Finalist: Staff of the Los Angeles Times

By Mark Puente, Brittny Mejia, Dakota Smith and Soumya Karlamanga

The operators of the Conception described the Labor Day diving charter as the perfect time to experience the marine life of the Channel Islands.

“The beginning of September is the best time to be at San Miguel [Island], which see strong winds and swell during much of the year. This rarely visited island is loaded with color: anemones, crabs, nudibranchs covering every inch of wall with a rainbow,” Truth Aquatics, which owns the Conception, said on its website. “Great for macro-photography. Nutrient rich waters bathing this island bring BIG fish: halibut, bugs, rockfish, wolfeels, lingcod.”

The Conception departed Saturday with dozens aboard and was set to return to the harbor Monday at 5 p.m.

Authorities now say the Conception caught fire Monday morning. Coast Guard officials said four bodies had been recovered and up to 30 people were believed to be missing. Five crew members managed to get off the boat, which was largely destroyed.

It appeared those missing were sleeping below deck when the fire broke out and might not have gotten out. Authorities said they got word of the fire from a mayday call around 3:30 a.m. The Coast Guard and some private vessels responded.

“The vessel currently has a portion of the bow sticking out of the water,” the U.S. Coast Guard said.

Family members of those who took the charter are now desperate for word about their loved ones, some gathering at Ventura Harbor.

At Santa Barbara Harbor, Truth Aquatics employees declined to comment, saying they were waiting to hear from the Coast Guard. Employees were hugging each other as tourists and people going fishing were boarding the Truth boat.

The Conception is a 75-foot vessel. The tour advertises gourmet meals, extensive diving opportunities and discussions about the marine ecosystem from a naturalist on board.

The website for the Labor Day tour spoke about the experience of the crew. “Their commitment to service shows through the smiles of crewmembers that love their jobs and undergo special safety training,” it said.

Truth Aquatics is a respected name in the diving world, running several boats off the Channel Islands. Owner Glen Fritzler won the California Scuba Service Award earlier this year for his pioneering work in the industry.

According to California Diving News, Fritzler built the Conception in 1981 and it was a major part of his life and business.

“Conception was California’s crown jewel of live-aboard dive boats. It’s also where Glen met the love of his life, Dana. On the couple’s first dive together they encountered a 17-foot great white shark, truly a memorable first dive-date experience,” Diving News reported.

Fritzler told the paper his firm’s boats had hosted more than 450,000 divers and over 1 million California dives.

In 2005, the Conception made headlines when a man described by authorities as a homeless drifter stole the vessel. According to the Lompoc Record, the boat was stolen from Santa Barbara Harbor and sustained damage when the suspect hit several other boats.

By Mark Puente, Dakota Smith, Hailey Branson-Potts and Brittny Mejia

The distress call crackled on Coast Guard radios around 3:15 a.m. Monday.

“Mayday, mayday, mayday! ... Conception ... north side of Santa Cruz,” a man yelled. “I can’t breathe!” He said dozens were trapped on board the Conception, a 75-foot commercial dive boat that was engulfed in flames as it sat anchored near the shoreline of Santa Cruz Island.

Around that time, surviving crew members woke Shirley Hansen as they pounded frantically on the side of her nearby fishing boat, the Grape Escape. They had paddled over in a dinghy, some of them injured.

Two crew members jumped back into the dinghy in hopes of rescuing others. “But they came back and there was no one that they found,” Hansen said.

At least 15 people were confirmed dead, and others were still missing late Monday, authorities said. Five people survived — the crew members, who had been awake and jumped overboard. Officials expressed little hope of finding anyone else alive.

The names of the dead and missing have not been released.

One crewman said his girlfriend was trapped aboard. Another said the Conception had celebrated the birthdays of three passengers — including that of a 17-year-old girl aboard with her parents — just hours before.

The horror of the event — one of California’s worst maritime disasters in recent memory — was palpable among officials.

“This isn’t a day we wanted to wake up to for Labor Day and it’s a very tragic event,” Coast Guard Capt. Monica Rochester said at an afternoon news conference. “I think we should all be prepared to move into the worst outcome.”

Into the evening, passersby stopped by a makeshift memorial at the Santa Barbara Harbor to pay their respects to victims. Around 7:30 p.m., Orlando Aldana, 42, lighted 34 candles at the memorial.

“Every candle that I lit made me feel like I was representing someone that passed away in the boat,” Aldana said.

Local, state and federal investigators were trying to determine exactly what went wrong on the Conception, a vessel once described by California Diving News as “California’s crown jewel of live-aboard dive boats.”

Victims who had signed up for a three-day dive excursion were believed to be in their bunks below deck when the fire started, about 20 yards off the north shore of Santa Cruz Island, part of the Channel Islands off the Ventura County coast.

“Most everybody was asleep,” said Santa Barbara County Sheriff Bill Brown, noting the combination of remote location, rapidly spreading fire and the victims’ vulnerable position on the boat. “You couldn’t ask for a worse situation.”

Fire crews rushed to extinguish the boat, which sank about 7:20 a.m. Monday and now lies inverted on the ocean floor, about 60 feet down.

Hansen said it had been a quiet night in the cove in Platts Harbor. She and her husband, Bob, had spent the day on the water, cooked a calico bass she had caught, and gone to bed. The Madera couple were unaware of the Conception, anchored about 200 yards away. They thought they were alone in the cove.

She described the pounding that awoke them as “horrific.”

“Our boat is very well made,” she said. “Having that sound come through [showed] they were very in need of help.”

She said there was so much smoke pouring from the Conception that she needed an inhaler. She said two of the crew members who made it off the dive boat had injuries to their legs. Some were in underwear. One of the crew members gave his name as Jerry and identified himself as the captain.

