Conception dive boat captain indicted on 34 counts

This Captain apparently came up in this California dive boat trade and has 30 years of experience. It’s what he knows. Apparently, it’s all he knows.

He did not ignore or neglect known risks. He followed the universal standard operating procedure in his trade, in his company, and on his vessel. He did exactly what he had been trained to do for 30 years. He knew that what he was doing was safe and acceptable because it had at least a 30 year track record of proven success in that trade, at that company, and on that vessel.

He failed to foresee the new element of danger from charging lithium batteries. How many of us might have foreseen that? 1% of us?

If he had “known any better,” and if he had refused to follow the standard operating company, and fleet wide, procedures in that trade, he would have been instantly replaced by someone that would follow the customs of that trade.

With the benefit of hindsight, what is needed here are major design, construction, and operating safety improvements throughout this entire fleet and trade, not a scapegoat , so that everyone else can dismiss this as a one time oddball event caused by a bad Captain, and then just continue with business as usual.

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You: Hey there fish, is that water wet?
Fish: What’s water?

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Ever get asked to do all the W&B in flight?
Me: “What the hell…why bother if I already took off? A little late to discover I’m heavy?”
Company: Well we don’t pay you to leave shit on the ramp, you’re loading it ALL.

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Blame does not prevent accidents.
Accidents almost always have a human involved who did or didn’t do something at some point.
The vast majority of these are errors or mistakes rather than wilful acts.
On very rare occasions the action or lack of action was the result of a wilful decision to act or not act in a manner which contributed to an accident.

In a just world, accountability still exists. For those rare occasions.

This particular case, involves a specific rule which was not complied with. The roving patrol.
Regular drills was also reported to be a problem.

The law was not followed, the requirement was written. Appears at first glance to be easy open and shut case.
March the guilty bugger in, try him fair and square, find him guilty and hang him from the nearest yard arm.
Problem solved.

In reality. It’s not that simple. In order to prevent incidents like this, or duck boats sinking.
We still have to determine, why
Not just why did this particular skipper not comply with requirement.

Why was it a common practice for the dive boat industry not to comply? Throughout this company and others.
Why was this requirement not monitored by the regulatory body?

There are plenty of people to blame.

Would the skipper have been fired if he chosen to follow this rule? I doubt the question ever occurred to him or his employer. There is no suggestion it did.

Anecdotal opinions of the regulatory body. This was one of the better run small passenger vessels companies in the area. With a good reputation for safety.
It is quite possible even probably, if this had ever been brought up or pointed out to the company they may have made the appropriate change.
The truth is they had 2 more Crew than the manning certificate required.
Indeed they appeared to have thought having one of the crew sleeping in the bunk area somehow met the requirement.
It would not have been a big cost to change this to someone being on watch.
No additional crew required, just rearranging how the existing crew worked.
It would have been a significant change in understanding what was required. Resulting in a significant change to “the way we do things”. Which might not have been popular or easily understood before this incident.
If only someone at sometime had said a a roving patrol means someone has to be on watch.
Particularly if this had been an inspector.
It would most likely have been complied with.

A common theme for accidents. Sometimes some of the best humans make some of the worst mistakes.

This incident and unfortunately several previous incidents highlight a ongoing problem with small passenger vessel operations. Which requires better regulatory oversight and education.
All of which have been recommended by the NTSB and not implemented by the regulatory body.

What it boils down to here is two ways of trying to understand this incident.

One way is to focus on what the captain did wrong. In this case the captain is responsible for the safety of the vessel, crew and passengers and he failed to set a watch as required and failed to identify the risk of fire.

A second way of looking at it is assume that the captain was experienced, wanted to avoid risks and hazards to his crew and passengers and did so to the best of his ability.

Of course, not knowing or understanding all the facts, that assumption may be wrong. Looking at this from that point of view is an attempt to understand, not a search for excuses.

2 posts were merged into an existing topic: An Engineering Approach to Safety

It’s hard to reconcile this reputation with the reality. In addition to no night watches being assigned, passengers reported that they slept on the boats the night prior to departure with no crew aboard and an incomplete safety briefing wasn’t delivered until after the 30 mile crossing to the islands. They didn’t even react to sparks coming from outlets when plugging in chargers or to a battery fire months before the tragedy.
Management, captains and most passengers were evidently comfortable with this level of complacency but I find it odd that over all those years not a single passenger with maritime knowledge ever questioned any of it. I also find it hard to believe the CG would have allowed any of it to continue if they’d been made aware of it.
The people running the business were lucky to get away with it for as long as they did.

