Fire on dive boat Conception in CA

[roakey]

Anyone who studies unusual (freak) accidents learns that they often result from a series of three or more system and minor human errors that compound in unanticipated ways. It is intellectually easy to focus on a single failure, but the vast majority of those have already been discovered and corrected.

Considering the decades long history and phenomenal number human-days of safe operation on this and very similar vessels, I think it is fair to say that the Conception disaster qualifies as a freak accident. The point is don't obsess on the simple when history indicates that the obtuse is likely.

^ This.

For anyone whose job it is to really understand the root cause of problems, rather than just blaming it on 'Human Error' - which is common excuse - may I recommend: "The field Guide to Undertanding 'Human Error'"; an excellent book that makes it painfully obvious that in many cases systems were designed in such a way as to promote 'Human Error', and as long as 'Human Error' is blamed, the root cause will never be fixed.

Roak

 

[Madacub]

Regarding realistic expectations:

1. Do you actually see any such “meets current standards” statements in use when you shop for a charter boat, or is that purely a “what if” concern?
2. Based on what you now know, assume any older boat was built to older standards. Your next questions are “how have those standards changed over the years?” and “was there a more recent renovation that required the boat be brought up to code?”

The main question then is what has changed in 40 years? Might not be all that much.

Good points. And thanks, cerich & Wookie, interesting. And I agree with Wooikie " No one on the entire planet gives 2 craps about the intricacies of what the safety inspection really consisted of". Me neither. But I could get interested if the captain was to be kind enough to engage with me - that's just me, and I'm sure many others. I like the technicalities - within reason.

1. Purely "what if".

2. I agree with you. But I would not want to see the meaning of the phrase "meets current standards" degraded, because then it would be a meaningless phrase. So I was trying to find out from industry people if this is already the case.

I'm done with this sub sub thread, so unless someone has something specific, maybe we could end it (?).

 

[Wookie]

Good points. And thanks, cerich & Wookie, interesting. And I agree with Wooikie " No one on the entire planet gives 2 craps about the intricacies of what the safety inspection really consisted of". Me neither. But I could get interested if the captain was to be kind enough to engage with me - that's just me, and I'm sure many others. I like the technicalities - within reason.

1. Purely "what if".

2. I agree with you. But I would not want to see the meaning of the phrase "meets current standards" degraded, because then it would be a meaningless phrase. So I was trying to find out from industry people if this is already the case.

I'm done with this sub sub thread, so unless someone has something specific, maybe we could end it (?).

Captains are unusually proud of their vessels. They will engage with you. As I do here. It's important for me to answer questions about why fires start, and what do we do to stop them, and what are the rules.

It keeps me sane. I had 3 friends and a crewmember die on that boat.

 

[nolatom]

New requirements may indeed come from this tragedy depending on the facts and the reaction thereto. Why don't we as designers, mariners, inspectors, regulation-writers, professionals (or amateurs), society in general, forsee and prevent such risk beforehand, even if no such tragedy has occurred in the last (fill in fairly large number here) years, or indeed never?? Why is hindsight so obvious, and foresight so cloudy?

Safety upgrades in the maritime world in general, have historically been more typically reactive than pro-active. I was advised in Coast Guard Marine Safety Basic Indoctrination Course ("MSBIC") years ago, "All the marine safety regs are written in blood", and unfortunately it seems to have been (and still be) the case in spite of efforts to anticipate and prevent.

From the SULTANA explosion, fire and sinking came boiler inspections and the beginning of vessel oversight by government, including licensing of ship engineering (boiler/machinery) officers.
From TITANIC, lifeboat requirements, Ice patrol, radio distress signaling and listening.
From GENERAL SLOCUM, tightened inspection of tour boats and firefighting equipment
From MORRO CASTLE, building ships with less-flammable materials, CASTLE, a cruise ship, burned like a torch off the New Jersey coast with many lost lives.
From ESSO BRUSSELS / SEAWITCH collision and the YARMOUTH CASTLE fire, the effectiveness of fire-resistant construction and the dangers of grandfathered-in ships with all the wood-furnished interiors and their reliance on roving fire-watches.

There are many other instances, dealing with different risks (pollution, navigation, sinkings), but these are the ones I remember that dealt mostly with fire. I won't get into T-Boat small passenger vessel regs as I'm just too rusty. Listen to Wookie (and the regs themselves), not me, in that regard.

Is it human nature to be complacent about such things? I've slept in the "down-under" dive boat accommodations and was careful to note where the hatch was in relation to my bunk, but didn't give too much thought to fire risk. And I do know from experience how hard it is as a watchstander, (especially when you're not underway), to stay awake in the couple hours before sunrise, the "4am factor" is a real thing in ship accidents; Effects of fatigue on safety - Wikipedia

I don't know if this adds to the discussion but you could look up any of those ship names if you're curious. As a former marine inspector, casualty investigator and retired Coastie (full disclosure here), with an occasionally-used 100-ton license, and a diver, and admiralty attorney, maybe I see "too many sides at once" when I look at something this awful happening to good people.

 

[Akimbo]

Why don't we as mariners, inspectors, regulation-writers, professionals (or amateurs), society in general, forsee and prevent such risk beforehand, even if no such tragedy has occurred in the last (fill in fairly large number here) years, or indeed never?? Why is hindsight so obvious, and foresight so cloudy?

