Conception

[MaxBottomtime]

I never took a sleeping bag on a TA boat, they always had a fleece blanket, that and clothing were the norm for me

This. I always slept in my clothes aboard TA boats. I rarely got more then a couple of hours sleep due to the rocking, talking, and sound of water hitting the hull. Most of the time, I would get up and go to the salon in the middle of the night.

 

[O-ring]

There are mentions of sandals (2 victims), slip-on shoes, ugg boots (two victims), slippers (2 victims)...

I have rarely seen people donning any of those to slip into their sleeping bags on SoCal boats (no bed linen were provided on the TA boats). Weather was nice on Sept 1-2, 2019, but not warm enough at night, especially at sea, to not use a sleeping bag. Some people will only use the provided blanket, especially if out of state and not used to the crude accommodations of SoCal liveaboards, but that does not seem to be the case of most passengers on that trip. And even then, I am not sure what sandals would do to protect from the cold.

Just be aware that coroner's reports have no pretension to establish a likely scenario and are open to interpretation. In fact, in one case I know intimately, the report was of absolutely no help in reconstituting the accident (which had several witnesses and a detailed police report, so that was luckily not necessary).
However, the present ones certainly raise many questions, besides the nature of the footwear found on some of the victims:

Why were all remains identifiable (by forensic analysis) but for one, limited to "a partial spine and pelvis" (which did not stop the coroner from establishing the cause of death as "smoke inhalation", next-to-last report)?

Why does one of the reports not refer once to burn marks, and quotes one of the lowest amount of CO detected in her remains? She was the youngest, and indeed the last one to be found, having drifted away in the kelp (last report). Scientific literature shows that young fire victims rarely succumb to such low CO % (https://doi.org/10.1016/0379-0738(91)90091-V).

Heather's article and her expressed hope that her sister died innocently in her sleep (hope that I initially shared), is probably not the final word on this tragedy, at least as far as other victims are concerned.

That was kind of where I was going with this, again, from a guy who has never been on a CA liveaboard, but has spent the night on a bunch of boats. I have never once slept in flip flops with an iPhone in my pocket or in a jacket. Not saying it didn't happen, but I bring a sleeping bag and usually don't wear footwear to bed. Smartphones, headlamps, etc. are nearby at the ready, but never clutched in my hand or stowed in a pocket. What the coroner's reports indicate to me is that some of the victims woke up, threw clothes on, grabbed essential items they thought they might need to call for help or get above decks safely (phones, flashlights, etc.) and made a go of it. Sadly, none of them made it, but I don't think the "dying innocently in their sleep" hypothesis fits with the evidence in the coroner's reports for a lot of the victims.

 

[Open Ocean Diver]

That was kind of where I was going with this, again, from a guy who has never been on a CA liveaboard, but has spent the night on a bunch of boats. I have never once slept in flip flops with an iPhone in my pocket or in a jacket. Not saying it didn't happen, but I bring a sleeping bag and usually don't wear footwear to bed. Smartphones, headlamps, etc. are nearby at the ready, but never clutched in my hand or stowed in a pocket. What the coroner's reports indicate to me is that some of the victims woke up, threw clothes on, grabbed essential items they thought they might need to call for help or get above decks safely (phones, flashlights, etc.) and made a go of it. Sadly, none of them made it, but I don't think the "dying innocently in their sleep" hypothesis fits with the evidence in the coroner's reports for a lot of the victims.

I din’t see where they mentioned flip flops or cell phone. Can you please let me know which report it was?

thanks,

 

[Ken Kurtis]

I've been watching this for a while (lurking) but thought I'd weigh in before this gets too far into the weeds. FYI, I spent about five hours today going through all of the Coroner reports and doing some tabulating and cross-referencing. Some generalities first.

One note of caution, and this is gently aimed at O-ring: Don't assume that what you (or anyone else) always do is what everybody does. Don't assume that the way you'd react is the way everyone would react. And especially when you say that you've never been on a CA liveaboard, realize that your conclusions may have no bearing on the way things are done on a CA boat. For instance, someone opined that the difference in CO levels was due to people at the far end of the bunkroom not being as exposed as those in the front. But the bunkroom was perhaps 20 feet long. Not a lot of difference between the front and the back.