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Just adjust your world view accordingly.

Before the EF I thought it was absolutely impossible for a ship to sail into the eyewall of a hurricane.

The fact that the wind circulates counterclockwise around a low pressure system (N. Hemisphere) is so fundamental that it’s just not possible that a professional mariner wouldn’t understand that.

Except it turns out it is possible.

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Not to mention the Bounty.

Yep, hard to reconcile, after the fact.
Lots of deficiencies. Some glaringly obvious. To many of us who have experience elsewhere.
Points to the complacency going further than just the vessel skipper and manager and owner.

The reputation, was not just a validation from the inspector, it was a selling point to the customers.
The passengers probably genuinely believed they were booking their trip on a well run ship on a tight safe operation.
Because nobody ever looked closely at it. Or questioned its many very questionable practices.
The reputation served as a free pass.

A half way competent ABS audit would have picked up most if not all of those deficiencies.
Probably not the construction or design flaws but the operational procedures or lack of procedures.
However Audits of this type are not required and audits can only measure against applicable standard.

There is no applicable standard to measure the company’s non existent procedures against.

Just the opinion of the skipper and the almost nil questionable feed back from the CG inspections.

One might even consider CG inspectors complacency. To have been negligent or incompetent.

They certainly played a significant contribution in the many underlying causes of this tragedy.

There’s a difference between being good at your job at sea and being good seaman. It’s possible to be good at your job but not understand some basic principles of seamanship.

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There a lots of people who are “good at their job” from the point of view of HR and “the office,” and perhaps even from the point of view of the Captain, but . . .

when it comes to seamanship, they wouldn’t be a goosebump on the left nut of a real seaman.

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The captain probably ran efficient and safe dive ops, kept track of maintenance, happy customers, exceptional boat handling and so forth.

Making sure that precautions against low probability high consequence events are in place can’t be left to be handled at the lowest level (the boat).

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True,
For a small single vessel operation, the entire process could be the vessels on board Management Team, which in the case of a very small vessel might be just a single person.

Part of the reason a good inspection or audit process is fundamental to a safe operation.
Is not just finding fault.
It’s educational.
A good seaman learns from good audits.

The audits were not good and good lessons about good practices were not learned.
This guy, worked for a company which left him to developing his own operation without much impute from outside.
With no information to the contrary, other operators within the company and local industry learned from this and other poor examples.
Coast Guard inspection rubber stamped it as a good example.
Leaving poor lessons learned in place, which were believed to be ok.
The result a horrible tragedy which could have been easily avoided.

Not an unfamiliar story, it goes back to the Titanic and beyond.

This is common when plugging in even fairly small switching power supplies like laptop chargers and phone chargers. There’s a heavy inrush current as the power capacitors get their initial charge. This becomes an arc in the initial stage of plugging in, when contact makes and breaks on a millisecond scale. Likely it would be heard rather than seen.

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I’ve experienced that on a very minor scale but the NTSB contains a statement that it was more than that. One of the crew reported actually seeing sparks when he plugged in his phone. Coupled with the fact a battery had already exploded in flames a few months previous should have drawn someone’s attention but of course all this is in hindsight.

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That’s an important point. A captain running a small boat with a small crew is the only one with a license and makes all the decisions by himself. There are no qualified mates or chiefs to advise him and none of the crew is likely to question his decisions unless he proposes doing something completely outrageous.
Of course there’s this: the captain of the EF ignored his qualified support system and continued head on into a hurricane.

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I get what your saying here with regards to no advice but the captain is not really making all the decisions. He’s operating the boat to meet requirements of the company. It’s the company that controls what the boat is doing in general.

If the captain had decided to skip serving meals to the passengers for example no doubt he’d of heard from the company. He could however skip the roving watch and the company evidently would say nothing.

I should add that I understand that the captain is responsible for the safety of the passengers. I imagine the owner saying that would sound like a very hollow excuse.

They think the fire was due to batteries igniting, it might be wise to make it a requirement that all unsupervised LiPo batteries must be stored in a fire proof battery box like the ZARGES K470 seen at the link below.

There is no SMS or audits for these small vessels

SMS and audits may be valuable on large vessels.

At least on tugs, I see SMS and the paperwork, and the “audits” as nothing more than pencil whipped bullshit with no value.

There is no substitute for having enough qualified crew. That is the major short coming.

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