(formatting not mine - cut and paste from the CC box at the bottom)
Findings:
Number one, weather and sea conditions were not factors in the accident
Number two, the use of alcohol or other drugs by the Conception deck crew likely was not a factor in the accident
Number three, the origin of the fire on the Conception was likely inside the aft portion of the salon.
Number four, 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
Number 5, the exact timing of the ignition cannot be determined
Number 6, most of the victims were awake, but could not escape the bunk room before all were overcome by inhalation
Number 7, the fire in the salon on the main deck would have been well developed before the smoke activated the smoke detectors in the bunk room
Number 8, although the arrangement of detectors on board the Conception met regulatory requirements, the lack of smoke detectors in the salon delayed detection and allowed for the growth of the fire. Procludeed firefighting and evacuation efforts and directly led to the high number of fatalities
Number 9 smoke detectors on is up chapter it, and K vessels would increase the chance that fires will be detected early enough to allow for successful firefighting and the evacuation of passengers and crew
Number 10, the absence of the required roving patrol on the Conception delayed detection and allowed for the growth of the fire precluded firefighting and evacuate efforts and directly lead to the high number of fatalities in the accident
Number 11, the U.S. Coast Guard does not have an effective means of verifying compliance with roving patrol requirements for small passenger vessels
Number 12, the Conception bunk rooms emergency escape arrangements inadequate because it was obstructed by a well developed fire
Number 13 subchapter T been old and new" are not ad equate because they allow for primary and secondary means of escape which could result in those paths blocked by a single hazard,
number 14, although designed in accordance with the applicable regulations, the evtiveness of the Conception bunk room escape hatch by means of escape was diminished by the location of bunks immediately under the hatch
Number 15, the emergency response by the Coast Guard and municipal responders to the accident was appropriate but was unable to prevent the loss of life given the rapid growth at the time of the dedetection of the Conception
number 16 safety regulations were was inadequate.
Number 17 had the safety management system implemented Truth Aquatics could have identified unsafe practices and fire risks on Conception and taken corrective action before the accident occurred
number 18, implementing safety management systems on all domestic passenger vessel would further enhance operators ability to achieve a higher standard of safety.
