NTSB CONCEPTION HEARING - THIS TUESDAY @ 10AM

[rjack321]

Otherwise we might be witnessing the end of overnight scuba trips in SoCal.

This is mostly likely the case. There are no overnight charter operators in OR, WA, BC or AK (anymore) either. There are a couple of motel places (in BC) which run day boats still.

 

[tursiops]

The low-hanging fruit is to take out those bunks obstructing the emergency exit and put in a ladder instead; put in interconnected smoke detectors; and have a roving watch from the moment a passenger steps on board. Oh, and move the charging station out of the salon, into a steel container, with its own circuit, and with a heat-detector and smoke detector in the box, and a camera to the bridge.

 

[Wookie]

NTSB has produced a 6-page summary of their findings:
https://www.ntsb.gov/news/events/Documents/2020-DCA19MM047-BMG-abstract.pdf

It contains a summary of the events of that evening, a summary of the safety issues, the 18 "Findings" mentioned upthread, as well as their 9 recommendations to the US Coast Guard (stricter regulations re: interconnected smoke detectors, egress to multiple spaces, and egress obstructions), and 1 recommendation to Truth Aquatics: to "Implement a safety management system for your fleet to improve safety practicesand minimize risk."

Interestingly, these recommendations do not cover the ignition sources themselves, nor the combustibility of materials such as seating. I agree with Ken that there is much to be said there for this case and others like it, but the NTSB has no recommendations on those matters at this time.

Not being a mariner, I have never heard of a Safety Management System (SMS). From the recording, it seems to basically be a way to log the roving patrol's movements throughout the boat over the course of the night. Having a log will empower the USCG to enforce this law, which today is essentially unenforcible. Do I have that right, or does an SMS refer to something else? Hopefully a proper mariner can chime in here.

SMS refers to everything safety on a vessel that needs a procedure. If a small passenger vessel needs an SMS, that’s news to me.

Here’s everything the Coast Guard knows about this voluntary program...

https://www.dco.uscg.mil/Portals/9/...ources_for_voluntarily_establishing_a_SMS.pdf

 

[Brett Hatch]

SMS refers to everything safety on a vessel that needs a procedure. If a small passenger vessel needs an SMS, that’s news to me.

Thanks. Sounds like SMS is a catch-all phrase, and it could refer to any number of other possible precautions. So if the USCG decided in the future to require roving patrol logs, that would come as part of an SMS that outlines other safety procedures? Or, is the SMS a particular set of procedures that all apply to many vessels, but not ones of this size? [edit: I see now that your post links to a USCG document explaining what an SMS is, and that it is recommended but not required for certain vessels.]

Regarding requiring SMS for small vessels, the document I linked in the last post ends with this:

Recommendation Reiterated in this Report

As a result of its investigation of this accident, the National Transportation Safety
Board reiterates Safety Recommendation M-12-3, which is currently classified as “Open—
Unacceptable Response”:

To the US Coast Guard
Require all operators of U.S.-flag passenger vessels to implement SMS, taking into
account the characteristics, methods of operation, and nature of service of these
vessels, and, with respect to ferries, the sizes of the ferry systems within which the
vessels operate. (M-12-3)

My reading of that is that the NTSB has previously recommended that the US Coast Guard implement new regulations that require an SMS on all US vessels, including these small ones. That recommendation is called M-12-3, and can be found on page 5 of their Safety Recommendation Letter, dated 2012-05-24, which can be found here: https://www.ntsb.gov/_layouts/NTSB/OpenDocument.aspx?Document_DataId=40376944&FileName=Safety recommendation transmittal letter - M-12-001 through M-12-003-Master.PDF

So yes, I think you're right that SMS is not required for this type of boat today, but the NTSB has felt that it should be required for at least 8 years or so.

 

[Wookie]

Thanks. Sounds like SMS is a catch-all phrase, and it could refer to any number of other possible precautions. So if the USCG decided in the future to require roving patrol logs, that would come as part of an SMS that outlines other safety procedures? Or, is the SMS a particular set of procedures that all apply to many vessels, but not ones of this size? [edit: I see now that your post links to a USCG document explaining what an SMS is, and that it is recommended but not required for certain vessels.]