“As it was burning, there would be explosions going off every couple of minutes,” Bob Hansen said. “It was probably some of the dive tanks exploding. It made me feel so helpless.”

Shirley Hansen said they brought the most injured crew member to an ambulance ashore, while the man who identified himself as the captain stayed behind with the Coast Guard.

“We don’t feel like good Samaritans,” she said. “We just happened to be in the right place at the right time.”

One of the Conception’s crew members is among the missing or dead.

The Conception launched from from its base in Santa Barbara Harbor on Saturday morning. At Santa Barbara Harbor, employees were hugging each other as people boarded boats on fishing excursions.

The company that owns Conception, Truth Aquatics, runs several boats off the Channel Islands and is a well-established name in the diving world. Glen Fritzler, the boat owner, won the California Scuba Service Award this year for his pioneering work in the industry.

The Conception is where Fritzler met “the love of his life, Dana,” California Diving News reported. “On the couple’s first dive together they encountered a 17-foot great white shark, truly a memorable first dive-date experience.” Fritzler told the paper his firm’s boats have hosted more than 450,000 divers and more than 1 million dives.

Ralph Clevenger, a photographer who regularly takes pictures of expeditions for Truth Aquatics, has been on hundreds of diving trips with the company since the 1990s. He said the man who usually captained the Conception was a veteran, top-notch leader.

“It’s a position where if you’re not good with people and your crew, and operating the boat, you just don’t last,” Clevenger said.

Rochester, the Coast Guard captain, said the Conception “has been in full compliance” with maritime regulations.

Bruce Rausch, a veteran dive master in Orange County, said he has been on more than a dozen diving trips aboard the Conception. He said dives are preceded by extensive safety briefings including the location of bunk room exits and life jackets.

On social media, the scuba diving community expressed grief Monday.

“The boat, owners, Captain and crew have always been exemplary and have kept us safe and returned us back to the dock,” according to a Facebook post from San Luis Obispo dive shop SLO Ocean Currents. “It is a humbling day and a reminder to make every day count.”

From Channel Islands Scuba, a Thousand Oaks dive shop: “I know we speak for the SoCal diving community when we say we were shocked to hear the news this morning.”

And Gov. Gavin Newsom posted: “Our hearts are with the families and loved ones affected by this tragic incident. As we wait to hear more, we are eternally grateful for our heroic first responders that are on site — working to ensure every individual is found.”

Times staff writers Soumya Karlamangla, Jaclyn Cosgrove, Laura Newberry, Louis Sahagun, Leila Miller, Matt Hamilton, Carolyn Cole, Ben Welsh and Christopher Goffard contributed to this report.

By Matt Hamilton, Richard Winton, Mark Puente and Hannah Fry

As investigators searched for answers in the worst maritime disaster in modern California history, there was growing focus Tuesday on the limited escape routes available to the 34 people who are believed to have perished when a diving charter boat caught fire early Monday during a Labor Day expedition around the Channel Islands.

When the fire broke out around 3 a.m., five crew members on deck jumped overboard and escaped, paddling a dinghy to a nearby boat. Everyone else — including another member of the crew — was in sleeping quarters below deck and unable to get out, with the only two exits apparently blocked by fire.

Santa Barbara County Sheriff Bill Brown said Tuesday that the victims were trapped below deck with no way of getting to safety.

“There was a stairwell to get down the main entry way up and down and there was an escape hatch and it would appear as though both of those were blocked by fire,” he said.

The main staircase led into the galley, and the hatch opened into the adjacent mess area, both of which were engulfed in flames.

The U.S. Coast Guard has said the Conception, operated by Truth Aquatics, had passed all recent inspections. But Marjorie Murtagh Cooke, former director of the National Transportation Safety Board’s Office of Marine Safety, said the inferno could expose a broader safety problem that needs correcting.

“With 30-plus people dying, the investigation could lead to changes in the way vessels are designed or protected depending on the findings,” she said.

Cooke, now a marine safety expert for Robson Forensic Inc, said the exit routes are likely to be a key issue for investigators.

The NTSB will try to determine whether passengers were told about escape routes in case of an emergency. “Did they know about both exits?” she asked.

She noted that vessels are required to have two exits for sleeping quarters. In the case of the Conception, she said, “it appears that both exits from the sleeping quarters bring you up inside the vessel.”

Dr. Aaron Roland, who has dived on the Truth Aquatics fleet numerous times, said the Conception was a wonderful vessel but escaping up the narrow staircase from below decks in a fire would be a nightmare.

Roland said he did not recall a second exit and didn’t believe the crew pointed it out to passengers.

But Chris Callahan-Dudley, 39, who worked for Truth Aquatics until 2016 and at times served as captain on Conception, said the crew was meticulous about following safety protocols.

“Yes, we do kind of bombard passengers throughout the trip. It was one of the focal points of my morning briefings,” he said. The crew repeated to guests how they should get out quickly during the night, he added. He delivered his trip safety briefings at the escape hatch, a slat of wood that was lighter than a door. “If you bat it from underneath — it would come off. It’s not like you are lifting a hatch.”

The captain on board when the fire struck, Jerry Boylan, is a highly respected veteran in the local maritime scene.

“He’s got a deeply rooted history in Truth Aquatics and the Channel Islands, “ Callahan-Dudley said. “I’d say he has always been a very customer-forward and safety-forward captain in my experience. I can certainly remember times when it was almost a little too much,” he said, “making sure [crew] were aware of things.”

NTSB board member Jennifer Homendy said the federal agency started its investigation Tuesday. The team of 16 investigators specializes in engineering, operations, survival factors and fire prevention.

“This was a terrible tragedy,” she told reporters Tuesday afternoon. “I cannot imagine what the families are going through.”