And overall, there's a lot of assuming facts-not-in evidence. There may be multiple explanations for things. But things always have to be viewed in totality, and not just come to a conclusion and then see only the things that support that conclusion. There's a domino effect to much of this. In other words, if A happened, it would have triggered B, which would have triggered C, which would have triggered D. And if B, C, and D aren't evident, then maybe your take on A isn't correct.

Also bear in mind that while trying to figure out what "really" happened, we are missing a HUGE piece of information that's usually critical to an accident investigation: Spatial relationships. In other words, where was this in relation to that? It can make a difference. Specifically with shoes, were people sleeping in their bunks with shoes on? Or were there shoes outside their bunks and they got up put them on? Knowing the location of the shoes may make a major difference in determining what happened. You can speculate all you want, but the reality is that we don't know.

Also remember that not only did everything burn/melt downward into the bunkroom as this fire ranged, but when the boat sank, it flipped over in 60+ feet of water. So things fell out on the way down, which again changed the spatial relationship. Then everyone and everything was on the bottom. 4 bodies were recovered that morning, 16 more by then end of the first day, 13 more by the end of the second day, weather then went bad and they couldn't dive for a while, and the final body was found about a week later. That entire time, things were moving and shifting, again changing the spatial relationships that might provide more context.

Staying on the importance of spatial relationships and the shoes, if the boat hadn't sunk and the report was that ten bodies with shoes on were recovered near the base of the stairs, I think then you'd have an additional piece of info to support the idea they were awake and trying to get out. But we just don't know with any level of certainty. So we need to be very careful about making leaps of faith and decide that this means that when it could possibly mean two or three other things too.

On to some specifics.

As you all likely know, CO (carbon monoxide) is a big problem. At 20%, it's incapacitating. At 50%, it's lethal. Also keep in the back of your mind that one part of the overall theory is that the ventilation system on the Conception may have been sucking in smoke and junk from the fire on the main deck and pumping it not only into the bunkroom but through the individual vents directly into each bunk. This could easily and quickly incapacitate people as one of the experts I've talked to about this says three or four breaths of this poison (CO) could be enough to kill you or severely incapacitate you. And since it was 3AM and people were asleep, there's argument that they simply never woke up.

On top of that, 17 people had traces of cyanide in them, which is given off when plastic burns. 3% and above is a lethal does, and 6 had less than 2% and 11 had less than 1% but even those small amounts can be incapacitating, especially when you add that on top of the effects of the CO.

The shoes certainly give one pause to think. The idea that at least some of those people were awake and put shoes on to try to flee may not be totally without merit. By the same token, I personally have slept in Uggs simply because my feet were freezing after a day of diving. And remember too that three people only had one shoe (yes, the other could have been burned up), and four of the people had shoes in the body bag but not on their feet. Of the 12 people with at least one shoe on, 7 of them have CO levels above 75%, 2 had levels 50-75%, and 3 had levels 39-50%.

As for the cell phone in hand (19-11426), I know plenty of folks who fall asleep at night listening to music through an iPod or cell phone. One test I would hope investigators would do if possible is with that phone. Since they know whose it is, they can get the number. I'm not sure if there's a cell tower on Santa Cruz but if there's a signal, it's possible to make cell calls from bunk room. (I've done it). Is there evidence of that phone trying to make a call? Or is it possible to pull the SIM card or something like that to see what the phone was doing? I don't know the answer to either of those but that would be information that could provide a more complete picture.

With the flashlight (19-11440), one of my DMs stopped by today and we were talking about this. She mentioned that she always sleeps with a small light in her hands, tucked under her pillow (hand and light), in case she needs to get up in the middle of the night. Yes, if you're up and its smokey, you might want to have a light to find your way. But again, that's not the only possibility.

The other reason I encourage caution about concluding too much are things like this:
• One person had a backpack full of clothes with them in the body bag (not wearing the backpack, just included) which means what? (19-11433)
• One person had on a necklace and earrings on, but I don't think for a minute it's because she wanted to look nice when she got out. (19-11445)
• One person had a portable lamp with them (19-11438) that was included in the body bag and I have no idea what that implies.

My overall point is there's a lot of raw information and it's easy to draw wrong conclusions when you take it out of context or don't consider it within the totality of what's known and what's not known. And sometimes the answer we're stuck with is, "I don't know." (And the speculation just in this thread is a good example of why investigative agencies are loathe to release info or comment before a final report is prepared.)

