The tragedies of Conception's fatal fire
Lessons are always learned in a catastrophic case because we are forced to analyse what went wrong and how it can be prevented. Today, our diving world is already different because of the Conception’s fatal fire. Changes have and are being made.
Why does it seem we need a horrendous accident for common sense safety changes to be made? Looking back in history, two tragedies come to mind, which resulted in significant changes to safety protocols. One was the sinking of the Titanic and another, more recently in 2010, the “Station” nightclub fire in the US state of Rhode Island. It took the loss of 100 souls for the National Fire Protection Association (NFPA) to re-write policies, and issue new code provisions in 2006 for fire sprinklers and crowd management in nightclub-type venues.
The Station nightclub fire
On 20 February 2003, an audience of 462 people (the nightclub was licensed for 404) initially mistook a blaze caused by a pyrotechnic display as a special effect. The fire reached the ceiling in 25 seconds. The band, realising there was something wrong, stopped playing after 30 seconds. Within less than a minute the stage was engulfed in flames and the fire alarm had been sounded. Although the club had four exits, human nature took over and the majority of the audience instinctively headed down a narrow corridor, towards the entrance they came in.
“Everyone for themselves.” — Robert Feeney, “Station” nightclub fire survivor
It took less than 100 seconds after ignition for the resulting bottleneck to become a crush. Some people were trampled. The corridor became impassable and a tangled mess of 31 prone bodies quickly blocked the exit. They died within minutes. Another 27 people died inside the club near the vicinity of the narrow corridor. This was possibly because a security guard had stopped the audience from trying to escape via the stage exit, saying that it was “for the band only” and “you have to go out the front [exit].” The bouncer too died in the fire. The building was constructed in 1946. Depending on which report you read, there is a difference in opinion as to whether the nightclub was exempt from fire sprinkler system requirements.
We do know the club did not have a sprinkler system, and the West Warwick fire inspectors did not pick up on this. Following an investigation by the National Institute of Standard and Technology (NIST), it was found that a sprinkler system would have controlled the fire for over five minutes, potentially giving everyone the chance to evacuate the club. As a result of this fire, the Chattanooga City Council passed a bylaw by one vote that required fire sprinklers to be installed in the city’s nightclubs.
Yet, just a handful of years later, in 2013, the Chattanooga City Council reversed their decision. They passed an ordinance that now frees most bar and club owners from installing fire sprinkler systems in their businesses because “this saves them added cost that hurts small businesses.” I do hope that we never find out just how costly this decision will be in the future.
In 1912, this iconic ocean liner sailed on her maiden voyage carrying just 20 lifeboats: two wooden cutters (40 pax capacity), 14 standard lifeboats (65 pax capacity) and four collapsible canvas lifeboats (47 pax capacity). Chief designer, Alexander Carlisle, had originally planned 48 boats (three per davit), but these were reduced for cosmetic reasons. In all, the lifeboats were capable of accommodating a total of 1,178 people, or 33 percent of the ship’s total passengers and crew.
This figure may sound as though White Star personnel were incompetent. They were not. Crucially, RMS Titanic was following the safety regulations of the day and complying with the Board of Trade laws. However, these laws had not been updated to reflect ships of Titanic’s size. We all know the story of RMS Titanic. So, I do not need to reiterate it here. However, you might not have the accident statistics at your fingertips.
An estimated 1,517 people died: 832 passengers and 685 crew. Just 705 people survived. From tragedy came a bitter triumph, written in blood. Following the Titanic disaster, the International Convention for the Safety of Life at Sea (SOLAS) was founded in 1914 to establish new regulations to ensure the safety of people who travel across oceans.
These regulations included ensuring that there are sufficient lifeboats provided for all passengers and crew aboard the ship, and that lifeboat drills must be properly and regularly conducted. In addition, all passenger ships must carry wireless radio communication equipment to be manned around the clock. These regulations are still adhered to today, 107 years on from the sinking of the iconic White Star liner.
The Conception fire
Early on Monday, 2 September 2019 (sometime between 2:35 and 3:14 a.m.), a fire broke out on the award-winning Truth Aquatics liveaboard boat, Conception. Within two hours of the Mayday call, the 38-year-old, wood-and-fibreglass boat had burned to the waterline. It subsequently sank off Santa Cruz Island, California, USA. Thirty-nine people were on board, of which 34 were likely to have perished from smoke inhalation (33 passengers and one crew), according to authorities.
