquatics, Inc., the operator of the vessel. The NTSB also reiterated its 2005 recommendation for the Coast Guard to require all U.S.-flag passenger vessels to implement a safety management system.

An SMS is an enterprise approach to risk management. It is a formal organizational tool, comprising policies, procedures, checklists and corrective measures to ensure that vessel crews are operating a vessel in accordance with regulations, company requirements and best practices, with a goal of continuous improvement.

Since 2005, the NTSB has investigated four passenger vessel accidents, including the Conception, where the lack of an SMS was an issue.

In December 2021, the Coast Guard issued interim rules addressing many of the recommendations issued by the NTSB issued as a result of the investigation, but not for the SMS recommendation. The Elijah E. Cummings Coast Guard Authorization Act of 2020 mandates that the Coast Guard carry out all of the NTSB recommendations issued or reiterated as a result of the Conception investigation.

The NTSB has advocated for SMS for passenger vessels since 2005, and in 2010, Congress explicitly granted the Coast Guard the authority to require such systems. Progress has been stalled since January 2021 when the Coast Guard took initial steps to address the NTSB’s recommendation.

The NTSB has recommended SMS in nearly all modes of transportation—aviation, rail and transit, pipelines, and marine—as well as for manufacturers. In 2015, the Federal Aviation Administration implemented a requirement that commercial airliners develop a comprehensive SMS to improve safety for the flying public. This lifesaving mandate has contributed to the remarkable record of safety in commercial passenger aviation since then.

The NTSB previously called out the lack of progress in implementing safety recommendations resulting from the Conception fire in September 2022, indicating that only one of the three associations with members operating small passenger vessels with overnight accommodations had implemented the NTSB recommendations.

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