NTSB Report on Dive Boat

This was an incident that should have never happened. This incident is also responsible for insurance companies going ape ****, costing recreational.


https://gcaptain.com/conception-div...139820873&mc_cid=2b961212c7&mc_eid=5b70bcca05

No overnight fire watch?

I would like to hear from Pau Hana whether commercial accidents affect and how much recreational vessels.

This incident is why I don’t go on overnight trips on boats that are not in my control. The secondary exit was a joke. It was on top of a 3 high bunk. You would have had to get into the bunk and lay on your back and climb up out. And it was a very small exit at that. The regulations absolutely need to be changed and if the boats can’t comply then they need to be removed from service. Not having someone on watch is inexcusable. Also there needs to be regulations on charging portable equipment since this is most likely the cause of the fire. Very sad situation.

Hope these A-holes go down hard!

“Captain in California dive boat fire indicted on 34 counts of manslaughter
Prosecutors alleged the captain failed to set a roving patrol, failed to conduct fire drills and failed to sufficiently train his crew.”

Read in Los Angeles Times: https://apple.news/AODrpy1XTSICJ5uskVUqz0w

Well, that is a start. They really need to update the laws and regulations concerning these type of charters. Too bad about all the lost people. Heartbreaking.

Copied from post #5.....


"Prosecutors alleged the captain failed to set a roving patrol, failed to conduct fire drills and failed to sufficiently train his crew.”


Maybe following existing rules is adequate.....more laws aren't always the answer.

psneeld said:

Copied from post #5.....
"Prosecutors alleged the captain failed to set a roving patrol, failed to conduct fire drills and failed to sufficiently train his crew.”

Maybe following existing rules is adequate.....more laws aren't always the answer.

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I find it totally unbelievable the captain did not have at least one roving watch both during the night and also the day.
AND no fire drills or life boat drills as currently required on cruise ships and US Navy ships.

Like a lot of laws and rules, they need to be enforced rather than writing more.

psneeld said:

Copied from post #5.....


"Prosecutors alleged the captain failed to set a roving patrol, failed to conduct fire drills and failed to sufficiently train his crew.”


Maybe following existing rules is adequate.....more laws aren't always the answer.

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Agree, more laws regarding watches, training and drills won't cure negligence and incompetence which the captain is guilty of and will pay the price for.

However there were glaring problems with the boat as well. An escape route that lead to the same area as the main access. Escape via a small hatch over an upper bunk. Why the boat was built that way and deemed fit for it's intended service by all parties, owner, insurance and USCG inspectors is beyond me. The captain also bears responsibility in that. It's part of the captain's job to ensure the boat is safe and to bring deficiencies to the attention of the above parties. But the buck shouldn't stop with the captain. All parties need to be held accountable.

If the captain had done what he was supposed to do maybe the fire would have been put out before it became a disaster. Maybe not. And once it got going those in the bunk room didn't stand a chance. The laws that govern that kind of construction do need to change.

Portage_Bay said:

However there were glaring problems with the boat as well. An escape route that lead to the same area as the main access. Escape via a small hatch over an upper bunk. Why the boat was built that way and deemed fit for it's intended service by all parties, owner, insurance and USCG inspectors is beyond me.

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I agree that this is an area where the USCG regs need to be enhanced. This doesn't relieve the captain from any of his obligations, or reduce the severity of his neglect, but I do think that if a boat requires two points of egress, which this one did, those need to lead to different spaces. It seems the biggest defect in the boat design is that both exit paths led to the same burning salon.


Also, I believe the charges claim there was inadequate fire alarming, and the fact that the fire was raging before anyone noticed certainly supports that. It seems completely reasonable to require comprehensive fire alarms on a boat.


So I think some regulation enhancement is called for, in addition to enforcement of existing regs.

In a past life I worked for the company that sold and serviced the main engines for their vessels, and I recall an event where one of their vessels, when coming in for a landing at their dock they crashed the dock, and immediately the blame was made on the machinery "no response from the engine/transmission controls".

We sent techs, and after several trials no trouble found, however we did find that the actuator for the gear was rated only slightly above the manufacturers spec/requirement for shift actuation torque requirement.

The customer (Truth Aquatics) insisted our technician told them verbally that "it would be fine", and that any faults, damages, or courses of repair were entirely ours as a vendor, and proceeded to threaten a lawsuit.

