American tragedy: why did the Conception fire kill so many?

In September 2019, a fire aboard a dive charter vessel lying at anchor off the Californian coast killed 33 passengers and one crewmember. It was a tragedy that put basic safety regulations firmly under the spotlight – and resulted in a long list of recommendations.

In the early hours of 2 September 2019, the US Coast Guard (USCG) centre in Los Angeles received a broken distress call from the captain of a 75ft (22.86m) dive charter vessel. Anchored 21nm southwest of Santa Barbara, the Conception was quickly becoming engulfed in a sudden, ferocious fire.

“Mayday, mayday, mayday! Three-nine POB. I can’t breathe… Three-nine POB…” called the captain as his crew rushed from their berths on the upper deck to help their passengers trapped in the bunkroom below the main deck.

Due to flames and smoke they found themselves unable to get close to the bunkroom, and were forced, instead, to jump overboard to save their own lives.

They swam to the stern to re-board the boat and try again, only to find access to the bunkroom via the aft corridor also blocked off by the raging fire.

With the captain, who had also now swum to the stern, the crew launched the vessel’s skiff and were quickly picked up by a nearby sailing yacht, from where the captain continued to radio for help.

When the USCG and other first responder boats arrived on the scene, dawn was starting to break. They found the Conception burning uncontrollably down to its waterline and beginning to sink slowly beneath the ocean waves.

All 33 passengers and one crewmember died in the blaze.

Conception at dawn, shortly before sinking (Credit: National Transportation Safety Board (Public Domain))

Coastguard and FBI investigate the Conception

When the wreckage was recovered from the seafloor it was laid out in a secure parking lot by investigation teams from the USCG and FBI in three sections: the main hull, the main deck, and the upper deck.

Identifiable engine room machinery and equipment was placed back into its original position in the engine room within the hull. Very little structural material remained from the upper deck and the main deck.

Conception wreckage layout at Port Hueneme, California (Credit: National Transportation Safety Board (Public Domain))

Investigation findings

The investigation determined that the fire had probably started in the aft main accommodation area, with the most likely ignition source being the vessel’s electrical distribution system, unattended batteries being charged, or improperly discarded smoking materials.

The Santa Barbara coroner’s office concluded that most of the victims were awake at the time of the incident but were unable to escape from the bunkroom due to the fire’s ferocity, dying eventually from smoke inhalation.

Recommendations highlight safety issues

The official accident investigation report by the National Transportation Safety Board (NTSB) identified a number of important safety issues, including:

• A lack of small passenger vessel regulations requiring smoke detection in all accommodation spaces. In accordance with the fire safety regulations applicable to the Conception, the only compartment required to have smoke detectors was the passenger bunkroom as it was the boat’s only overnight accommodation space. There were no smoke detectors in the main deck area where crewmembers reported first seeing the fire

• Lack of a roving patrol. The Conception regularly operated in contravention of regulations which required a roving patrol at night and while passengers were in their bunks to guard against, and give alarm in case of, a fire, man overboard, or other dangerous situations. The absence of a roving patrol delayed detection of the fire, allowed it to grow, precluded fire fighting and evacuation efforts, and led directly to the high number of fatalities
• Small passenger vessel construction regulations for means of escape. The Conception was designed in accordance with the regulations in force at the time of its construction. As such, it was required to have at least two emergency egress pathways from all areas accessible to passengers. It had two means of escape from the bunkroom: spiral stairs forward and an escape hatch aft, accessible from either port or starboard aisles by climbing into one of the top aftermost inboard bunks. However, both paths led to the main accommodation area, which was filled with heavy smoke and fire

• Ineffective company oversight. This included a lack of crew training, emergency drills, and the roving patrol.

USCG cutter Narwhal arrived too late to save the Conception (Credit: USCG/Petty Officer 1st Class Patrick Kelley)

NTSB called for a long list of recommendations

The NTSB called on the USCG to revisit its regulations to ensure: 

• New and existing vessels with overnight accommodation have smoke detectors in all accommodation spaces
• Inspection procedures can verify that small passenger vessel owners, operators, and charterers conduct roving patrols
• New and existing small passenger vessels with overnight accommodation provide a secondary means of escape into a different space than the primary exit so that a single fire should not affect both escape paths
• All US-flagged passenger vessels implement a safety management system that takes into account the characteristics, operation, and nature of service of the vessel.

Read the full NTSB official report.

Dennis O’Neill is a maritime journalist.