NTSB Renews Call for US Coast Guard to Strengthen Passenger Vessel Safety

August 31, 2023

The fire-stricken Conception shortly before it sank off Santa Cruz Island in September 2019. All 33 passengers and one of six crewmembers died of smoke inhalation after they were trapped in the berthing area while a fire raged on the deck above. (Photo: Ventura County Fire Department)

Four years after the fire aboard the Conception dive boat claimed 34 lives, the National Transportation Safety Board (NTSB) renewed its call for the U.S. Coast Guard to require safety management systems (SMS) for passenger vessels. The recommendation, which the NTSB reissued following its investigation of the September 2, 2019, fire aboard the Conception, remains open.

NTSB Chair Jennifer Homendy sent a letter to the Coast Guard Commandant today emphasizing the need to issue the regulations within 30 days.

“While the Coast Guard has implemented so many of our recommendations from the Conception investigation, we’ve yet to see the necessary action taken on one of the most important ones: safety management systems,” said NTSB Chair Jennifer Homendy. “We’ve been advocating for SMS on passenger vessels for nearly two decades. The public can’t afford to wait any longer.”

The NTSB has advocated for SMS for passenger vessels since 2005, and in 2010, Congress explicitly granted the Coast Guard the authority to require such systems. Progress has been stalled since January 2021 when the Coast Guard took initial steps to address the NTSB’s recommendation.

An SMS is an enterprise approach to risk management. It is a formal organizational tool, comprising policies, procedures, checklists and corrective measures to ensure that vessel crews are operating a vessel in accordance with regulations, company requirements and best practices, with a goal of continuous improvement.

The NTSB has recommended SMS in nearly all modes of transportation—aviation, rail and transit, pipelines, and marine—as well as for manufacturers. In 2015, the Federal Aviation Administration implemented a requirement that commercial airliners develop a comprehensive SMS to improve safety for the flying public. This lifesaving mandate has contributed to the remarkable record of safety in commercial passenger aviation since then.

In December 2021, the Coast Guard issued interim rules addressing many of the recommendations the NTSB issued as a result of its investigation of the Conception casualty, but not for the SMS recommendation. The Elijah E. Cummings Coast Guard Authorization Act of 2020 mandates that the Coast Guard carry out all of the NTSB recommendations issued or reiterated as a result of the Conception investigation.

The Conception was anchored in Platts Harbor, off Santa Cruz Island, Calif., when it caught fire in the early morning of September 2, 2019. The vessel burned to the waterline and sank less than 100 feet from shore. All 33 passengers and one crewmember died of smoke inhalation after they were trapped in the berthing area while a fire raged on the deck above. Both exits from the berthing area led to the same fire- and smoke-filled area above. The NTSB concluded that had an SMS been implemented, Truth Aquatics, Inc., owner and operator of the Conception, could have identified unsafe practices and fire risks on the Conception and taken corrective action before the casualty occurred.