Following the NTSB investigation into the fatal fire and loss of the passenger vessel Conception off California in September 2019, AMSA shed focus on key points of concern for Australian vessels and informed that it will consider the NTSB report in full when reviewing the current regulatory requirements for domestic commercial vessels, including standards for fire safety and accommodation and arrangement.
Five crew members were asleep in the crew berthing area on the upper deck. One crew member and all 33 passengers were asleep in the bunkroom below.
A crew member sleeping in an upper deck berth was awakened by a noise and got up to investigate. Upon seeing a glow outside, he realized that fire was rising up from the saloon compartment directly below, and he immediately alerted the other four crew members sleeping on the upper deck. The master was able to send a distress message to the Coast Guard.
The crew members attempted to access the saloon to assist the passengers and the other crewmember in the bunkroom below the main deck, but access was blocked by fire and thick smoke.
Of the 39 people on board, 34 perished in the incident.
The NTSB report drew 18 conclusions, the following of which are considered worthy of note by those persons involved in operating passenger vessels in Australia:
- Although a definitive ignition source cannot be determined, the most likely ignition sources include the electrical distribution system of the vessel, unattended batteries being charged, improperly discarded smoking materials, or another undetermined ignition source.
- Although the arrangement of detectors aboard Conception met regulatory requirements, the lack of smoke detectors in the saloon delayed detection and allowed for the growth of the fire, precluded firefighting and evacuation efforts, and directly led to the high number of fatalities in the accident.
- The absence of the required roving patrol on Conception delayed detection and allowed for the growth of the fire, precluded firefighting and evacuation efforts, and directly led to the high number of fatalities in the accident.
- Conception’s bunkroom emergency escape arrangements were inadequate because both means of escape led to the same space, which was obstructed by a well-developed fire.
- Although designed in accordance with the applicable regulations, the effectiveness of Conception’s bunkroom escape hatch as a means of escape was diminished by the location of bunks immediately under the hatch.
- Conception’s operator provided ineffective oversight of its vessels’ operations, which jeopardized the safety of crew members and passengers.
- Had a safety management system been implemented, the operator could have identified unsafe practices and fire risks on the Conception and taken corrective action before the accident occurred.
Implementing safety management systems on all domestic passenger vessels would further enhance operators’ ability to achieve a higher standard of safety,
…the report found.
Following the NTSB investigation, AMSA reminded operators to:
- Review your risk-assessment for your operation regularly, and update your safety management system as required.
- Consider emergency escape options for your vessel.
- Consider watch arrangements on your vessel, including the use of a roving watch during sleep periods.
Ensure that smoke and fire detection systems on your vessel are suitable, allow for proper coverage and are properly maintained.
- Consider whether your vessel’s electrical systems are capable of dealing with the safe simultaneous charging of large numbers of personal electronic devices such as mobile phones, tablets and computers, all of which utilize lithium-ion batteries.