NTSB Report on Dive Boat

[Comodave]

I’m short on details and investigation here, so don’t roast me. But, didn’t it have a smoke detector? I can’t even overcook bacon at home without dealing with one. Even if the fire is advanced too far to fight, why didn’t they at an absolute minimum have time to know it’s as happening? To escape?

On my 41’ boat I have 5 smoke detectors that are linked wirelessly. I will be adding 2 more because I am adding a house bank inside a cabinet in the salon, so it will get a detector and one on the flybridge so I can hear if they activate while I am at the helm. It would seem that a boat with that many lives on board would have a better system for smoke detection than I do. I was removing a through hull that had wood backing plate and I used a multi tool to cut it. It made some small amount of smoke. The alarms started going off and in the end I had to remove the batteries from all of them to get them to be quiet. I am not familiar with the smoke detector required on that boat, but it should be better than what they had or didn’t have.

 

[OldDan1943]

I suggest, smoke and CO detectors

 

[bligh]

Also there needs to be regulations on charging portable equipment

What? iPhone charger police?

 

[ghost]

I mean, like smoke detectors are cheaper than dirt. Oh I’m sure “marine” branded are a bit more, but still cheap. I thought I recalled the charging station was like near the galley, so like does that mean they didn’t even have one in a likely location to need one?

Look hindsight and armchair quarterbacking and all that, but to lose that many people over twenty bucks worth of fire alarms is truly tragic. I wouldn’t think I would want to try to explain that in front of a jury. Worse, I wouldn’t want to try to tell myself years later, late at night, that I had done everything I could. These things come back to haunt you.

I’ve spent enough time being responsible for people on and in the water on dive boats. I’ve unfortunately seen people who did not make it first hand, luckily not on my watch, but to a very capable close friend. Wasn’t his fault, he wasn’t the one who screwed up. Didn’t really matter. The shoulda coulda’s eventually come calling. The lives destroyed are not just the victims. All I really know is this, complacency is vastly underestimated. Ironically, those with the most experience are often the hardest hit. I worried so much more about the simple routine things. Something complicated, everybody was on their A game. But sleeping, yeah, it makes sense. Everyone gets relaxed, but the dangers never really go away.

This sucks and it hurts.

 

[Comodave]

What? iPhone charger police?

Yes, on commercial boats. They can easily limit how many things are charged in an area. Some reports had many, many things being charged in the area that caught fire. Some scooter batteries, and other miscellaneous things. On your boat do what you want but on commercial boats where others lives are in the hands of the crew there need to be some safety requirements. This may be a prime example of why. Remember the Samsung (I think) phones that would catch fire?

 

[twistedtree]

Shifting the topic a bit, it would be interesting to hear what changes people have made to their boats or operations as a result of the Conception fire. It's certainly raised my attention to boat fires. Has anyone added fire alarms, built escapes, or anything else?



I can think of a few things I've done.


- I have started to make a habit of always removing larger batteries like power tool batteries from their charger once they are charged. This is both at home and on the boat. I think it's a simple safety precaution.


- On the boat build we are completing, there was a lot of review of escape routes from various parts of the boat, especially the cabins on the lower level. The only way out of each cabin is through the door to a common hallway. Some boats have installed ceiling hatches to get out, but that was not possible given the layout of our boat. Also, the hatches would have exited to the same place that the hallway does, and we learned the lesson on that with Conception. So instead the alternate route out is down the hallway aft, through the ER, into the laz, then out the hatch into the cockpit. So two paths out, leading to different parts of the boat. The problem we encountered, and others might want to look at this, is that it's not possible to unlock the hatches from inside. They can only be opened from the outside. We looked at a couple of solutions, and ultimately settled on one that they yard dreamed up.


- I'm in the process now if designing the smoke and CO alarm system. The smoke detectors are combo smoke and heat rise detectors. In addition to the living space and engine room, I'm also locating them inside each electrical cabinet where there are breakers and switches, figuring those are higher probability locations for a fire to start. And I'm putting one inside the battery enclosure. Any detector going off will sound a central wake-the-dead sounder.

 

[SoWhat]

- I'm in the process now if designing the smoke and CO alarm system. The smoke detectors are combo smoke and heat rise detectors. In addition to the living space and engine room, I'm also locating them inside each electrical cabinet where there are breakers and switches, figuring those are higher probability locations for a fire to start. And I'm putting one inside the battery enclosure. Any detector going off will sound a central wake-the-dead sounder.

What is supplying power? What happens if a fire cuts the power source?
What happens if the connection to the central alarm corrodes? Can you get out the hatch of your sleeping berth?

Nobody plans on having an accident or a fire, and all the tech equipment can fail. Have a lot of redundancy and a well practiced escape drill.

 

[rslifkin]

I'll be adding a set of linked smoke detectors on my boat this winter. Just trying to confirm placement and how many units I'll need before I pull the trigger.