At that time since I was a lowly manager I just handed it to Sr. Management and walked away from the problem. I don't recall the outcome but it was a rather ugly situation overall, and we were instructed to never do business for them again.

Prior to the falling out I remember that they were rather hard to deal with (being charitable), and I was relieved to be done with them when the time came!

To me it seems they had a chronic problem with "holier than thou" attitudes, that now appears to have come to rest on their heads.

My deepest sympathy goes out to the people and families that have suffered loss in this tragedy.

Mako said:

Hope these A-holes go down hard!

“Captain in California dive boat fire indicted on 34 counts of manslaughter
Prosecutors alleged the captain failed to set a roving patrol, failed to conduct fire drills and failed to sufficiently train his crew.”

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Let's crucify the Captain for no fire suppression system on the boat, no fire fighting equipment on the boat, no smoke detectors in the berthing compartment, no escape access from the berthing compartment..
Yep. 20 years in prison will fix all the problems.

NTSB has completed ignored the probable reason fore the wire claiming there was no evidence because the boat burned to the waterline. Most technical people have agreed that charging everyone's laptops, cell phones, dive computers, etc from 1 outlet was the likely source of ignition. Everything followed from that. NTSB should have addressed it.

Captain was certainly negligent, but the designer/builder of the boat was off the charts negligent.

SoWhat said:

Let's crucify the Captain for no fire suppression system on the boat, no fire fighting equipment on the boat, no smoke detectors in the berthing compartment, no escape access from the berthing compartment..
Yep. 20 years in prison will fix all the problems.

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Well, it's good thing then that he's NOT being charged with any of that.

SoWhat said:

NTSB has completed ignored the probable reason fore the wire claiming there was no evidence because the boat burned to the waterline. Most technical people have agreed that charging everyone's laptops, cell phones, dive computers, etc from 1 outlet was the likely source of ignition. Everything followed from that. NTSB should have addressed it.

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What actual evidence is there that that was the cause? Everything I've head is just arm-chair speculation. "I heard about it on the 787, so it must be what happened here". "Maybe it was lithium batteries", and turns into "it was lithium batteries"

SoWhat said:

Captain was certainly negligent, but the designer/builder of the boat was off the charts negligent.

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And the captain is being charged for his specific points of negligence, as seems appropriate.


You say there was no firefighting equipment on the boat? Are you sure about that? It's CG regulation even for recreational vessels, and I believe they had been recently inspected and were fully compliant. I haven't heard of any required equipment that failed or was missing. Has anyone else? So it's hard to fault a builder and operator for running a compliant inspected boat. Now a good operator would perhaps go above and beyond. But I think this really brings us back to the areas where the regulations are weak and should improved. It's not a question of enforcement, it's a question of what's required.

Well the captain is responsible for everything that happens on a cruise. Even if he wasn’t aware of the problem, because he should have been aware of the problem. He absolutely was responsible for the lack of a roving patrol and the lack of training. Yes the design of the boat sucks and part of that problem is on the shoulders of the CG and the designer of the boat, or someone that maybe modified the boat. The regulations and applicable laws need to be changed. The photos of the second escape hatch show an unfortunately bad design that wouldn’t function in an emergency. The boat builders and buyers have to design a boat that has readily accessible and usable escape routes. But unfortunately that will not be done until it is mandated by either laws or regulations. I sincerely hope that this tragedy helps spur those changes.

Plus...was the boat designed and built for what it was being used for?

Many commercial vessels are retreads as far as use goes....if it met the minimums required by the USCG....might be hard to assign blame back to the designer and builder, even the captain...yet he can be blamed if required equipment was not working properly.

Does she have a sister ship?
I suspect the USCG, NTSB and the insurance companies would like to inspect it too.

Were the upper berth approved in the original plans?

The buck stops at the Captain. He could have demanded things change or leave the boat.

Here's a link to its final COI: https://dms.ntsb.gov/public/64000-64499/64213/638774.pdf

It was equipped with a fire pump and two 1.5 inch hose boxes, along with the usual dry chemical extinguishers and the engine room fire system.

Interesting that the COI specifically calls out the requirement for a roving watch all hours while the bunk areas are occupied. Admittedly, I haven't personally read a lot of COIs for passenger vessels, just some, but I've never seen that language. This should be a T boat and that requirement is already in the subchapter. I wonder if this language was mitigation for some concern about the egress, or something else.