“This is going to be a very lengthy, detailed and comprehensive investigation.” — Jennifer Homendy, NTSB
A National Transportation Safety Board (NTSB) team was on site within hours. The team’s role was to conduct a safety investigation, not a criminal investigation. They were the lead investigators, and when they publish their report in about 12 months’ time, it will include a set of recommendations. A separate criminal investigation is being conducted by the FBI, the US Coast Guard (USCG), the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) and the US Attorney in Los Angeles. It is possible that this will result in prosecutions. The federal authorities have been busy.
They have searched Truth Aquatics’ offices and its two other liveaboards, Truth and Vision; served warrants; seized documents and data (maintenance records, policy and procedures, operation manuals, etc.); requested emergency services dispatch records; and have either interviewed or plan to interview past employees. Furthermore, the survivors—the captain and the four crew members—have been tested for alcohol and drugs.
“There was an extraordinarily hot fire and the bodies do exhibit signs of extreme thermal damage.” — Bill Brown, Santa Barbara County Sheriff
In the meantime, specialist teams have recovered all the bodies from the Santa Cruz waters, and DNA is being used to identify the victims. The inverted wreckage of the Conception has been videoed and photographed in situ. It was also mapped using side scan sonar prior to it being salvaged and transported by barge to Port Hueneme naval facility for further analysis.
Dive safety briefing
Allegedly—the following is anecdotal from two different sources, and I cannot find any firm verification of this—three of the crew have been asked extensive, detailed questions by the federal authorities, whilst at the behest of the US Coast Guard, the two remaining crew have not. Apparently, previous patrons of Conception will also be interviewed to determine what kind of safety information they were given when they joined the boat. Can you remember every point made in your last dive safety briefing? I, along with many of my colleagues in the dive industry, have given complete and comprehensive safety briefings to divers.
That does not mean that every customer listens attentively, and/or they may not remember pieces of information. For this reason, the questioning of Conception’s previous patrons will certainly open a can of worms—some customers have already stated on social media that they cannot remember being briefed about the second escape hatch. This lapse is easy to demonstrate.
Most dive agencies have a quality control system in place. As a PADI Pro, I am aware that PADI can and will survey my students after they have been certified, to check that standards are being adhered to. For instance, when I conduct a controlled emergency swimming ascent (CESA) in open water, I must use a control line to help me stop a student if they ascend too quickly. Newly qualified PADI divers are often asked if a rope was used during the CESA assessment.
Some divers will honestly reply “no,” at which point PADI will contact the instructor to provide verification details. (Invariably, a fixed line was used; the diver just does not remember it). We are human. We all forget stuff. Hence, I fully expect the authorities to hear from some Conception customers that they cannot remember being briefed about the second escape hatch.
“Gave no safety briefings, cut corners and left inexperienced divers without help.” — The Sun
As you would expect, the mainstream media has published misinformation and conjecture—they don’t wholly understand diving and boats—whilst the legal profession has used some potentially provocative language. On 8 September, I wrote an article to bring some clarity to this devastating incident, and you can read it on the X-Ray Mag website at: https://xray-mag.com/content/californian-dive-boat-fatal-fire.
In summary, the Truth Aquatics boats are custom designed and built specifically for scuba diving. Unlike several liveaboards, they are not previously used, converted vessels. It is important to reiterate that at the time of the fire, Conception was in compliance with US Coast Guard regulations—you cannot cut a USGC certificate off the back of a cereal packet—and the vessel had been inspected several times by marine safety professionals.
“There is no indication that the boat [Conception] was not following regulations, and I would know, as I had a similar boat doing similar things for 20 years. I can quote chapter and verse of the applicable regulations, and there is no reason to think that there was a wink and a nod to any of them.” — A US dive boat captain
Review of current regulations
One does have to ask, however, are some of these regulations still adequate and fit for purpose, or do they need reviewing? Remember, Titanic was complying with Board of Trade lifeboat regulations, and these were updated after the accident. Conception was required to have two means of escape that “must be widely separated and, if possible, at opposite ends or sides of the space to minimize the possibility of one incident blocking both escapes” (from the Code of Federal Regulations, Title 46 – Shipping, Subchapter T, Part 177 Construction and Arrangement).
The Conception did have two means of escape as described above. The main access to the sleeping accommodation was towards the bow, via an open staircase located at the front of the passenger lounge and galley salon.
The open berthing bunk room also had a second alternative small emergency exit hatch. This was located as far away as feasibly possible from the main staircase, and it was accessed by climbing or scrambling up and over three bunks, and then pushing a hatch open. According to regulations, “A door, hatch or scuttle must open towards the expected direction of escape from the space served.”
