Dive Boat Conception

For 15 Years, the National Transportation Safety Board Has Warned the US Coast Guard That Preventive Maintenance Reforms Were Urgently Needed to Avoid Catastrophes Such as the Dive Ship “Conception”

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Posted by Robert Frump
Copyright 2019

By Robert R. Frump

For more than 15 years, the National Transportation Safety Board sharply has warned the US Coast Guard that it should require preventive vessel maintenance programs to avoid future small passenger ship fires such as the one that killed more than 30 people last week on the dive ship “Conception,” an in-depth look at NTSB records reveals. 

“With a required, ongoing preventive maintenance program, owners might be less likely to operate substandard vessels that place the public at risk,” the NTSB said just nine months ago after investigating a 2018 fatal fire on board a casino shuttle vessel.

The safety board also has advocated for required fire safety training for crews.

The cause of the Conception fire is not yet known and may not be related to the NTSB warnings about preventive maintenance and crew training.

But a check of NTSB records seems to show that every serious small passenger vessel fire in the past 20 years has been associated with poor systems maintenance that might have been avoided by a preventive program.

Moreover, the NTSB 15-year prophecies about substandard ships came true last year when a lack of preventive maintenance contributed to a ship fire that killed one person — 42-year-old Carrie Dempsey, a mother of 12-year-old twins.

It has said again and again over the years that poor preventive maintenance on hard-to-reach machinery and wiring poses real risk to tens of thousands of passengers on ferries, offshore casino transport vessels and dive ships such as the Conception — all vessels of under 100 gross tons (a measure of volume.)

“”These small passenger vessels, under 100 gross tons, are subject to far less stringent construction, maintenance and equipment standards than larger passenger vessels (those over 100 gross tons),” said Richard Hiscock, a former Congressional Committee staffer who has studied marine safety issues for many years. “There is a real gap between the two classes of vessels that urgently needs to be addressed.”

Instead of tightening regulations, the Coast Guard has resisted, rejected and ignored most of the NTSB recommendations, stating at times that the safety requirements would be unfair to ship owners and better implemented voluntarily through passenger vessel associations.

We believe that the recommended requirements would be unnecessarily burdensome and duplicative of existing requirements,” the Coast Guard said about one NTSB suggestion to require preventive maintenance designed to avoid overheating and fuel line fractures. “We intend to take no further action on this recommendation and request that it be closed.”

That response, answering an NTSB analysis of a fire onboard the Island Express II casino boat in 2002, did not close the case for the NTSB and the agency has reiterated the recommendations consistently over the years underlining them pointedly as recently as this past December.

That searing reminder in December, 15 years after the original accident occurred, came when a similar fire on a similar vessel owned by the same company in the same casino offshore shuttle trade erupted and endangered the lives of 53 passengers, this time killing a passenger.

In the 2018 incident, the casino shuttle ship Island Lady, burned on the Gulf coast of Florida. The cause of the accident, the NTSB said, was a failure to keep the ship systems properly maintained, resulting in overheating and fire. 

Island Lady

Specifically, the pump that fed the engine’s cooling system failed, causing the engine to overheat, resulting in such high temperatures that the ship caught fire in the “lazarette” – an unmanned space near the engine room – and quickly engulfed the vessel. 

Had the Coast Guard completed implementation of Safety Recommendation M-02-5, (the owners) would have been required to have a compliant preventive maintenance program subject to Coast Guard oversight, and the Island Lady fire may have been prevented,” the NTSB said. 

The NTSB followed that assessment with a detailed analysis of the ship fire, showing how the owners did not on their own adequately perform preventive maintenance as the Coast Guard says owners do:

“(The company) said that it had implemented a preventive maintenance program for its vessels after receiving Safety Recommendation M-06-12 in response to the 2004 Express Shuttle II fire. However, when investigators interviewed company officials and reviewed maintenance records, they discovered several issues with the program that indicated that it was not adequate or robust.”

The company instead had performed just normal service items such as oil changes. The importance of preventive maintenance, the NTSB said, is that owners must periodically assess the condition of critical ship systems that are not easily viewed or accessed. 

