Way back in the day pretty much every airplane crash got blamed on the pilot, who was frequently in no state to defend himself, being dead and all.
ALPA, the union for many airline pilots, did fantastic work with “human factors”, figuring out systemic flaws in the airplanes or procedures that were to blame for many of the wrecks.
This captain should not escape blame, but as you say - hanging him high isn’t going to magically change the way everyone else has always done it. It isn’t like this guy was an outlier.
I still get mad thinking about a $20 smoke detector saving everyone.
for me, ever since this happened no one gets on my boat anymore without me showing them how to get out of the forward hatch. It is easy if you know how and impossible if you don’t.
I think they are incredibly valuable to those of us in the operational side of marine and aviation industries. For the rest of society, they are nothing more than journalistic or literary feedstock.
As input to captured regulators, historically they are a waste of paper.
Was it just me that missed this or did the full report not get much coverage here?
It details what I consider pretty crap actions by the US Attorney:
The Office of the US Attorney is conducting a criminal investigation of this accident. The Assistant US Attorney assigned to the case requested the National Transportation Safety Board (NTSB) not interview the captain of the Conception out of concern that the interview could hinder the ability of their office to bring criminal charges against the captain. The NTSB obtained significant information from the other crewmembers; however, the Conception’s captain had many years of experience on the same vessel, so the owner and surviving crewmembers referred many of investigators’ questions to the captain, which remain unanswered. The Office of the US Attorney also requested that NTSB investigators not interview the first galley hand, who was hospitalized at the time, or any Truth Aquatics employee responsible for operations
I agree with that. As long as the checks clear sometimes companies rather not know what’s happening on the boat. Even if it’s explicitly known shortcuts that are being taken, they are just betting that the captain knows what shortcuts are OK and which are not.
In this case it’s a low probability high consequence event. Depending on experience an individual captain may not appropriately judge the proper countermeasures.
That hatch doesn’t have support arms. If you have the arms you need to undo the knobs far enough so the arms come loose when you open it all the way, otherwise you won’t fit out.
Not something someone not used to boats will think of in a panic in the dark.
speaking of not used to boats, it isn’t a door, how many people are used to getting out of ANY room by climbing up to an opening in the ceiling?
I feel some sympathy for the captain of the Conception. He had gotten away with not having an effective night patrol for many years as do most other boats of this nature. Apparently the owners of the vessel did not insist on proof of a night patrol via watch station clock or whatever. Did the USCG question the crew about a roving night watch during their inspections ? Doubt it. The NTSB in its report lists past incidents similar to the tragedy on the Conception where they made recommendations which were not implemented and have not been implemented by the USCG. So, the owners felt no need to change a thing or change the way the captain had been operating the vessel. He just kept doing the same job he had for years and why not? The USCG inspectors found the vessel and crew to be compliant with regulations. The owners were happy too. Then there was a fire.
When asked by investigators, Coast Guard inspectors stated that they could not verify compliance with the roving patrol requirement, since inspections were not conducted during overnight voyages with passengers embarked.
Not only gotten away with it. I’m sure that he was taught to do it that way.
He had worked for Truth Aquatics since 1984 (with a 3- year hiatus in the late 1990s), starting as a deckhand and then rising to captain in 1985 once he had obtained his 100-ton master’s credential.
Obviously in hindsight a roving watch was needed but with a small crew that’s not without its trade-offs.
Putting a crew on watch at night means one less crew available for diving ops during the day. Diving ops are not without risks. Past experience may have given more salience to day-to-day risks related to diving then the possibility of a fire.
That’s exactly how the normalization of deviance sets in as SOP on these boats. I never met a captain on them who didn’t start out as a deckhand on the same boat or a sister boat and they only knew a handful of routes repeated over and over again. The shallow depth of knowledge of the entire crew is enough to keep the operation running. Most of the time.
Out of shape divers were also a cause of worry for me but that’s another story. I bailed before somebody got seriously hurt.
I agree. But honestly how much do you think things will change if this guy goes to prison? Will the USCG change the standards of these and similar boats? Will companies pay to modify their boats to make them more safe or will they add more crew, even at the risk of increasing ticket prices? Will other captains change their ways? Maybe for a month or so but no systemic change will happen. We all know that. Meanwhile this guy who did his job just like many others in the same business goes to jail. Accomplishes nothing. Put the owners in jail? Now that is a signal to the industry.
Likely asking questions about a roving patrol was not on the CG inspection checklist. I wonder what the captain would have said if he’d been asked about it? Or if he’d been asked to produce some evidence like a watch list or log entries of completed rounds?
If he was asked and lied about it or fabricated some log entries that to me would seem more like criminal negligence or worse.
The USCG is apparently incompent in regulating vessels of this type if the goal is to ensure the safety of the people on board. The NTSB report lists previous accidents and recommended actions. What did the USCG do? Nothing. Regulatory capture.
How could it not be covered under Are you in compliance with the COI?. The COI only required a few things. After Show me your current COI and Show me credentials for your required number of Captain/Mate/Deckhand seems the logical next question from the inspector should be Show me how you provide the required Watchman?.
I’m interested in why the company would not be charged with anything. Take the article a few days ago about an oil pollution incident. In that case the person violating the law, Chief Engineer, was charged and fined $5,500. The company was charged and fined $12 Million. Among others, the company was charged with Failure to Notify the U.S. Coast Guard of a Hazardous Condition.
So in this instance, is it likely that none of the three Truth Aquatics vessels had a night watchman? Have the authorities asked this question? Sure the Conception’s Captain appears guilty of violating the conditions of the COI, but isn’t this company itself also guilty of failing to notify the USCG of this hazardous condition?
I wouldn’t assume that they never set a night watch. Conditions that night may have led the captain to slack off. The weather was calm, eliminating any concern that the anchor might drag and IIRC people were tired after a late birthday celebration
IDK, maybe they did ask. If the captain provided misleading answers then he deserves some legal troubles.
But in that case this answer is somewhat odd.
When asked by investigators, Coast Guard inspectors stated that they could not verify compliance with the roving patrol requirement, since inspections were not conducted during overnight voyages with passengers embarked.
Makes it sound like the CG inspectors were using a checklist approach, fire extinguishers expiration dates and the like.
A better answer from the CG would be something along the lines of “the captain produced evidence of a roving patrol to the satisfaction of the inspecting officer.”
Agreed. Stating they couldn’t verify compliance because they couldn’t witness active compliance at the time seems like utter BS. Inspectors don’t witness me completing all maintenance on main engines or properly operating the OWS underway. But they do verify compliance by viewing my maintenance records and ORB. To me that statement sounds like they simply did not attempt to verify.
Not that that would in anyway absolve the captain of responsibility. There are plenty of things inspectors don’t have time to verify individually and that doesn’t mean they aren’t still required. Just seems like this would one of the few things that would be checked since it was one of the only things to check.