Homendy said she was “100% confident” that investigators would determine the cause of the fire.

About a dozen FBI agents boarded the Vision, another Truth Aquatics boat that was docked at the Santa Barbara Harbor Tuesday evening. The agents, wearing khaki cargo pants and navy T-shirts that identified them as an FBI Evidence Response Team, took pictures of the Vision’s interior, decks, staircases and entryways. They pinned sheets of paper with block letters beside some parts of the boat — an A next to a life preserver, a B next to the door to the top deck — and took pictures from several angles.

The wood-hulled Conception was built in Long Beach in 1981, according to Coast Guard records and the company’s website, and was powered by 550-horsepower Detroit Diesel engines, with a total fuel capacity of 1,600 gallons.

The below-deck sleeping area had 20 single bunks and 13 doubles, some stacked three-high, to accommodate up to 46 people.

Rescuers suspended their recovery Tuesday of the 34 victims trapped aboard the Conception off the rugged coast of Santa Cruz Island, saying crews need to stabilize the sunken vessel before divers could safely enter to recover more bodies.

After combing the island’s nearby shore and surrounding ocean, U.S. Coast Guard and Santa Barbara County first responders said there were no signs that any of the missing had survived.

Searchers had retrieved the remains of 20 people who had been found in and around the wreckage, 64 feet deep. That left 14 people still missing, including four to six bodies that rescue divers had seen inside the boat Monday but could not access.

“It is never an easy decision to suspend search efforts,” said U.S. Coast Guard Capt. Monica Rochester. “We know this is a very difficult time for family and friends of the victims.”

The boat was anchored 20 yards offshore in Platts Harbor, a cliff-lined cove on the north side of the island, with 39 people aboard, when the fire started around 3 a.m. Monday. It was set to return to Santa Barbara Harbor, 25 miles north, that evening.

The Conception had a good reputation among divers; California Diving News once called it “California’s crown jewel of live-aboard dive boats.”

There was a fire-suppression system in the vessel’s engine room, as required by the Coast Guard, and fire extinguishers near the exits. The equipment was all present during the boat’s last inspection, officials said.

The names of those who died have not been released.

Santa Barbara County Fire Chief Mark Hartwig said he knows the families of the victims are awaiting information about their loved ones. He said officials would do “everything in our power to find out what happened aboard that vessel in the last moments of these family members’ lives.”

“As this community continues to deal with the unfolding tragedy ... the county fire district is committed to — on behalf of the county of Santa Barbara — expending all necessary means to find out the cause of origin of this fire.”

Times staff writers Matthew Ormseth, Lilia Miller, Louis Sahagun and Soumya Karlamangla in Ventura County, Susanne Rust in San Francisco and Dakota Smith, Colleen Shalby, Laura J. Nelson, Joe Mozingo and Hailey Branson-Potts in Los Angeles contributed to this report.

By Richard Winton, Mark Puente and Matt Hamilton

A preliminary investigation into the Conception boat fire has suggested serious safety deficiencies aboard the vessel, including the lack of a “roaming night watchman” who is required to be awake and alert passengers in the event of a fire or other dangers, according to several law enforcement sources familiar with the inquiry.

The probe also has raised questions about whether the crew was adequately trained and whether passengers received a complete safety briefing, said the sources, who spoke on the condition of anonymity because they did not have approval to comment publicly about the case.

Investigators have so far interviewed surviving crew members and others connected to the worst maritime disaster in recent California history, which killed 34 people.

A U.S. Coast Guard spokesman declined to comment other than to describe the investigation as wide-ranging.

Investigators from the Bureau of Alcohol, Tobacco, Firearms and Explosives are joining the investigation into the fire, which started in the early morning hours Monday while the ship was anchored off Santa Cruz Island.

Authorities have not suggested the fire and fatalities were the result of any criminal wrongdoing, but prosecutors from the U.S. attorney’s office in Los Angeles were at the scene on Thursday preparing to assist investigators and keep tabs on the unfolding inquiry.

A federal law dubbed “seaman’s manslaughter” was used last year in Missouri by federal prosecutors to charge a duck boat captain and two others in connection with the loss of 17 lives when the amphibious craft capsized in a storm. In that case, it was Coast Guard investigators who built the case for criminal negligence. The captain is accused of failing to assess the weather, steer the vessel appropriately and prepare the passengers for abandoning ship.

The intensifying investigation in the Conception case comes as more details emerged on what it was like aboard the boat when the fire broke out. The sources emphasized that the investigation was still in its early stages and could take months to complete.

Jennifer Homendy, who is overseeing the National Transportation Safety Board’s investigation, said the surviving crew members have told authorities the fire was too intense to save any of the passengers trapped below.

“What’s emerging from the interviews is a harrowing story of the last few minutes before the boat was engulfed in flames,” she said. “They felt that they had done what they could do in a very panicked situation.”

All 33 passengers, who had signed up for a three-day scuba diving trip aboard the boat, died in the fire, along with a member of the crew sleeping below deck.

Homendy said at least one crew member was awakened and left his bunk and, at some point, because of the heat, smoke and fire, jumped over the side with other crew members to try to rescue passengers.

“The galley area was engulfed in flames,” Homendy said, recounting what the crew member told investigators. “They tried to enter through the double doors but couldn’t get in because of the flames. They tried to access the galley from the front through the windows, but the windows wouldn’t open.”

One of the crew members broke his leg in the jump from the boat. Two other crew members swam to get the skiff and picked up their injured colleague to take him to a good Samaritan vessel.

They contacted authorities and “returned to the vessel to find survivors,” Homendy said.

The crew member who initially heard the noise got up to look over the side. He looked down and flames were coming up.