This incident has made me give some real thought to escape routes from the aft cabin. There is no escape hatch back there (window onto the aft deck above the bunk doesn't open). So I'd like to figure out a way to install a better solution than sliding a side window open, popping out a screen and squeezing through (which isn't the easiest climb, and it's onto the narrow side decks).

 

[Portage_Bay]

Shifting the topic a bit,......
- On the boat build we are completing, there was a lot of review of escape routes from various parts of the boat, especially the cabins on the lower level. The only way out of each cabin is through the door to a common hallway. Some boats have installed ceiling hatches to get out, but that was not possible given the layout of our boat. Also, the hatches would have exited to the same place that the hallway does, and we learned the lesson on that with Conception. So instead the alternate route out is down the hallway aft, through the ER, into the laz, then out the hatch into the cockpit. So two paths out, leading to different parts of the boat. The problem we encountered, and others might want to look at this, is that it's not possible to unlock the hatches from inside. They can only be opened from the outside. We looked at a couple of solutions, and ultimately settled on one that they yard dreamed up.

Escape routes are a very important part of fire planning. It's good that you've identified the problem and found a solution. But your route sounds challenging at best should you really need to use it in a fire. I can think of a couple of things I'd do to improve my chances.

First actually practice, drill, using the route, in the dark, no flashlight. Can you, all of you aboard, find your way out to safety by touch and memory? You might have to. Remember drills and training were cited as a big part of the problems with the dive boat fire.

Second I'd consider breathing assistance to buy more time to get out. There are emergency escape breathing devices like the Ocenco M-20.2 Emergency Escape Breathing Device. Or a mask and filter like theiEvac the only American Certified Smoke Hood/Fire Mask. Or a simple mask like the Anti-Fire Smoke Mask Safety Escape.

I'm interested to learn what you come up with for fire detection. Please post your design when you have it finalized.

 

[Portage_Bay]

Portage Bay, Maybe 4 hrs on watch 4, 6 or 8 hrs off then start the new day.

And a roving or roaming watch does not mean sitting in a chair.

Checking for fires and flooding and other unsafe conditions. There should be a written commentary of each tour.

Yes, that works. IF you've got the crew to do it. Too many small boats also have small as in understaffed crew. If the work load is such that everyone is busy all day for a long day who will stand the roving watch? Another common issue on small boats carrying lots of passengers is no good place for the night watch to rest.

Please don't misunderstand me. I'm not cutting the captain any slack. His hide has been nailed to the wall as it should be. I'm saying there is always more to the story. The owner and manager business practices need to be examined and if they were part of the problem need to be held accountable. All too often the focus is on keeping profits up before running a safe operation. One way to do that can be to run with the smallest crew the COI allows and work them as hard as you can.

Another way the owner and manager fell down on the job is they should have monitored the captain's drills and crew training. Spotted he wasn't doing his job and addressed that.

I tried my hand at running a dive boat. I didn't last long because the risks were just too high.

 

[OldDan1943]

Many years ago, I did a couple week long dive trips on the Nekton.
I do not recall any drills nor the location of any PFDs or life boats.
The boat is no longer in service but, it was a great boat for diving.
In hindsight, I personally should have asked LOTS of questions.

 

[Comodave]

When we bought our current boat the PO had removed the escape hatch from the aft cabin which left only 6, 5”x12” portholes, that I certainly had no chance of getting through. The first, absolutely first, thing I did was cut the deck open and replace the hatch. I did that the second day I was on the boat and I didn’t sleep well that first night either. I thought that was good enough but after the Conception incident I thought that I had better try to climb out of the hatch. I found it almost impossible to get up and out of the hatch, and I had been so satisfied when I put the hatch in. I bought a small 3 step ladder and found that I could set it on the bed and even though it is a bit unsteady it makes it possible to get out of the hatch. It folds flat and stores below the berth on top of all the other stuff there.

Then I added 5 linked smoke detectors, aft cabin, salon, forward cabin, engine room and behind the electrical panel. I am moving the house bank from the engine room to the salon in a cabinet for the new lithium batteries. So I will add 2 more linked smoke detectors, in the cabinet with the lithium batteries and on the flybridge so when we are underway we can hear the alarms if they go off.

The Conception was an eye opening event. It really makes one think about the possibility of a fire aboard. It also makes me more certain that we will never go overnight on a vessel that isn’t in our control. It also makes one sad about the lives lost and the loved ones left behind from the tragedy.

 

[twistedtree]

Rather than answering questions here about the fire and CO alarm system that I'm designing, I started this new thread. I'm very interested to get feedback and suggestions on it.


Thanks

 

[twistedtree]

Escape routes are a very important part of fire planning. It's good that you've identified the problem and found a solution. But your route sounds challenging at best should you really need to use it in a fire. I can think of a couple of things I'd do to improve my chances.

First actually practice, drill, using the route, in the dark, no flashlight. Can you, all of you aboard, find your way out to safety by touch and memory? You might have to. Remember drills and training were cited as a big part of the problems with the dive boat fire.