Several maintenance items that were identified in the … maintenance schedule were not included in Tropical Breeze Casino Cruz’s monthly maintenance reports, such as the zinc rod replacement, crankcase oil analysis, auxiliary water pump inspections, hose and clamp inspections, engine speed/timing sensor inspections, valve lash adjustments, and fuel injector checks, among other items. Several of these maintenance items were critical for proper operation, and the infrequent maintenance and inspection likely resulted in undetected, wear-related damage.

The owners of the passenger ship said at the time:

“As a small inspected passenger vessel, the Island Lady and its captain had passed all USCG inspections and were in compliance with all required licenses.” 

But the NTSB’s point was that the Coast Guard inspections did not cover the important systems that appeared to malfunction.

It is still unclear what caused the fire in the Conception. Some have speculated that the wiring within the ship was inadequate or faulty, causing overheating, that coffee pots shorted out systems, or even that phone chargers caused circuit overloads. Others have suggested that a fuel line leaked or that some other system, not easily accessed or maintained, failed and overheated.

The Conception underwent Coast Guard inspections and passed, but proof of preventive maintenance and crew fire training is not required in such inspections.  

The conflict between the two agencies now takes center stage as both prepare to investigate the loss of the Conception, classed as a small passenger ship, which catered to divers off the coast of California. She burned last week with the death of more than 30 passengers who were sleeping below decks when the ship caught fire.

The NTSB is an independent government review board with no enforcement capabilities, while the Coast Guard is   assigned responsibility for creating and enforcing ship safety regulations. 

The long simmering issues may create some great discomfort among the investigators because generally major hearings are held jointly with both NTSB and Coast Guard officials present.  

However, there is some thought that the Coast Guard will be more open now to self-examination not just because of the paper trail of warnings, but also because the agency has become more introspective in recent years. 

For example, in its examination of the 2015 loss of the SS El Faro cargo ship and her crew of 33, the Coast Guard Marine Board of Investigation was sharply critical of its own safety inspectors and called for reforms, many of which were quickly implemented. 

Still, the 15 years of interagency conflict has at times been acerbic. At one point, the NTSB accused the Coast Guard of simply not updating progress on standing NTSB recommendations for two years.  

The NTSB recommendations examined here deal directly with factors that might have affected the “Conception” and arose from investigations of small passenger vessel fires dating from the year 2000 aboard vessels similar to the Conception in size. (The Conception is distinct in one matter: It housed passengers overnight in below-deck beds.)

The first recommendation for reform came after an electrical malfunction started a fire that burned and destroyed the Port Imperial Manhattan passenger ferry on November 17, 2000 as she traveled from Manhattan to Weehawken, NJ. 

The NTSB report stated;

The National Transportation Safety Board determines that the probable cause of the fire aboard the Port Imperial Manhattan was …inadequate inspection and maintenance of the vessel’s electrical system.

Contributing to the extent of the damage were the lack of a fixed fire detection and suppression system and the crewmembers lack of knowledge of proper marine firefighting techniques.

As a result, the NTSB made this recommendation to the Coast Guard:

Require that companies operating domestic passenger vessels develop and implement a preventive maintenance program for all systems affecting the safe operation of their vessels, including the hull and the mechanical and electrical systems. 

Seventeen years after the accident, the matter is still pending. The file is marked by the NTSB as: Open – Unacceptable Response.

The NTSB also made this recommendation:

Establish firefighting training requirements for crewmembers on board small passenger vessels in commuter and ferry service.

Today, the Coast Guard response is still marked by the NTSB:  Open— Unacceptable Action.

A second case concerned the burning of the Island Express II off Port Richey, Florida, in 2004. In that case, a poorly installed fuel line cracked and sprayed a fine mist of diesel fuel into the engine room. The mist ignited and the fire burned intensely.

The fire burned hotter still when the crew — ignoring established fire protocol — opened the hatches, allowing oxygen to feed the fire. They forgot about built-in Co2 extinguisher systems and attempted to use a water fire hose — which did not work because it was dependent on the ship’s malfunctioning engines for power. 

The NTSB investigation reiterated the importance of preventive maintenance and added this new recommendation to the Coast Guard:

Establish firefighting training requirements for crewmembers on board all small passenger vessels. 