He tried to use the ladder, “but the ladder was engulfed in flames,” Homendy said. “They just couldn’t get in.”

The escape hatch and the entrance were blocked by flames.

What did the first crew member see?

“He heard no smoke alarm, he smelled no smoke, but he did see flames when he looked over,” she said. “They didn’t hear anything.”

She described the smoke alarm on the vessel as one that can be bought at Home Depot. She said the Vision — a boat she toured Wednesday that is very similar to the Conception — also had one smoke alarm, but it is not wired to a centralized system with alarms. The latter type of alarm was not required when the boats were built, she said.

Though slightly larger than the Conception, the Vision has a similar layout. Single and double bunks are stacked two and three high in the boat’s sleeping quarters below deck. A wooden staircase leads from the sleeping area up to the galley.

Authorities say the exit on the Conception — along with an escape hatch that opens up near the dive deck on the boat — was blocked by fire.

Both boats are owned by Truth Aquatics, which operates the fleet for diving and other excursions around the Channel Islands. The Coast Guard has said the Conception had passed all recent inspections.

The NTSB has questions on the wiring and electrical systems, she said. There was a lot of photography equipment and extra batteries on board charging.

“Did that provide the ignition source? But we’re not closing in on that,” she said. “We’re not ruling out anything at this point.”
The agency is still reviewing records. Older boats had different fire standards compared with newer vessels, she said.

The boat was not at full capacity and could accommodate more passengers, Homendy said. The agency is looking at whether “there needs to be new safety standards to make sure this does not happen again.”

“I definitely have concerns about the ability of those passengers being able to evacuate during a fire,” she said.

Homendy said she was “taken aback” by the size of the emergency hatch when she toured the Vision on Wednesday with a team of investigators.

She and the investigators turned the lights off to see what it would have been like for the passengers trapped on the Conception. Getting to the emergency hatch was difficult, she said, adding that they couldn’t find the light switches in the dark.

“You have to climb up a ladder and across the top bunk and then push a wooden door up,” she said. “It was a tight space. We couldn’t turn the light on.

“It surprised me how small it was and how difficult it was to access,” she said about the escape hatch. “I couldn’t see the people in front of me.”

A source familiar with the crew’s actions said that hours before the fire broke out, the passengers had performed a night dive. A crew member was awake on the boat and straightening up items in the galley and mess area but went upstairs to the wheelhouse about 2:35 a.m.

Before the crew member went upstairs, he checked that the stove was cold and nothing flammable was out, said the source, who spoke on the condition of anonymity because he was not authorized to comment publicly. Sometime between 2:35 a.m. and 3:15 a.m., the crew member heard a noise and thought somebody had tripped. The crew member went down to the middle level and saw the fire. The flames prevented him from getting down into the galley, the source said.

In the aftermath, the crew has speculated that the fire began in the seating area in the galley area, the source said.

No crew members have reported hearing an alarm sound, the source said.

By Kim Christensen and Matt Hamilton

A day of diving off Santa Cruz Island ended like countless others aboard the Conception, with dozens of divers asleep in tightly arranged bunks that all but filled the belly of the 75-foot boat.

As always, there were two ways out in case of emergency — up a curved stairway at the front of the cabin, or through an escape hatch in the ceiling over bunks at the rear.

Before dawn on Labor Day, when flames devoured the 38-year-old wooden-hulled vessel, no one below deck made it out of either exit. The only survivors were five crew members who were up top in the wheelhouse and managed to jump into the water and then onto a dinghy.

Now, as investigators search for the cause of the fire that killed everyone in the bunk room — one crew member and all 33 passengers — questions are mounting about the design of the Conception and its emergency escape routes.

By various accounts, both the design of the boat and the layout of its sleeping quarters met federal standards and both are widely popular among California operators of overnight dive and fishing excursion vessels.

Like other such commercial boats, the Conception was subject to annual inspections by the Coast Guard, most recently in February, when it was certified to be in compliance with all regulations.

But just because it passed muster with the Coast Guard does not mean the Conception was as safe as it could be, according to some naval design and safety experts who have raised concerns about the placement of the escape routes from the bunk room.

John McDevitt, a former assistant fire chief from Pennsylvania who is an accredited marine surveyor and the chairman of a National Fire Protection Assn. committee on commercial and pleasure boat fire protection, called the Conception “a compliant fire trap.”

“What bothers me is that the vessel was inspected by a Coast Guardsman within the last 12 months,” said McDevitt, who thinks the design of emergency exits was problematic. “This boat has been checked by the Coast Guard for 40 years almost.”

The Conception was one of three “live-aboard” dive boats operated out of Santa Barbara Harbor by Truth Aquatics Inc., which has been in business since 1974 and is now owned by Glen Fritzler. He declined The Times’ requests for an interview, but has defended his crew members’ actions in trying to save the doomed passengers.

Fritzler said in a statement that he is working with National Transportation Safety Board investigators and is “committed to finding accurate answers as quickly as possible.” He also said he and his family are “utterly crushed” by the accident.

“My family and I are speaking today with extremely heavy hearts,” he said. “No words will ease the pain that loved ones are feeling. We extend our deepest condolences to all those involved in this horrific tragedy.”

The Conception was built in Long Beach in 1981, designed by its original owner and the company’s long-retired founder, Roy Hauser, specifically for multiday dive trips.

“I designed the entire layout of the vessel,” Hauser said. “I drew it out a quarter inch to the foot and then gave it to a marine architect. They put together the final Coast Guard papers, if you will. Glen has all the plans and they are all stamped ‘approved.’ … Everything you do has to be approved by the Coast Guard.”

Hauser said Fritzler had kept the boat in “immaculate” condition and he defended its design characteristics as “absolutely” safe. He noted that many of its features are common to California dive and fishing boats, an assertion backed by others in the industry.