Once open, a diver could then wiggle and climb up into the same lounge and galley saloon. This time, they would find themselves closer to the stern, near the main door onto the dive deck. This vessel was purpose-built, so why did both exits lead into the same room, not a second entirely different area? Common sense tells us that this was not an optimal solution.
“When you put two exits into the same common area, you are not providing two means of egress; it’s still only one.” — John McDevitt, former assistant fire chief
As part of their investigation, the NTSB team visited another vessel in the Truth Aquatic fleet to get a sense of the layout of Conception. They walked around Truth. Whilst this is not an exact replica ship, it is a pretty close design. Jennifer Homendy of the NTSB team expressed concerns about the ability of passengers to escape in an emergency. She stated she was “taken aback” by the size of the escape hatch.
Like it or not, “round” is a shape. Forty years ago, divers were all much fitter, thinner, nimbler and younger. It is a sad fact that today the majority of the diving population is aging, fatter, and far less fit and flexible. What might have seemed “adequate” or “good enough” a feasible escape route in an emergency in the 1980s is not the case now.
Adequate? Good enough?
Hands up, I am a Brit. In the main, in the United Kingdom, we work to different codes and licenses than other countries do, and I am certainly not saying that our maritime laws and standards are superior. But I must admit that I also shared Homendy’s thoughts when I saw footage of the escape hatch and the access to it. I am not a marine architect, but I would have expected the three bunks to have been converted to three short storage shelves, and a purpose-built vertical ladder fixed to the wall, to give divers an easier and unencumbered access to a larger escape hatch.
As an aside, in June this year, I dived off a Scapa Flow liveaboard. This boat had two means of escape in the sleeping quarters, with the exits leading to two different areas on the vessel. The room I slept in had a vertical fixed ladder leading up to the escape hatch. If I had climbed the ladder, it would have brought me out onto the main dive deck.
“In the Great Ocean Race out in the Atlantic, a hose came off a pressure alcohol stove. The boat went from not on fire to being filled with flames bow to stern below in seconds. The flames poured out of a hatch and burned up the life raft. Crew below had to run out through the flames for their lives and at least one was badly burned. They all jumped overboard with what they were wearing, and the boat very quickly burned to the waterline and sank. No distress calls were made—there was no time.” — Sailinganarchy.com
I do wonder though, in this instance, if having a different, second evacuation route would have made any difference to the number of survivors. Unless the general public has experienced a real fire—and I am not talking about a barbecue or a controlled “event bonfire” here—they have little or no understanding that once a fire gets going, it rapidly gets hot, and it can spread exceedingly quickly. If you have ever viewed the footage of the Rhode Island “Station” nightclub fire, you can see 100 seconds after the fire started, there were thick, black, rolling clouds of smoke and a fatal crush at the main entrance.
Boat fires are fast and fierce; they get out of control, and they give off noxious fumes because of the varnish, fibreglass resin, paint, in a boat’s construction. Therefore, people on a ship can get overcome by smoke inhalation very quickly. (See a boat burn test at: https://www.boatus.org/findings/55/)
It’s going to get ugly
Several people who work professionally with boats in the recreational scuba diving industry know that this is going to be an ugly fight. Key personnel with expertise in running liveaboards are now keeping their heads down because this will be nasty.
“If the hearse chasers were not showing up at the dock, then a strategy such as this would not be necessary.” — Joel Silverstein, Tech Diving Limited
Three days after the fire, the lawyers for Truth Aquatics filed a petition asking a judge to limit the company’s financial liability. Whilst this move was condemned as a predictable, callous tactic, it is a pretty common action, following a US maritime disaster. However, this protection could no longer be relevant in light of the NTSB preliminary report (Marine DCA19MM047) being issued.
“The information in this preliminary report is subject to change and may contain errors. It will be supplemented or corrected during the course of the investigation.” — NTSB
The NTSB’s executive summary is one page long, and states: “At the time of the fire, five crewmembers were asleep in berths behind the wheelhouse, and one crewmember was asleep in the bunkroom.” A summary text of the US Coast Guard regulations states that a vessel carrying overnight passengers should have a suitable number of watchmen patrolling throughout the vessel during the night time, whether or not the vessel is underway, to guard against and give alarm in case of fire, man overboard or other dangerous situations such as the anchor dragging. This initial NTSB report is potentially damaging in that it indicates this standard was not followed by Conception’s captain. This could well result in prison time for key Truth Aquatics personnel.
Truth Aquatics update
In the meantime, Truth Aquatics has updated its website with the following statement: “With the continued calls and request[s] for tours, we want to announce that we are officially suspending all operations on our Truth Aquatic fleet for a to-be-determined amount of time. We apologise to customers who have been seeking reservations as well as those with reservations—and truly appreciate the expressions of support . . .