Fifteen years after the Island Express II incident, the NTSB still has the item marked unresolved on its books. The Coast Guard response is marked as: – Unacceptable Action

One response of the Coast Guard, in correspondence with the NTSB, is that after meeting with passenger vessel associations, the Coast Guard declined specific firefighting training requirements.

The Coast Guard said in 2009 of the Island Express II recommendations on firefighting training:

Based on the consensus reached by those in attendance (at a meeting with owner representatives), we decided to keep the guidance (on firefighting) general in nature, which allows the small passenger vessel industry the flexibility to develop and tailor the training and firefighting drills to the specific needs of each small passenger vessel.

As to a requirement of ongoing maintenance for machinery and electrical circuits, the Coast Guard declined, stating in 2003 after the year 2000 Port Imperial case:

Since vessels engaged in commuter and ferry service have accounted for only 8.4% of the fire casualties suffered by small passenger vessels from 1992 through 2000, we do not believe that extending these requirements to those vessels is justified. We intend to take no further action on this recommendation and request that it be closed.

But the NTSB kept the case open — and responded to the Coast Guard with increasing frustration because the Coast Guard seemed to ignore the NTSB entirely. In 2016, the NTSB wrote the Coast Guard:

This letter concerns 40 open safety recommendations that the National Transportation Safety Board (NTSB) issued to the US Coast Guard between 2002 and 2015. 

For several years, the NTSB received an annual update on all open safety recommendations issued to the Coast Guard; however, for 25 of the 40 recommendations listed, we have received no update in over 2 years regarding the status of action either taken or planned to address these important safety issues.

The NTSB fired off another searing letter to the Coast Guard in December 20, 2018, pleading for the Coast Guard to implement rules requiring companies to implement an ongoing preventive maintenance after a third ship fire on another casino boat in Florida. 

Preventive or periodic maintenance programs are an integral part of any well-run vessel operation, and a requirement to develop and implement such programs should not be burdensome to vessel operators. 

With a required, ongoing preventive maintenance program, owners might be less likely to operate substandard vessels that place the public at risk. 

However, the Coast Guard has yet to require preventive maintenance programs for small passenger vessels….


…. Had the Coast Guard completed implementation of Safety Recommendation M-02-5, Tropical Breeze Casino Cruz would have been required to have a compliant preventive maintenance program subject to Coast Guard oversight, and the Island Lady fire may have been prevented.


One part of the NTSB’s concern deals with how crew members deal with passengers. In the case of the New York ferry, passengers narrowly escaped being trapped on the burning ferry. Passengers estimated that the ferry they were traveling on was completely engulfed in flames just 30-seconds after they departed. Many said they received no clear instructions from the crew — and a passenger actually was the first to report the accident to firefighters via a cell phone to 911.

Said the report: 

The passengers milled about on the foredeck and began to discuss among themselves what they should do to protect themselves from the fire. One passenger, at her own initiative, used her cellular telephone to contact the 9-1-1 emergency operator to report the fire and to call for assistance. Other passengers considered whether they were going to have to abandon ship…

…. The inability of the crew to manage the passengers caused some passengers to panic and take actions that potentially placed them in jeopardy. 

One passenger reentered the smoke-filled passenger cabin to retrieve lifejackets for him and the other passengers. This action placed him in a life-threatening situation in which he could have been overcome by the smoke before he could make it safely back to the foredeck. 

Another passenger, after hearing an explosion on board the vessel, had to be restrained from jumping into the river. Given the low visibility at night, the swiftness of the current, and the coldness of the water, a passenger jumping over the side without a lifejacket probably would have drowned before being located and rescued by emergency responders. 

Consequently, the Safety Board concludes that the crew of the Port Imperial Manhattan were unable to properly manage the passengers during the emergency because they were over tasked with fighting the fire and lacked adequate resources and training.

From its investigation of this accident, the NTSB identified safety issues in the following areas:

Lack of company guidance regarding engine high-temperature alarms

Lack of fire detection in unmanned spaces with exhaust tubing

Insufficient preventive maintenance

Insufficient crew training and documentation

Inappropriate material and design of fuel tank level-indicator system

In correspondence with the NTSB regarding the recommendation, the Coast Guard stated that small passenger vessels are already subject to a comprehensive set of regulations designed to promote vessel safety, and that operators are responsible for maintaining their vessels accordingly.