Ken Kurtis, a veteran California diver and instructor whose Reef Seekers Dive Co. has organized trips since 1988, said he’d been aboard the Conception many times.

He described its three-level design as very similar to other such boats: sleeping quarters below deck, a main deck that includes a covered galley toward the bow with open-air dive area at the stern, and the wheelhouse with the captain’s controls at the top.

Kurtis said there was nothing extraordinary about the 75-foot boat’s combination of double- and triple-stacked bunks, or its passenger limit of 46 — the count was 13 below that capacity when the fire broke out.

“Passenger loads vary by the size of the vessel,” he said. “They had on this one 33 passengers. That’s a normal number for a dive boat. Most of the big dive boats are 30 to 35 and they are all designed pretty much the same way, with the bunks at the bottom, the galley and salon in the middle, and the wheelhouse on top.”

Chris Barry, chairman of the Society of Naval Architects and Marine Engineers’ small craft technical and research committee, agreed that the Conception’s structure and cramped sleeping quarters were not unusual.

Some California divers have dubbed the popular configuration a “cattle boat” style of excursion, because of the tight space and lack of staterooms and other cabin amenities.

“The people who are on these dive boats are just crashing below,” Barry said. “These aren’t luxury staterooms. All they want to do is crash and sleep — they don’t need a lot of luxury and there’s obviously a trade-off between the amount of space per person and the cost.”

The crowded quarters might “look a little rough” but they are “absolutely legal,” he said, noting that sailors on Coast Guard cutters also sleep in three-high bunks.

“There’s nothing that unusual about the vessel,” he said.

The fact that no passengers below deck escaped has focused attention on the bunk room’s exits. The stairs in the sleeping quarters led to the galley. The escape hatch over bunks in the rear of the room opened up into a dining area adjacent to the galley and just a few feet from the open-air dive deck.

Officials have said fire blocked both exits.

“I definitely have concerns about the ability of those passengers being able to evacuate during a fire,” NTSB board member Jennifer Homendy told The Times this week.

Homendy said she was “taken aback” by the size and location of the emergency hatch when she toured the Conception’s sister ship the Vision, which has a nearly identical design.

“You have to climb up a ladder and across the top bunk and then push a wooden door up,” she said. “It was a tight space. ... It surprised me how small it was and how difficult it was to access.”

The vessel appears to meet current federal regulations, which require boats such as the Conception to have “at least two means of escape,” including stairways and emergency hatches.

“The two required means of escape must be widely separated and, if possible, at opposite ends of the space to minimize the possibility of one incident blocking both escapes,” the regulation states, noting also that exits must be “sufficient for rapid evacuation in an emergency.”

It’s not clear if passengers ever had a chance to try to escape. Santa Barbara County Sheriff Bill Brown, who is also the coroner, said smoke inhalation is the likely cause of death.

Still, McDevitt, the marine surveyor who also is a Coast Guard-certified captain, said that the design of the boat was flawed. He questioned why both egress points — the stairwell and the hatch — deposited passengers into the galley and adjacent dining area.

“When you put two exits into the same common area, you are not providing two means of egress — it’s still only one,” he said. “You are exiting into the galley and common area.”

He said that irrespective of the minimum standards, the volume of passengers seemed to call for more exit passages.

McDevitt suggested adding “another hatch, and maybe a bigger hatch,” but noted that options would be limited on a boat of that age.

“You don’t want to make a boat less seaworthy, so you can’t put hatches in the side,” he said. “If they built that boat today, they could do more. …. When you put people down there in that dungeon, it’s got to be watertight.”

Paul Kamen, a forensic naval architect and mechanical engineer based in Berkeley, said he thought the size of the roughly 2-feet-square escape hatch was adequate, but he also questioned placing both points of exit in the galley and nearby dining area.

“The common areas for fire to start are the galley or the engine room, so there’s always one [other] escape route. Whatever one is on fire, you go out the other way,” he said. “The problem here is both escape routes went through the galley, and you lost that redundancy when the galley is engulfed in flames.”

Kamen had no problem with the boat’s passenger capacity, agreeing that many divers “would think it’s cool to be stuffed in an environment like that — it’s a connection with the traditions of the sea to be in a triple-high bunk bed with 30 other people.”

He said he is more intrigued by the fire’s rapid growth.

“The big mystery is why the fire propagated so far and so fast,” Kamen said. “I don’t think the fact that wood furnishings in the passenger cabin really explain it.”

By Richard Winton and Mark Puente

The Conception dive boat accident that killed 34 people on Labor Day was one of the worst maritime disasters in California history, but the safety lapses that led to it were hardly unprecedented.

For years, small passenger vessels have gone up in flames for a variety of reasons, prompting repeated calls by the National Transportation Safety Board to improve fire-safety measures.

But a Times review of federal documents spanning nearly 20 years shows that the U.S. Coast Guard, which has the sole authority to mandate safety measures, has often rejected the board’s recommendations.

The NTSB found that issues such as an electrical malfunction, a poorly maintained fuel line and a failed cooling pump had caused fires aboard small vessels over the past 20 years. But the safety panel also concluded that a lack of preventive maintenance and fire training for crew members had contributed to the blazes.

It repeatedly has called on the Coast Guard to require small vessels to establish procedures for conducting regular inspections and reporting maintenance and repair needs for all of a boat’s systems — including the hull and mechanical and electrical operations. This, the NTSB said, would better ensure safety on vessels between Coast Guard inspections, which occur every one to two years.

But the Coast Guard has pushed back on the recommendation, calling it “unnecessarily burdensome and duplicative of existing requirements.”