Right now, we feel it’s important [we] dedicate our entire efforts to make our boats models of new regulations that we will to work on with the NTSB and [the US] Coast Guard.” Everything I have read and heard about the Truth Aquatic boats has relayed that they were well-kept.
When the US Coast Guard inspections threw up an issue, the problem was rectified. We are a close community. It is no surprise that this tragedy has touched many divers across the globe. When we make friends in diving, we make strong friendships; hence, our community has rallied and paid into several fundraisers for the families and the crew.
“This is the community wanting to support the community.” — Pete Murray, ScubaBoard
At the time of this writing, ScubaBoard has raised US$23,431 for the families, whilst the AAUS, California Diving, Catalina Cylinders, DAN, Dolphin Divers Sacramento, DUI, NAUI, PADI, PSI, PCI, Scubapro, SDI, SSI, Undercurrent and WDHOF have jointly launched an appeal, which divers have also paid into, and raised US$204,830.
When the Conception was designed and built almost 40 years ago, divers were not diving equipment that needed recharging. No one had a mobile or cell phone—these did not really start becoming the norm until the mid-90s; and GoPro cameras were not launched until 2004. Today, I routinely bring an extension cord with me on trips, because I will need to charge at least five devices: my mobile, laptop, camera, GoPro and Fitbit. I know other divers who bring rechargeable dive computers, strobes, DPVs and rebreather heads.
It is therefore not unreasonable to calculate that each person on Conception could have had at least three rechargeable devices on board, a total of 117 devices. At present, we do not know the origin of the fire, and we may never know how it started and why. It is quite possible, though, that 39 devices were recharging at the same time on Conception—one per customer and member of staff.
So, could the fire have been caused be a battery charger or a strain on the boat’s electrical system? (See a video of a lithium-ion battery fire and explosion conducted by the Department of Fire Protection Engineering, University of Maryland:
“On US government-owned vessels, taking on lithium batteries is a very involved process for the approval chain.” — A USA dive boat captain
As an aside, vape pens are prohibited on US government-owned vessels, not because of the health risks, but because they contain lithium batteries.
What has changed
Just over a week after the Conception fire, the US Coast Guard issued a safety bulletin. The document urges crews to “reduce potential fire hazards and consider limiting the unsupervised charging of lithium-ion batteries and extensive use of power strips and extension cords.” Boat operators must also “limit unsupervised charging of cellphones and other electronic devices.”
The document also recommended that vessel owners “immediately” review crew training and make sure emergency routes are clearly identified and unobstructed and that required fire-fighting and life-saving equipment is on board. Dive boat operators, however, are not waiting around to make changes. One US liveaboard owner has already said there will be no more charging stations available between 8 p.m. and 6 a.m. “The outlets in the bunkroom are not to be used to charge any device at any time whatsoever.
The only acceptable use of an outlet in the bunkroom is for medical devices, such as CPAP machines.” Divers with scooters, cameras or rechargeable lights may have to skip any night dives or the morning dive after a night dive. Undoubtably, because liveaboards are a customer service industry, the ones that focus on higher-end consumers will figure out a safe way to allow 24/7 charging.
Passengers will now be stopped from sleeping on board the night before the boat departs. And the liveaboard owner has also stated he will hire an additional crewman so that a 24-hour watch can be kept. “A crew member or ‘roving patrol’ will be on deck or in the galley at all times when at dock, anchored or underway,” he said.
What is telling is that one former liveaboard captain with at least 20 years or experience (not connected to Truth Aquatics) received phone calls from other companies after the fatal fire asking: “Did you really conduct proper watchkeeping? Did you really keep a 24-hour watch?”
The liveaboard captain replied that he and his crew did, which is a fact I can confirm, having dived off the liveaboard in question. Physical changes are being made to vessels too. The Nautilus Gallant Lady’s departure was delayed after the owner decided to install a fire suppression and sprinkler system below deck, and an additional escape hatch was been constructed from the below deck cabins.
What could change
There is no need to reinvent the wheel. The present rules need to be enforced. The dive boat captains who think they are just water taxis need to stop playing at driving boats and realise that they are professional sailors; they must understand this and comply with all that this entails. It is possible that in light of this tragedy, the US Coast Guard will review and issue new guidance on the following:
- The maximum number of passengers that can sleep on board a liveaboard (there will need to be an equation applied to this)
- Double bunks—will they be banned?