If the captain wasn’t fully satisfied with the boat as it was equipped and maintained then he had the choice to refuse to captain it. That is the choice that the CG and the CG Aux drill into every coxswain and it also applies to every captain, recreational or paid.

Comodave said:

If the captain wasn’t fully satisfied with the boat as it was equipped and maintained then he had the choice to refuse to captain it. That is the choice that the CG and the CG Aux drill into every coxswain and it also applies to every captain, recreational or paid.

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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.

twistedtree said:

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.

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That's why I said accountability shouldn't stop with the captain. I'm not cutting him any slack on training and drills. Roving watch? I'm not sure about that. It depends in part on the work load the business, created by the owner and or manager, puts on the crew. Who's gonna stay up all night if everyone has worked all day?

OldDan1943 said:

Does she have a sister ship?
I suspect the USCG, NTSB and the insurance companies would like to inspect it too.

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The sistership, owned by the same co. was an integral part of the investigation. The Captain is a sacrificial lamb, offered up defect blame from the lack of enforceable regulators and makes it appear as though someone is doing something.

In fact, no regulations have been changed and NTSB can only make recommendations.

USCG certified this vessel as safe. The Commanding Officer of the unit that signed off on it should be charged along with the ship's captain.

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.

twistedtree said:

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.

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Assuming he was a diligent captain, I will bet he wished he had walked away now. Sure it is a difficult position but that is the position and he knew what the responsibilities were when he took the job. So saying that it wasn’t his responsibility doesn’t work, for me at least. You want too be the captain, own the responsibility.

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?

sowhat said:

the sistership, owned by the same co. Was an integral part of the investigation. The captain is a sacrificial lamb, offered up defect blame from the lack of enforceable regulators and makes it appear as though someone is doing something.

In fact, no regulations have been changed and ntsb can only make recommendations.

Uscg certified this vessel as safe. The commanding officer of the unit that signed off on it should be charged along with the ship's captain.

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fwiw

according to the company owner and former captains of truth aquatics vessels, the captains of the conception, vision, and truth were given broad authority over the operations of their vessels, to include the hiring, training, and dismissal of crewmembers, the conduct of routine maintenance, and the establishment and enforcement of vessel operating procedures. The owner stated that there were no company-wide operating procedures or crew work/rest policies; these were left to the
qualified captains of each vessel to establish and manage.

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Comodave said:

So saying that it wasn’t his responsibility doesn’t work, for me at least. You want too be the captain, own the responsibility.

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ghost said:

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?

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There's no mention of them in the factual report that I've found, though I didn't read through every attachment. One crewmember witness thought he heard a faint beeping during the early moments of the emergency but couldn't specifically identify what the noise was. I don't think prior subchapter T required them, though insurance might.

ghost said:

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?

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I'm not sure what fire alarms are required on a boat like that. Anyone know?

SoWhat said:

The sistership, owned by the same co. was an integral part of the investigation. The Captain is a sacrificial lamb, offered up defect blame from the lack of enforceable regulators and makes it appear as though someone is doing something.

In fact, no regulations have been changed and NTSB can only make recommendations.

USCG certified this vessel as safe. The Commanding Officer of the unit that signed off on it should be charged along with the ship's captain.

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A five year inspection has specific criteria including that the conditions required when the vessel was manufactured are still being adhered to, as well as some of the other, possibly newer regulations such as crewing and required safety equipment. If this boat had been substantially rebuilt post-1996, when many USCG regulations were updated, the egress paths might have been required to be different. As it was, they were considered safe under the rules that were in place when it was manufactured in 1981. The language in the conditions of operation signals to me that the CG wanted to emphasize the need for a lookout while the spaces below were occupied for sleeping, possibly to mitigate some concern they might have had about those spaces, since that requirement already exists in the regulation I don't understand why else they would restate it in the operating conditions.

Subchapter T places the requirements for training, drilling, watchstanding procedures etc. on the Master, not the owner. Certainly not on the US Coast Guard.

twistedtree said:

I'm not sure what fire alarms are required on a boat like that. Anyone know?

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Actually, I was wrong. Subchapter T vessels are required to have an automated smoke alarm in all enclosed overnight accommodation spaces, and either an alarm or automated fixed gas fire extinguishing systems in engineering spaces.

In this case, having a smoke alarm(s) in the bunk space when the fire had already spread significantly in the spaces above which weren't required to have smoke alarms, was probably moot