Regarding requiring SMS for small vessels, the document I linked in the last post ends with this:


My reading of that is that the NTSB has previously recommended that the US Coast Guard implement new regulations that require an SMS on all US vessels, including these small ones. That recommendation is called M-12-3, and can be found on page 5 of their Safety Recommendation Letter, dated 2012-05-24, which can be found here: https://www.ntsb.gov/_layouts/NTSB/OpenDocument.aspx?Document_DataId=40376944&FileName=Safety recommendation transmittal letter - M-12-001 through M-12-003-Master.PDF

So yes, I think you're right that SMS is not required for this type of boat today, but the NTSB has felt that it should be required for at least 8 years or so.

As an operator of Small Passenger Vessels for the past 40 years, there are a lot of things that lots of folks would like the USCG to implement. They don't. That isn't always their fault, like with all industries, the lobbying group, the Passenger Vessel Association, (I'm a member) works to stop/mitigate new regulations. Lots of folks have stated that the TA boats fell under grandfathering. In regulatory parlance, that means they fell under "Old T", T meaning subchapter T to 46 CFR, which is the small passenger vessel (these vessels aren't necessarily small, they are less than 150 passengers and 100 Gross Regulatory Tons. I recently served on a 200 foot oilfield boat that was under 100 GRT) regulations. Any T boat that is built falls under "Old T", that is, the regulations they were built under. When my boat was built in 1976, fire suppression systems in the engineroom weren't required. Neither were smoke detectors, but sometime in the 90s, every passenger vessel with berthing had to install smoke detectors. So "Old T" isn't the end all be all of who gets grandfathered. When the USCG proposes a new regulation that applies to existing vessels, someone like the PVA comes in and does a cost analysis of how much it will cost to bring every vessel in the fleet up to compliance. As you can imagine, bringing every T Boat into compliance with engineroom fire suppression systems might cost in the tens of billions. Then, they will include in their analysis how many vessels/crew/passengers are lost per unit time to engineroom fires. I would expect that that number is low, but not zero. I'm studying calculus 2 right now, and studying paradoxes. The paradox the professor puts forth is on air travel. If we increase Small Passenger Vessel (SPV) safety it will cost maybe 10% on a per ticket price. That will stop some percentage of folks from riding their commercial SPV, and they will use an alternative. The alternative may not be as safe as the vessel would have been before the new regulations/price increase. So we may end up with a safer boat, but the overall safety of the entire system may actually decrease.

And no one wants to spend money they don't have to. Creating SMS (I had to have one, I sailed on international voyages) is not cheap unless you happen to be a technical writer. I am happy to report that parts of my SMS (Live Boat Diving and Diving Accident Management Plan) were actually adopted by parts of NOAA for diving from their own vessels.

 

[KevinNM]

And no one wants to spend money they don't have to. Creating SMS (I had to have one, I sailed on international voyages) is not cheap unless you happen to be a technical writer. I am happy to report that parts of my SMS (Live Boat Diving and Diving Accident Management Plan) were actually adopted by parts of NOAA for diving from their own vessels.

According to the NTBS board members, sometime in 2010 Congress told the USCG to create something involving SMS for small vessels. And they haven't. The NTBS clearly wasn't impressed by this lack of action. I'm unclear if it was to be mandatory, voluntary, or what but it hasn't been done.

 

[dmaziuk]

... and move the charging station out of the salon, into a steel container, with its own circuit, and with a heat-detector and smoke detector in the box, and a camera to the bridge.

You really want to have those heat and smoke detectors along the entire length of the wire from the battery/generator banks, not just over the charging station.

 

[KevinNM]

The low-hanging fruit is to take out those bunks obstructing the emergency exit and put in a ladder instead; put in interconnected smoke detectors; and have a roving watch from the moment a passenger steps on board. Oh, and move the charging station out of the salon, into a steel container, with its own circuit, and with a heat-detector and smoke detector in the box, and a camera to the bridge.

Except that the ladder may not be acceptable per the NTSB discussion. The changes to the Vision clearly enhanced safety, but the USCG seems to have had a major freakout over them.

I'm not sure how you can put a stairs in that opens to another space without major changes that requires every single boat to have individual approval by the national level Marine Safety Center, naval architects reports, engineering designs, stamped plans, etc.

 

[dead dog]

What I don't understand to this day is why the smoke alarms didn't wake the crew sooner.
By the time they knew the fire was fully engulfed in the Salone heading to the bridge.
At home, I have had a smoke alarm go off to the point I had to use a hammer to turn it off.

 

[KevinNM]

Apparently the only smoke alarms were in the berthing area, two decks down from crew. So it had to go up the stairs, through the salon, out the door, up to the top deck, across the sundeck and through the back of the top deck. It’s like hearing the smoke alarm from your neighbors basement.