This was a terrible tragedy. We've just been inundated with new information. Take some time to digest it and really see what it means or doesn't mean. But changes have already been made both in our attitudes and awareness as divers, and in procedures and protocols that boats, not just in CA but around the world, are implementing. And as horrible a day as September 2, 2019 was, perhaps something good can come from it to insure that it never happens again.

- Ken

 

[DandyDon]

As you all likely know, CO (carbon monoxide) is a big problem. At 20%, it's incapacitating. At 50%, it's lethal.

I don't want to derail you here, and while I greatly appreciate your expert input, I'm confused here. 20% would be like 200,000 ppm which if several times a lethal level, so maybe I am reading it differently than you intended?

 

[O-ring]

Thanks, Ken, point well taken. Do you know if there is any additional testing/investigation going on to determine any of the spatial context of victims or items on what is left of the hull? I am not a forensics guy, but I wonder if it would be possible to do some DNA sampling (or other testing) on what remains of the hull to figure out the in situ position of some of the victims prior to the capsizing. That may not be possible due to the heat, but I do know in some instances that DNA can still be recovered/tested even after substantial thermal degradation.

 

[Ken Kurtis]

Do you know if there is any additional testing/investigation going on to determine any of the spatial context of victims or items on what is left of the hull? I am not a forensics guy, but I wonder if it would be possible to do some DNA sampling (or other testing) on what remains of the hull to figure out the in situ position of some of the victims prior to the capsizing. That may not be possible due to the heat, but I do know in some instances that DNA can still be recovered/tested even after substantial thermal degradation.

To my knowledge, no. In addition to the heat, the fact that the hull sat in salt water for well over a week coupled with the agitating action of whatever currents and surge it was exposed to (remember that operations were suspended for a while because weather/water conditions deteriorated) I would think might wash a lot of that away.

 

[Ken Kurtis]

20% would be like 200,000 ppm which if several times a lethal level, so maybe I am reading it differently than you intended?

I appreciate your input Don. I agree it reads a bit confusingly but the lab the samples were sent out to report it back in %, not ppm. These are derived from blood samples, not measuring the actual gas. I think they're likely measuring COhb which is what's produced in your blood when you're breathing CO. They then calculate the % of the hemoglobin bonded with the CO. It's significant because that hemoglobin is then not available to carry O2 to vital organs. As an example, smokers have a COhb of 3-8% when inhaling smoke from cigarettes over a period of time. I can't recall (or find) the specific reference I used for the 20% and 50% thresholds, but here's a publication from NIH (National Institute of Health) that's a bit wonky but gives similar thresholds and much more detailed info: https://www.ncbi.nlm.nih.gov/books/NBK220007/

ADDENDUM (just thought of this after I walked away from the computer): We're looking at opposite ends of the same issue. It's input vs output. For input, we're looking at the actual gas and using ppm as the measurement. For output, we're looking at what that ppm resulted in, and the unit of measurement is % (of COhb in the blood, even though it's referred to as CO).

 

[DandyDon]

I appreciate your input Don. I agree it reads a bit confusingly but the lab the samples were sent out to report it back in %, not ppm. These are derived from blood samples, not measuring the actual gas. I think they're likely measuring COhb which is what's produced in your blood when you're breathing CO. They then calculate the % of the hemoglobin bonded with the CO. It's significant because that hemoglobin is then not available to carry O2 to vital organs. As an example, smokers have a COhb of 3-8% when inhaling smoke from cigarettes over a period of time. I can't recall (or find) the specific reference I used for the 20% and 50% thresholds, but here's a publication from NIH (National Institute of Health) that's a bit wonky but gives similar thresholds and much more detailed info: https://www.ncbi.nlm.nih.gov/books/NBK220007/

ADDENDUM (just thought of this after I walked away from the computer): We're looking at opposite ends of the same issue. It's input vs output. For input, we're looking at the actual gas and using ppm as the measurement. For output, we're looking at what that ppm resulted in, and the unit of measurement is % (of COhb in the blood, even though it's referred to as CO).

Ok, thanks, that makes more sense.

 

[Bob DBF]

• One person had a backpack full of clothes with them in the body bag (not wearing the backpack, just included) which means what? (19-11433)

I don’t know if you would know how the evidence was collected, but would they pick up everything in the immediate area of the body?