The NTSB, an independent federal agency, has no authority enforce its recommendations, so regulators such as the Coast Guard and the Federal Aviation Administration are not bound by them.

Last year, after a deadly boat fire in Florida, the NTSB said the incident might have been prevented had the Coast Guard required small boats to have a preventive maintenance program.

“All over the country this morning, crew training is either being conducted, or it is being neglected. Manufacturers’ recommended maintenance programs are being followed or they are being disregarded, leaving the safety of vessels and their passengers at risk,” NTSB Chairman Robert Sumwalt said in December 2018.

In September, a fire broke out on the Conception during a weekend diving excursion in the Channel Islands, killing everyone who had been sleeping below deck. Since the accident, investigators have cited some of the same deficiencies pointed out by the NTSB in other boat fires: lack of crew training and inadequate safety measures and maintenance.

A preliminary NTSB investigation found that the Conception had violated a requirement that it have a roving watch during the night, saying the five crew members who survived awoke to discover the flames. The agency also has raised concerns about the functionality of the two exits in the area where passengers slept in stacked bunks beneath the waterline.

Even so, the Conception passed Coast Guard inspection, a fact that some say underscores the problem.

“Yes, it complied with all the Coast Guard regulations, but that didn’t mean it was safe,” said John McDevitt, a former assistant fire chief and chair of a National Fire Protection Assn. committee on boat fire protection. “A string of recommendations have been ignored about early warning systems, detection and training.”

An official with Truth Aquatics, which owned the Conception, did not respond to a request for comment.

Since the fire, the Coast Guard has issued warnings about charging lithium batteries on boats, cracked down on the number of bunks on vessels and demanded some exits be expanded and made more accessible. Hundreds of boats like the Conception have been reinspected. Some were told to make fixes before heading out to sea again.

The results from the NTSB investigation into the Labor Day disaster could take 18 months to complete. Agents from the FBI and the Bureau of Alcohol, Tobacco, Firearms and Explosives are trying to determine what sparked the blaze.

Still, a growing belief throughout the boat industry is that the Conception fire could finally lead to safety rules that the NTSB has been proposing for years.

The Coast Guard declined to comment on why it had not followed specific NTSB recommendations, but released a statement defending its actions.

“The Coast Guard highly values NTSB’s input and recommendations concerning all marine casualty investigations, and we work closely with them to identify ways to improve the safety of the maritime industry,” chief spokesperson Lt. Amy Midgett said in a statement. “When NTSB makes recommendations, the Coast Guard carefully considers the proposed measures and is required to weigh the benefits and impacts of implementation.”

The laws governing the high seas stem from the era of passenger steamships, when tragedy heightened awareness for boat safety. The Coast Guard regularly inspects commercial vessels carrying six passengers or more and certifies that they meet federal standards.

In the last 19 years, several fires erupted on ferries and passenger boats that led the NTSB to make numerous safety recommendations for smaller vessels. But the Coast Guard has not implemented many of them, and rejected some.

In November 2000, an electrical malfunction caused the Port Imperial Manhattan to burn as the ferry headed to New Jersey from Manhattan. None of the eight people on board was hurt.

An NTSB report concluded that inadequate inspection and maintenance of the electrical system, as well as insufficient fire detection systems and crew training, all contributed to the blaze. The board warned of the need for a preventive maintenance program and proper fire training.

The Coast Guard pushed back, arguing that “small passenger vessels are subject to a comprehensive set of regulations that are designed to promote vessel safety.”

To this day, the NTSB file notes that its recommendation has not been fulfilled. The file is marked “Open — Unacceptable Response.”

In the years that followed, according to a 2006 NTSB report, a series of preventive maintenance failures led to fires on similar vessels.

In 2010, Congress approved the Coast Guard Authorization Act, requiring that it set rules to mandate safety management systems. But the Coast Guard has concentrated on larger ships, not smaller passenger vessels.

The conflict between the NTSB and the Coast Guard reached such a point that in 2016, the safety board — in a letter — scolded the Coast Guard for failing to adopt 25 of 40 safety recommendations. The next year, the NTSB again chastised the Coast Guard for what is said was a delay in instituting safety rules.

Not long afterward, in January 2018, a fire erupted on the 72-foot Island Lady off the Florida coast. Fourteen passengers on the casino shuttle boat were injured. One person died.

The vessel, the NTSB concluded in December, had erupted in flames because a lack of preventive maintenance had led to pump failure and engine overheating. The agency identified several shortcomings in maintenance schedules for the boat’s systems and said the owners had failed to install fire detection equipment in unmanned spaces.

The NTSB could find no record of the last time the crew tested the heat detectors, and it said the Coast Guard inspection didn’t detail whether the fire detection system had been checked. The captain said the system had been tested, but the files were lost in the fire.

The board faulted the Coast Guard for failing to adopt a preventive maintenance program.

“This is just absurd,” NTSB Chairman Sumwalt said during a two-hour hearing

Like the Conception, the Island Lady had passed Coast Guard inspections. A 2015 examination of the fire detection system found it “satisfactory.”

“All of the Coast Guard’s regulations are written in blood,” Richard Hiscock, a former congressional staffer who helped shape maritime policy, said. “They are the result of deadly disasters on the high seas.”

While boat operators across Southern California said they expect the NTSB to issue a slew of new recommendations in the wake of the Conception tragedy, the Passenger Vessel Assn. — which represents hundreds of mid- and large-size boat operators nationwide — has tried to distance itself from the incident.

“PVA member vessel companies are not involved in overnight diving operations such as the Conception,” a statement said. “This company is not a PVA member.”

The organization, however, did distribute the Coast Guard’s September safety bulletin that urged operators to review emergency training and the condition of passenger accommodations. The bulletin also warned about limiting the unsupervised charging of lithium-ion batteries, power strips and extension cords aboard vessels.