- The size and access to escape hatches
- Crew numbers and roles when passengers board, when the vessel is tied up in dock, underway, and when it is at remote anchor
- Battery charging protocols
Although I knew no one on this liveaboard, I am one degree of separation from at least six of the victims. Several of my colleagues are distressed at having lost friends and customers. But I cannot remember the last time I did a fire drill. And I have never done one on a dive boat before, and I have been diving off boats for over 25 years.
This fire has been a chilling awakening and it is a game changer. A little bit of our innocence has been lost. We do not know why this fire spread so quickly, and why there was such a large, catastrophic loss of life. But I can guarantee one thing for sure. For this moment at least, divers are now giving their full attention and respect to boat safety briefings. One fellow diver said, “The fire on the Conception has scared the complacency out of me.”
Steps to safety
We need something positive to come out of the Conception fire. With this in mind, what are some practical steps we adopt that will help us, our fellow divers, and the boat crew? Here are some suggestions:
1) Less booze. I am not getting puritanical here but do think about your alcohol consumption. We know for a fact that alcohol, diving and dehydration are not an optimal mix when it comes to diving physiology. By all means, have a beer post dive if you wish, but do not get off-your-face drunk. You do actually need to be capable of self-rescue should something happen.
2) Handy flashlight. Take a flashlight or dive torch to bed with you that works, so that if the power or electricity goes down, you can still find your way out of your sleeping quarters.
3) No unattended devices. Do not leave your plugged-in mobile or cell phone unattended in your cabin or on your bunk. Please do not leave your charger switched on and plugged in either, when you remove a device, because blazes can happen. Try not to mix chargers—use the charger supplied (if you can). And if possible, try and charge your phone during the day in a place where someone is about.
4) High quality chargers. Think about the charger and batteries you buy. The quality can vary widely. It can be challenging to ensure you are being a responsible customer, but where possible please, try and use due diligence and purchase the real thing rather than a cheap knockoff.
5) Lithium battery safety. It is time we took charging lithium batteries seriously. These batteries offer many advantages; however, we must remember they are high-energy devices. The US Navy considers them “hazardous at all times.” For this reason, do not leave your equipment charging where it is unsupervised. Charge your gear in a common area where it is in clear sight of others, just in case it needs unplugging. End all battery charging some time before “lights out” You might want to consider purchasing a fireproof safe bag for your batteries.
6) Airplane mode. Make sure all your batteries and devices are charged prior to boarding a dive boat and put them into airplane mode when they are not in use.
7) Learn the exits. Be safety savvy. If you do not do so already, start taking notice of your surroundings; this advice applies to land accommodations too. Just where is the nearest fire extinguisher? Where are the fire escapes, the stairs, the hatches and the emergency exits? How do they work? You will have been briefed on where the life jackets and lifeboats are, but did you really take notice, and do you remember what this life-saving equipment is?
8) Radio-speak. You just might end up having to make a call on a radio. Learn your phonetic alphabet. Alpha, Bravo, Charlie, Delta, etc., and consider going on a radio course. It is fun to learn, and it is a useful practical skill to have under your belt. You should at least know how to use the Channel 16 VHF (156.8 MHz) marine radio frequency to broadcast an urgent or distress message, and how to send a Mayday or Pan Pan. Never ever call a Mayday or Pan Pan unless you absolutely must, or you will likely be prosecuted for a hoax call.
9) Fire drills. Trip leaders, if your liveaboard does not do an actual “all hands” (passengers and crew) fire drill, ask them to, after a thorough safety briefing. To be effective, it should cover muster stations, a head count, evacuation procedures and donning of life preservers. (Remember, this kit must work for real, so if it has a one-time-use inflater, please do not mess with it).
10) Quick clothing. Think about how you are dressed. I am unlikely to get upgraded on a plane because I tend to wear walking boots, walking trousers or jeans, and a warm jumper. It is perhaps because I have reread Desmond Bagley’s High Citadel one too many times. (It is a book about a hi-jacked plane that crash-lands in the Andes. The surviving passengers come up with ingenious ideas in an attempt to survive until help arrives). But I work on the premise that if something happens to the plane, it is better to be dressed in practical warm clothing, than look pretty in high heels and a skirt. So, either sleep in practical boat pyjamas, or have them ready, so you can put them on in seconds.
“We will learn from this tragedy. We will improve. We will move forward.” — Ken Kurtis, Reef Seekers Dive Co.
What is the final thing we can do? Well, I for one do not intend to give up liveaboard diving. I will continue to sleep in bunk rooms and cabins. I am not going to let fear stop me from living. I hope you will too. ■
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