Here my take on the Boat fire accident analysis.
Read the NTSB report, it’s probably the best analysis you are going to see.
Given the limitations which come from a completely burnt out boat, having little to go on other than witness or survivor testimony and comparison with other vessel procedure.
They did pretty good.
The report contains a pretty good theory about what probably happened.
The report has pretty good theory why it probably happened.
The important part of the analysis is how to best prevent it from probably happening again.
If the NTSB recommendations are actually accepted and implemented it probably want happen again.
The public prosecutor is not happy leaving it there so criminal charges have been filed and a trail will probably take place.
At the end of which some one will be Guilty or Not Guilty.
Which in my opinion is not a very effective method of preventing accidents. But it is the way things work.
The hard part of our personal analysis of this incident. Is the finding a big contributing factor, existing regulations were not followed.
The rounds and apparently drills.
To some of us the answer to this question is common practice in the local dive boat community and industry.
To other the answer is somebody didn’t follow the regulations and broke the law.
Which leaves us with an important question outstanding.
Why did the Master and crew routinely not follow the regulations?
It was the common practice in this particular small company.
Possibly or even probably with other similar companies.
Leaving us still asking why did this company and others think this was ok.
Part of the answer is poor oversight by regulators. Partly because the regulator though they were a good company, And the regulator didn’t have a clue how to monitor or appear to have even contemplated monitoring the rounds.
A few years A Master I worked with,
Decided to take a part time business Management degree course.
Most of the concepts he tried learned about sound like BS to me.
One interesting concept
I think was call “Emergent Behaviour” Reading up on this will make your head hurt, all kinds of academic studies and papers. Applying this to all kinds of industries.
The very short version. As I understand it.
Any group of people (average humans) working together as a group, particularly if they are working in isolation.
Will gradually, unconsciously start to change the process or procedures of what they are engaged in and create their own rules.
Over time unless corrected, a group naturally creat their own rules and their own procedures which slowly deviate further from what was originally intended.
Additionally, most of these crews and masters probably started out on pleasure boats, moving up to these very small passenger vessels, learning from the guy ahead. Who came up the same way.
It is entirely possible even probable the regulations had never been followed correctly.
Is it possible, someone could look at a certificate only read it occasionally if ever and completely fail to understand what a roving patrol actually meant? For 30 years.
Apparently, Yes. Quite a few people.
The frustrating part. We don’t know why, He didn’t follow the regulations. Because the NTSB was never able to ask him.
The US DA requested the NTSB not to question the Master. In the interest of prosecution.
So it is entirely possible the Master will never be asked.
My limited understanding of American criminal law.
The accused Master has the right to remain silent.