Second I'd consider breathing assistance to buy more time to get out. There are emergency escape breathing devices like the Ocenco M-20.2 Emergency Escape Breathing Device. Or a mask and filter like theiEvac the only American Certified Smoke Hood/Fire Mask. Or a simple mask like the Anti-Fire Smoke Mask Safety Escape.

I'm interested to learn what you come up with for fire detection. Please post your design when you have it finalized.

I agree, and like the idea of breathing hoods. We have talked about keeping two in each cabin, but of course haven't done it. Now's the time!

 

[BandB]

That's true on paper, but in practice it means walking away from your livelihood, so unlikely to happen. It places a captain in a very difficult position.

Why is it unlikely to happen? We will do something we know endangers others to keep a job? That's really a sad indictment. I know several captains who have walked away, who have refused to do what owners said. Yes, it's hard to walk away but we all face decisions in life and it's not just in these type jobs. Business executives, accountants have to decide whether to do things the right way or cheat. And when they choose their job over doing the right thing, hundreds and thousands get hurt. When they choose to become whistleblowers, ultimately they may collect big, but meanwhile get threats to their life.

It's no different than "I was just doing what I was ordered to do."

You're responsible for your own actions.

 

[BandB]

I toss out another target for blame. The lack of regular spot inspection. We need safety inspections at the docks, before boats go out though some combination of CG, state and city. I imagine in addition to their CG licenses, there are also business licenses on most. It would have taken someone less than 30 minutes to find out that boat had serious weaknesses when it came to safety. Let's do more prevention and not just incident investigations.

 

[Alaskaflyer]

2019: Coast Guard marine inspectors conducted 21,471 inspections aboard U.S.-flagged vessels, including inland towing vessels, and identified 31,738 deficiencies. The rate of deficiencies identified per inspection increased from 1.26 to 1.48, about a 20.5 percent increase. The Coast Guard has a staff of 671 marine inspectors—533 military and 138 civilian—who are responsible for inspecting U.S.-registered passenger and cargo vessels, foreign-flag vessels calling at U.S. ports, mobile offshore drilling units, and towing vessels and barges carrying hazardous cargoes.

 

[twistedtree]

Another thing that I don't think has come up is the number of people on the boat. I'm not trying to say that fewer people might have prevented the fire - I'm just surprised it was so crowded. The boat was what, 75'? I can't image 35 people bunked up in a 75' boat. And the CG certification was for 103 (including crew). Maybe I don't have a good reference point, but that seems like an awful lot of people.

 

[Comodave]

The bunk room was stacked 3 high and went on for many rows. It would have been crowded during normal times, much less in an emergency.

 

[twistedtree]

Why is it unlikely to happen? We will do something we know endangers others to keep a job? That's really a sad indictment. I know several captains who have walked away, who have refused to do what owners said. Yes, it's hard to walk away but we all face decisions in life and it's not just in these type jobs. Business executives, accountants have to decide whether to do things the right way or cheat. And when they choose their job over doing the right thing, hundreds and thousands get hurt. When they choose to become whistleblowers, ultimately they may collect big, but meanwhile get threats to their life.

It's no different than "I was just doing what I was ordered to do."

You're responsible for your own actions.

I'm not trying to suggest it's the right thing to do. Just acknowledging the flip side when you have a family, no savings, debt and bills, and are living paycheck to paycheck. This was a topic among the professional captains in one of the classes I took a while back. All agreed that if they refused home-office requests due to captain's judgement, their bag and a replacement captain would be waiting at the next dock. Most people live with no cushion, and that gives employers a lot of leverage over them. Some abuse it.

 

[OldDan1943]

Folks said, the captain was afraid he might lose his job if he pointed out safety issues.
Well. after 34 folks died, he doesn't have to worry about losing his job.
Now he doesn't have a job, a captain's license and he has to worry about how many years he will get, in prison.
I guess he would have been better off if he did complain or refused to sail.

 

[Comodave]

Folks said, the captain was afraid he might lose his job if he pointed out safety issues.
Well. after 34 folks died, he doesn't have to worry about losing his job.
Now he doesn't have a job, a captain's license and he has to worry about how many years he will get, in prison.
I guess he would have been better off if he did complain or refused to sail.

Absolutely. You have to accept responsibility or don’t take the position.

 

[BandB]

I'm not trying to suggest it's the right thing to do. Just acknowledging the flip side when you have a family, no savings, debt and bills, and are living paycheck to paycheck. This was a topic among the professional captains in one of the classes I took a while back. All agreed that if they refused home-office requests due to captain's judgement, their bag and a replacement captain would be waiting at the next dock. Most people live with no cushion, and that gives employers a lot of leverage over them. Some abuse it.

Yes, it's a risk to captains. Crew risks captains giving them inappropriate orders. But then it's a risk on any job. Store clerks get told to lie to customers or to falsify their time records. I appreciate the difficult circumstances, but in any field carefully selecting employer is important. I wish there were better places to turn to report such owners. I would love to see some way for captains to report such to the CG and they would take action. We don't provide enough protection for those jobless in these situations.