NTSB faults poor oversight and lack of roving watch for Conception boat fire that killed 34

The dive boat Conception smolders off Santa Cruz Island on Sept. 2, 2019.
The Conception smolders from a fire that engulfed the dive boat off Santa Cruz Island on Sept. 2, 2019.
(Ventura County Fire Department)

A deadly fire engulfed the Conception dive boat off the Channel Islands last year because its owner, Truth Aquatics, failed to have effective oversight of the vessel and did not operate a required roving watch that likely would have detected the fire sooner and could have saved lives, the National Transportation Safety Board said Tuesday.

In announcing the findings of its investigation into the fire that killed 34 people sleeping below deck, the agency recommended sweeping changes to small vessel oversight by the U.S. Coast Guard, including better smoke detection systems and emergency exits that lead to different areas of the boat.

Although the NTSB determined the fire began in the back of a middle deck salon where lithium-ion batteries were being charged, the agency could not say whether it was the batteries, the ship’s electrical system or an unattended fire source that ignited the blaze.

But NTSB Chairman Robert Sumwalt said regardless of the source of the fire, the 33 passengers and one crew member below deck probably could have escaped if there had been early detection of the blaze. The agency found that the fire was burning for at least 30 minutes before a crew member sleeping in the wheelhouse atop the three-deck boat was awakened by a pop, crackle and the glow of the flames from the middle deck.

The NTSB cited the failure by the boat’s captain, Jerry Boylan, and Conception’s owner, Truth Aquatics, to comply with a Coast Guard requirement that it operate a roving watch whenever passengers were below deck. Sumwalt said the NTSB interviewed captains and crew members from other Truth Aquatics vessels, and all stated that the practices on their vessels were the same as those on the Conception.


That failure was identified in a Times investigation last year, the NTSB board noted Tuesday. No roving watches were set while in port or at anchor in direct violation of Coast Guard requirements for the Conception, according to NTSB investigators.

“It is a grim picture, a picture of a charter boat company that repeatedly disregarded its procedures. The most critical of those deviations, in my opinion, was the failure to require a roving patrol that in my opinion contributed to the high loss of life,” Sumwalt said. “It is also a picture of a calm Pacific Ocean on Labor Day morning in the pre-dawn hours when the ocean is illuminated by the bright glow of the fire aboard the Conception that unfortunately claimed 34 lives.”

The Coast Guard, the NTSB board members noted, did not require logs of roving watches, so no vessel operated since the 1990s has been cited for failing to have a roving watch.

Board member Jennifer Homendy, who led the NTSB investigation on the ground, said, “at the end of the day there was one person in charge of safety: Truth Aquatics.”

“This is the greatest loss of life in many decades,” Homendy said. “We never want that to happen again.”

The NTSB also found that the Conception did not have smoke detectors installed in the area of the boat where the fire started. And while placing much of the blame on Truth Aquatics, the agency did not spare government regulators, finding that “contributing to the undetected growth of the fire was the lack of United States Coast Guard regulatory requirements for smoke detectors.”

“It is amazing we have an unattended room with batteries charging in it, a griddle, two burners as well as a refrigerator and we have no regulation that requires smoke detectors,” NTSB Vice Chairman Bruce Landsberg said.

The agency also faulted the limited ways in which passengers below deck could escape from the blaze.

“Contributing to the high loss of life were the inadequate emergency escape arrangements from the vessel’s bunkroom, as both exited into a compartment that was engulfed in fire, thereby preventing escape,” the NTSB said.

Glen Fritzler, the owner of Truth Aquatics, has denied wrongdoing and insisted that a crew member was awake when the fire was detected. His attorney has said that a crew member was in the salon area less than half an hour before the fire was discovered.


The panel determined that most of the 33 passengers and one crew member below deck were awake — some with their shoes on — as the fire engulfed the vessel about 3 a.m., but could not escape the bunk room and died of smoke inhalation. Santa Barbara officials have long said that the 34 who perished likely never knew of the fire.

After presenting its findings and probable cause, the NTSB board adopted a slate of recommendations. It called for vessels similar to the Conception with overnight accommodations to be required to have interconnected smoke detectors in all passenger areas. It recommended that a secondary means of escape lead into a different space than the primary exit. The agency also called on the Coast Guard to develop and implement an inspection program to verify that roving patrols are conducted as required for the safety of sleeping passengers and crew.

“The Conception may have passed all Coast Guard inspections, but that did not make it safe,” Sumwalt said. “Our new recommendations will make these vessels safer, but there is no rule change that can replace human vigilance.”

Coast Guard chief spokesman Kurt Fredrickson said in a statement that it “will carefully consider the National Transportation Safety Board’s recommendations through a deliberate process, which will include review by all subject matter experts and senior leaders responsible for implementing the potential regulatory changes.”

He added that the Coast Guard is conducting a Marine Board of Investigation into the fire. “We will look at all possible factors that may have caused this incident, including those associated with regulations or oversight, and make recommendations for any necessary changes,” he said.

Kathleen and Clark McIlvain, whose son Charles was among those killed in the fire, expressed appreciation for the NTSB’s efforts.

“Reliving the Conception disaster that took our son’s life and that of 33 others was extremely painful but we are grateful to the NTSB for their thorough investigation,” they said in a statement. “Our hope is that the safety recommendations proposed by the NTSB are swiftly adopted as regulatory requirements by the Coast Guard to ensure no other family experiences this pain and grief.”