The trade group told its members to expect the Coast Guard to step up inspection of vessels with overnight accommodations, focusing specifically on fire safety, vessel operations and safety management.

For decades, however, the Coast Guard’s oversight process has come under official scrutiny.

After the 1993 loss of the El Toro II fishing charter with 23 people aboard and the drowning of 13 people in 1999 aboard the Miss Majestic duck boat, the Coast Guard’s highest-level inquiry found that its inspectors had lacked necessary knowledge and had failed to notice critical missing parts on the vessels.

And after the 2010 Deep Water Horizon oil rig explosion left 11 dead and spilled about 206 million gallons of oil, a Department of Homeland Security Inspector General’s report found the Coast Guard did not have “adequate processes to investigate, take corrective actions and enforce federal regulations related to the reporting of marine accidents.”

The report blamed it partly on the Coast Guard’s inability to retain personnel.

In 2018, Rear Adm. John Nadeau, then the Coast Guard assistant commandant for prevention policy, testified that 1,000 more inspectors and inspections would not solve the issues.

“This problem involves training,” he said. “This problem involves getting the right information. This problem involves getting the right policy and procedure in place.”

To address the problem, some members of Congress have pushed for marine safety to become a separate agency — much like the Federal Aviation Administration. The Coast Guard is part of the U.S. Department of Homeland Security.

Last month, top Coast Guard leaders in Washington, D.C., ordered inspectors across the country to re-examine vessels that accommodate from seven to 150 overnight passengers — many of which are old and have been modified to handle different types of excursions like diving, fishing or sailing charters.

In California alone, that is 152 vessels.

“We need to make sure everybody is crystal clear on what is required,” U.S. Coast Guard Lt. Cmdr. Matt Kroll said. “We are going through these with a fine-tooth comb. There is a very specific checklist.”

The Coast Guard, he said, expects the NTSB to make new safety recommendations within 18 to 24 months.

Numerous operators from Santa Barbara to San Diego told The Times that as many as four inspectors had scrutinized nearly every inch of their boats.

Besides fire training and fire hoses and smoke detectors, the owners said, inspectors are scrutinizing paperwork to check whether companies test employees for drugs. Investigators are also focusing on the number of bunks below deck, mattress pads to make sure they’re fireproof and whether emergency hatches are wide enough.

“If there was anything that got missed, it was the needle in the haystack,” said Joe Chait, who owns the 65-foot Pegasus fishing boat in San Diego.

Ted Cumming, owner of Spectre dive boat in Ventura County, said inspectors determined that double bunks without an open space on either side needed to be single bunks. Inspectors also told him that a water-sealed door needed to be widened from 20 inches to 24 inches, he said.

“They are really beefing up the inspections and rules,” Cumming said. “They checked everything and anything.”

Times staff writer Leila Miller contributed to this report.

By Mark Puente and Richard Winton

The Conception dive boat, on which 34 people died in a Labor Day fire, had been exempted by the U.S. Coast Guard from stricter safety rules designed to make it easier for passengers to escape, documents and interviews by The Times show.

The Conception was one of about 325 small passenger vessels built before 1996 and given special exemptions from safety standards that the Coast Guard imposed on new vessels, some of which required larger escape hatches and illuminated exit signs, records show.

The rules require vessels to have an escape hatch of at least 32 inches wide and exit signs that are illuminated. The Conception, built in 1981, had an escape hatch that was only 24 inches wide, according to several federal regulators who requested anonymity in order to speak on the matter. It also did not have illuminated exit signs.

It’s unclear whether such measures would have made a difference on the Conception, on which passengers on a weekend diving expedition were trapped in the hull during an early morning fire and unable to escape. Crew members on the deck said they were unable to reach the passengers because of intense flames.

But federal officials investigating the worst maritime disaster in modern California history immediately zeroed in on the functionality of the two exits in the area where passengers slept in stacked bunks beneath the waterline. National Transportation Safety Board investigator Jennifer Homendy told The Times in September that she was “taken aback” by the small size of the emergency escape hatches, adding that she thought it would be difficult for passengers to exit during an emergency in the dark.

In the aftermath of the fire, the Coast Guard has stepped up inspections of similar boats across the country. Several boat owners have said that among the issues inspectors have raised is the size of escape hatches, fire protection systems and crew training in emergencies.

The Coast Guard is already under scrutiny in the wake of the Conception fire. Earlier this month, The Times reported that the Coast Guard had often ignored NTSB recommendations to improve fire-safety measures for nearly 20 years.

The safety exemptions the Conception and other boats received in the 1990s are raising new questions.

“I am deeply concerned about the fire and sinking of the Conception, and the so-called grandfathering of boats under older boat safety regulations,” Rep. Julia Brownley (D-Westlake Village) told The Times.

“I am eager to receive NTSB’s final report on this incident and NTSB’s recommendations for updating federal laws in this area to ensure the safety of passengers and vessel crews.”

Kyle McAvoy, a marine safety expert at Robson Forensic and former Coast Guard chief of the Office of Commercial Vessel Compliance Policy, said the grandfathering of older vessels often happens when meeting new regulations is economically unfeasible and impractical.

When adopting changes to the Subchapter T regulations in the 1990s, McAvoy said the Coast Guard wanted to ensure improvements and safety for new boats, but also had to address what to do with existing vessels. Before the new standards were adopted, the Coast Guard sought public comment and conducted feasibility studies.

Older vessels “may not be able to change what they have,” said McAvoy, who retired as a Coast Guard captain in 2016.

The Coast Guard has the authority to make immediate safety changes in the wake of incidents such as the deadly Conception fire, McAvoy said.

