NTSB Suggested Tougher Standards After Fires on Two Other “Conception”-sized Passenger Vessels Showed How Flames Easily Go Undetected and Then Spread Rapidly

By Robert R. Frump

In two previous cases, on vessels similar to the dive ship Conception, the National Transportation Safety Board called for tougher fire safety and detection systems for small passenger vessels so that the crew could be warned earlier of fires developing in hard-to-access areas of the vessels.

The most recent call for improved systems came in December 2018 after the NTSB feared it was seeing repeat cases of the original 2004 casualty. The NTSB first called for tougher standards in April 2006, more than 13 years ago.

The most recent report on the Island Lady, a vessel close to the age and size of the Conception, said:

“As a result of its investigation, the NTSB issued four safety recommendations including two to the U.S. Coast Guard which seek a requirement for fire detection systems in unmanned spaces with machinery or other potential heat sources on board small passenger vessels…”

The report added:

“The US Coast Guard does not require small passenger vessels to have preventive maintenance programs and, importantly, even when such programs are voluntarily in place (such as in this case), the Coast Guard provides no enforcement oversight.”

Caption: Island Lady Fire

The NTSB report about the January 2018 Island Lady fire was released in December 2018. — more than nine months after The Conception was inspected in February and March 2018.

It is not certain whether the findings in these two cases have a direct bearing on the “Conception,”  but the past case studies sketch a likely path of inquiry for the NTSB now. The tragedy is likely also to result in a formal Coast Guard Marine Board of Investigation — the Coast Guard’s most formal level of inquiry.

The previous NTSB  reports show vividly how fires can start on small passenger ships and spread without crew awareness if leaking lines in hidden areas spray fuel on hot manifolds or overheating engines in hard-to-reach areas of the vessel.

It is not clear whether the Coast Guard now requires fire detecting systems in areas that are hard to access as suggested by the NTSB this past December or whether the Conception was equipped with such a system — required or not. The Conception is said to have had fire suppression systems, but if not coupled with detection systems, the suppression system may not have helped.

The vessels in question were similar in age, size and purpose.  The Island Lady was 30 years old, 72 feet long  and could carry 149 passengers. She is listed at 65 gross tons. The dive ship Conception was 38 years old, rated to carry 99 passengers, was 75 feet long and listed at 97 gross tons.

If the warning systems had been present, the NTSB said, the ship’s crew of the Island Lady could have more effectively fought the fires sooner.  In both cases, one in 2004, and the other in 2018, the NTSB recommended that the Coast Guard focus on fire systems inspections and require owners to regularly maintain wiring and other systems.

The Island Lady suffered a fire on January 14, 2018 in the waters of the Pithlachascotee River, near Port Ritchey, Florida, ferrying passengers to a casino.  She was carrying 53 people including 36 passengers. One passenger died.

The NTSB investigated the Island Lady in part  because of a similar fire in 2004 on board the Express Shuttle II, another of the operating company’s casino vessels. It was more than a decade ago that the NTSB first raised the issue of fires starting in hard-to-access areas.

The Island Lady fire was discovered when the captain received a high-temperature alarm for the port engine’s jacket-water system.  But by that time, a fire was already well underway because of engine and exhaust overheating Smoke began filling the vessel and  the captain was able to deliberately beach the ship. Most passengers were able to wade ashore.

It is not known how the Conception fire started, but appears to have been discovered only after it was far advanced.  Passengers on the dive vessel passenger ship were trapped below and many are thought to have perished.

The NTSB report showed how complex systems can poentially go wrong and cause fires aboard such passenger ships as the Conception and the Island Lady.  Essentially, on the Island Lady, the engine and exhaust cooling systems failed causing the fuel tubing to degrade, resulting in leakage and ignition.

“The NTSB’s investigation determined that lack of guidance on  engine high-temperature alarms resulted in the captain idling the engines rather than shutting them down, helping lead to the fire.  

“Moreover, the absence of fire detection and suppression systems in unmanned spaces housing exhaust tubing prevented swifter detectin and response, and the failure of the port engine’spump led to overheating the engine and exhasut tubing.

“Moreover, the use of plastic tubing on  tank level indicators with no automatic shutoff valves released diesel fuel, which made the fire worse.  The report also states that the Coast Guard did not correctly assess the Island Lady’s fuel system’s compliance with its own systems. “

In the 2004 incident, a similar chain of events lead to the fire. A fractured fuel line, improperly installed, was not detected because the fire detection system was faulty.

“The National Transportation Safety Board determines that the probable cause of the fire on board the Express Shuttle IIwas a fractured, improperly installed fuel injection line on the inboard side of the starboard engine that allowed diesel fuel to spray onto the engine and ignite. Contributing to the cause of the fire was the failure of Paradise of Port Richey to have a preventive maintenance program, which could have identified the company’s ongoing problem with the vessel’s fuel lines before a failed line led to the fire. Contributing to the extent of the damage were the vessel’s faulty fire detection system and the crew’s failure to employ proper marine firefighting techniques.”

Here is a link to the full Island Lady report, and below are the NTSB summaries of the two reports.