b'Ineffectivecompanyoversight.The NTSBfoundseveralunsafepracticeson companyvessels,includingalackofcrew training,emergencydrills,andtheroving SAFETY patrol. In reviewing the companys policies and procedures, the company had been deviating fromrequiredsafepracticesforsometime. The company owner during interviews with theNTSBstatedtherewerenopoliciesor proceduresinplacetoensurecrewtraining andcompliancewithregulations.Vessel Mastersweregivensoleresponsibilityto operatecompanyvessels.Crewmembers stated they had not been part of a fire drill for months.The NTSB stated If the company hadbeenactivelyinvolvedinensuringthe safety practices required by regulations were enforced, most notably the requirement for a roving patrol, it is likely this accident wouldThe Emergency Escape Hatch on the M/V Conception can be seen (or not) above the have not happened. The NTSB continued thatbunk on the left. Photo: NTSBhad a safety management system been in place it would have likely included procedures foroversightofitsvesselandcrewmemberRECOMMENDATIONSroving patrols that complied with regulationsoperations, including requirements to ensureWhile not finalized the NTSB focused most andacompany-involvedauditprocessthat a roving patrol was maintained, whichoftheirrecommendationsontheCoast foridentifyingandcorrectingwhennon- allowedafireofunknowncausetogrow,Guard and regulatory change. They called for conformities existed. undetected, in the vicinity of the aft salon onrevisions to small passenger vessel regulations in the main deck.subchapter T to require vessels with overnight The evidence compiled by the NTSB and theaccommodations to have smoke detectors in all safetyissueraisedduringtheinvestigationContributingtotheundetectedgrowthaccommodationspaces.Inaddition,NTSB promptedNTSBBoardMemberJenniferofthefirewasthelackofaCoastGuardrecommended that smoke detectors on all small Homendy to state that It is not an accident ifregulatory requirement for smoke detectionpassenger vessels regulated by Subchapters K you fail to operate safely. in all accommodation spaces. Contributingand T be interconnected such that when one to the high loss of life were the inadequatedetectoralarms,theyallalarm.Regarding PROBABLE CAUSE emergencyescapearrangementsfromthetherovingwatch,theNTSBrecommended The NTSB determined the probable cause ofvesselsbunkroom,asbothexitedintoathat the Coast Guard develop and implement the fire and subsequent sinking was the failurecompartmentthatwasengulfedinfire,inspectionprocedurestoverifythatroving of Truth Aquatics, Inc., the owner and operatorthereby preventing escape. watches are being conducted. The remaining oftheM/VConception,toprovideeffectiverecommendations to the Coast Guard focused on egress from passenger compartments and the need to have egress to separate spaces so a fire in one space will not hamper egress.TheNTSBalsorecommendedthatPVA, theNationalAssociationofCharterboat Operators,andtheSportfishingAssociation ofCaliforniasharethefindingsofthe investigationwiththeirmembersspecifically regarding smoke detectors and passenger egress from vessels with overnight accommodations.Finally,theNTSBrecommendedthatthe owner of the M/V Conception, Truth Aquatics Maintenance implement a safety management system.In Simplified! doing so, the NTSB also reiterated a previous recommendationthatalldomesticpassenger vessels implement a safety management system.The NTSB has released the full version of its 17 report.An executivesummary of its findings 978-562-5211 and recommendations may be found here.A collectionofevidenceandtechnicalreports WheelHouseTech.com underlying the investigators conclusions may be found here.SAFETY MATTERS 34 FOGHORN'