NTSB CONCEPTION HEARING - THIS TUESDAY @ 10AM

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Watching now. Lack of a roving patrol is being emphasized as a big issue. Truth Aquatics vessels regularly operated without roving patrol. There was no way to verify roving patrols occurred. No requirement for a log of such patrols.

USCG has not issued a fine or citation since 1991 for lack of roving patrol (on small passenger vessels?).
 
I missed the first couple hours. Now they are discussing mandating interconnected smoke detectors and developing systematic safety planning/procedures. They are also discussing the earlier fire on the Vision due to lithium batteries and the subsequent rule to not allow charging at night. The owner said he was never made aware there was ever a fire on the Vision, but the Captain says he was informed. A fire extinguisher was discharged and would have to have been recharged, etc. so there are questions about how the owner could not be aware. They are on a 17 minute recess right now.
 
A dominant theme has been that Truth Aquatics had a reputation for being a very safe operation, but they didn’t follow their own safety procedures. The owner repeatedly said he left it up to captain’s discretion for drills and such.

Talk about normalization of deviance. Reliance on luck instead of safety procedures until many small defiance’s built up into one big one.

The lack of a roving patrol seems to be the one big issue so far as well as the escape hatch
 
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I've watched every minute, will rejoin after the break. Truly frightening
 
From my review of the Nautilus Explorer May 2019:

The safety briefing was very complete. Alarms, emergency lighting and all exits were pointed out. The main exit from the lower level was toward the stern, up a wide stairway, onto the dive deck, outside of the salon. The emergency exit was next to my room, up a ladder, through a hatch, into the dining room. After the briefing, with permission, I tried out the emergency exit and found the climb and hatch to work well. Ahead of time, I decided to use the main exit, unless it was unavailable to me. There was a full practice evacuation drill with gathering of everyone at the muster station on the dive deck and donning of PFDs. Several guests had to redo their PFD, until they had it right. One day, during the trip, the crew held a timed fire drill, without guest participation, in which they put on full firefighting dress and deployed hoses and other gear. I was told they perform the drill on each trip. Charging was only allowed in the cabins when you were present. I did not fully appreciate all of the safety measures until several months later.

Revillagigedos on the Nautilus Explorer, May 24-June 1, 2019
 
A dominant theme has been that Truth Aquatics had a reputation for being a very safe operation, but they didn’t follow their own safety procedures. The owner repeatedly said he left it up to captain’s discretion for drills and such.

Talk about normalization of deviance. Reliance on luck instead of safety procedures until many small defiance’s built up into one big one.

The lack of a roving patrol seems to be the one big issue so far as well as the escape hatch
The other big issue is interconnected smoke detectors, everywhere.
 
It really sounds like a completely broken system to me. Hard to even say that safety was an afterthought, I have the impression it wasn't thought about at all.

I wonder if the captain or owner will win the finger pointing contest they have going on.
 
(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.
 
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