Sometimes disasters are predicted. Take the Challenger space shuttle for example. People have to make judgements when evaluating risk. Usually we are right, until proven wrong. Here is one my favorite quotes:

The great majority of the cumulative knowledge presented in diving classes at all levels resulted from accidents that scared the hell out of, injured, or killed someone. Thanks to all the pioneers the preceded me, living or not.​

 

[cerich]

Because of work, I spend about three months staying in hotels, because of my past experiences and knowledge I "almost" always look for the fire escape routes before I go to sleep. Last night, I stayed in a Sleep Inn and while I noted the fire exit, didn't give it more thought until about 20 mins later when I realized I had left my shaving bag in the car. Being only on second floor and fighting the fat, decided to take the stairs. The marked fire escape stairwell door from the second floor was locked. The only egress from the second floor would have been the elevator (don't use in fires), breaking out the room window or the hallway did have a place that overlooked the lobby that I could have made a 20 ft or so jump to tile. I called the fire department and reported them.
Regardless, I'm a wee bit paranoid about this stuff and how many don't even note where the fire escapes are?

I guess what I am saying is that there is risk in life, mitigate when you can but don't let fear stop us from living.

 

[rjack321]

Let me suggest that people do a search here on Scubaboard on the subject of the PST high pressure cylinders that were produced under an exemption certificate and how the divers reacted when it looked like for a while that the exemption certificate would not be renewed and people would not by law be able to get their HP exemption PST cylinders hydro tested nor filled, nor would they be lawful for transport.

How many divers have either PST, Worthington or Faber exemption cylinders? Are they all being irresponsible?

Exemptions series steel tanks are still being built (because of the way CFR sausages get made or not) so IMHO a better example would be an exemption 6351 aluminum cylinder with a 3AL overstamp and VE+ stamp that is still in service in 2019.

 

[Dirty Mac]

I am new to this board so forgive me if I make some mistakes in etiquette. I've been a lifelong boater since I'm 9 yrs old and am 58 now, and I come from a long line of professional seamen. I've been diving for 20 years now. This story has overwhelmed me both as a sailor and as a diver. I've read every single post in this thread over the last week and I finally felt I needed to put my 2 cents, FWIW

1.) Regarding the speculation on the source of the fire being charging stations/batteries: Yes we are speculating at this point, but according to the preliminary statements made by the NTSB, recounting their interviews with the surviving crew....even one of those survivors "speculated" the same thing as we are.

2.) Why does everyone assume the fire was amazingly fast? Also according to NTSB statements based on survivor interviews: A crewmen was last in the galley/salon area approx. 2:35 AM. At approx. 3:15 AM a crewmen heard a sound that he thought may have been a person tripping. Upon investigating that sound, the fire was first discovered and it was already a full blown conflagration. No alarms either sounded or were heard for whatever reason. That means even if the fire started 5 minutes AFTER the crewmen left the galley...that leaves 35 minutes for the fire to build and spread before being detected at 3:15 AM. This is way more than enough time for it to become the conflagration it was.

3) Lastly on the issue of having passed CG inspections and having been found compliant. All such codes, are based on the concept of "minimum" requirements. This is the same across all industries. In other words, this is the minimum needed to be compliant. This is not a "get out of jail free card" as confirmed by a good friend of mine who is a lawyer specializing in civil and criminal tort cases. If a case can be made in court that the minimum standards were not sufficient to the specific circumstances / design of that boat, house, car etc. and that a reasonable person could reasonably foresee a situation in which those minimum standards were inadequate, that owner can be found to have had a responsibility to go above those minimum requirements. I.E. minimum CG standards require 2 points of egress, but in this case, both those exits lead into the same enclosed space, and that space is the galley /salon, and most boat fires start in engine rooms and galleys, which could lead to both exits being blocked by fire. And he told me this is precisely the argument he would make and this is precisely why the insurance company has moved so aggressively to try to limit its exposure here using an 1851 law that has been employed since the sinking of the Titanic.

Just some food for thought.

 

[PDX Diver]

My professional work involves the 8D problem solving process, "a detailed, team oriented approach to solving critical problems". I feel we are in essence performing the first four steps:

D0: Preparation and Emergency Response Actions: Plan for solving the problem and determine the prerequisites. Provide Emergency response Actions
D1: Use a Team: Establish a team of people with product/process knowledge.
D2: Describe the Problem: Specify the problem by identifying in quantifiable terms the who, what, where, when, why, how, and how many (5W2H) for the problem.
D3: Develop Interim Containment Plan: Define and implement containment actions to isolate the problem from any customer.

The containment actions that we are working out could save lives. I think we all feel less safe, and have the strong desire fix it. Go team!

The remaining steps will be handled by the professionals, and will take a year or more. This is why the containment action is so important. Their report due out any day now will be in essence a step to define containment. Who knows, maybe they're reading this board thread, they probably should be.

Fortunately my work as a software engineer doesn't involve mission-critical systems, and my mistakes don't kill people. I think about this whenever an incident like the Boeing 737 Max comes up, I just can't imagine... I have and hope for compassion towards ALL those involved.

 

[pauldw]

We don't accomplish the goal of facilitating learning by excessive censorship.

Let me fix that for you: We don't accomplish the goal of facilitating learning by censorship.

Sadly it may be a year or more before such a report comes out.

NTSB said their bureaucrats would take a year or more. However, they also said they'd announce preliminary information this month (and that does seem like adequate time to interview people and get a decent feel for the case). NTSB, however, is not the only agency investigating. The district attorney, for example, isn't likely to take a year and a half to make a decision.

As contradictory as this is going to sound, it wouldn't bother me if SB said that until the announcement comes out, people can post something but have to wait until overnight to rethink and reapprove what they said before it actually shows up.