He said he is not surprised inspectors are already scouring vessels across the country and he noted that owners can always go beyond the minimum standards to ensure passenger safety, adding: “The Coast Guard regulations are the floor, not the ceiling.”

The original regulations, written in the late 1950s, required two means of escape, but did not specify minimum dimensions or say where the exits needed to be located.

Currently, the Subchapter T regulations govern about 5,000 vessels on U.S. waterways. Of those, about 325 still fall under the original rules.

The Coast Guard had made numerous minor revisions to the original regulations throughout the years, but they were not sufficient to keep abreast of the changes affecting the small passenger vessel fleet since the 1960s, according to Coast Guard records.

Prior to the Coast Guard updating regulations in 1996, the last major revision occurred in 1963, records show.

The reasons for updates included vessels getting larger and not keeping up with fire-prevention technologies. Another reason was significant casualties on waterways, including 87 fire deaths between 1981 and 1986, federal records show.

Among the incidents was a fire aboard a vessel on the Mississippi River that claimed three lives. The Coast Guard determined that a $200 vapor detector would have prevented the deaths. Additionally, 32% of all fires occurred on wood-hulled vessels. And during that period, 57% of all fires started in the machinery spaces aboard the boats.

After multiple casualty investigations, the NTSB and Coast Guard each agreed that new rules were needed “to prevent casualties or alleviate damages and injuries from future casualties,” Coast Guard records show. “The Coast Guard agrees with many of the investigation recommendations that have been made.”

The 1996 revision required a larger “means of escape” for passengers to flee during an emergency. It also said the two “means of escape must be widely separated and, if possible, at opposite ends or sides of the space to minimize the possibility of one incident blocking both escapes.”

The rule also said the means of escape must allow for the “easy movement of persons when wearing life jackets. There must be no protrusions in means of escape that could cause injury, ensnare clothing or damage life jackets.”

Additionally, the rule stated: “The minimum clear opening of a door or passageway used as a means of escape must not be less than” 32 inches in width and “illuminated exit signs are required and must be installed.”

Truth Aquatics owner Glen Fritzler has defended his crew members’ actions in trying to save the doomed passengers. On Thursday, he said he supports safety regulations.

“We have always followed Coast Guard regulations and whatever is required,” he said in a statement. “Our past inspections reflect our commitment.”

In the days after the fire during a weekend excursion in the Channel Islands, the NTSB, Coast Guard and federal agents toured the Vision — an 80-foot vessel similar to the Conception.

Both boats are owned by Truth Aquatics, which operates the fleet for diving and other excursions around the Channel Islands. The U.S. Coast Guard has said the Conception had passed all recent inspections.

Though slightly larger than the Conception, the Vision has a similar layout. Single and double bunks are stacked two and three high in the boat’s sleeping quarters below deck. A wooden staircase leads from the sleeping area up to the galley. Authorities say the exit on the Conception — along with an escape hatch that opens up near the dive deck on the boat — was probably blocked by fire.

Homendy toured the Vision with Coast Guard Capt. Jason Neubauer, who oversees the Marine Safety Board of Investigation. She said she and the investigators turned the lights off to see what it would have been like for the passengers trapped on the Conception.

Getting to the emergency hatch was difficult, she said, adding that they couldn’t find the light switches in the dark. The small hatch also was troubling, especially for larger people, she said.

“It was very difficult,” Homendy said about trying to exit the escape hatch. “I was taken aback by that.”

Industry experts and numerous vessel captains told The Times they expect the government to adopt stricter safety regulations as a result of the 34 deaths.

“It is clear that the regulations are in need of serious revision,” said a Los Angeles maritime lawyer who requested anonymity. “Whatever ‘means of escape’ is, it needs to actually work in an emergency for everyone on the vessel.”

After the fire on the Conception, investigators have cited some of the same deficiencies pointed out by the NTSB in other boat fires: lack of crew training and inadequate safety measures and maintenance.

A preliminary NTSB investigation found that the Conception had violated a requirement that it have a roving watch during the night, saying the five crew members who survived awoke to discover the flames. A Santa Barbara County coroner’s review determined the 34 killed died of smoke inhalation.

While discussing marine casualties during the House hearing on Nov. 14, Coast Guard Rear Adm. Richard Timme, assistant commandant for prevention policy, said vessel owners and crews are the first line of defense to protect passengers.

“Equally important, the vessel master and crew play an essential role and should be the first to recognize problems and take early corrective action,” he said. “The vessel owner is obligated to support the master and crew’s ability to maintain the vessel and operate it safely.”

The results of the NTSB investigation into the Conception boat fire are expected to be released in 2020. The Bureau of Alcohol, Tobacco, Firearms and Explosives is working with the Coast Guard and NTSB on determining a cause of the deadly blaze.

Coast Guard investigators along with the FBI have served search warrants on Truth Aquatics and its vessels as part of a criminal investigation. The evidence gathered along with dozens of interviews is being reviewed by federal prosecutors as part of the ongoing probe.

During a House Subcommittee on Coast Guard and Maritime Transportation hearing about passenger safety on Nov. 14, Rep. Salud Carbajal (D-Santa Barbara) asked a top Coast Guard official why the Conception operated under outdated safety regulations.

“It has been brought to my attention that Conception was operating under ‘old T’ safety requirements, meaning they were not following the most up-to-date safety rules,” Carbajal told Timme.

Small passenger vessels weighing less than 100 tons fall under Subchapter T of the Code of Federal Regulations for boats.

Timme called the regulations “valid construction standards today” and said many vessels currently operate under them without any issues.

But if a formal Marine Board of Investigation, the highest-level marine casualty investigation in the Coast Guard, finds that the old construction standards contributed to the Conception tragedy, changes could happen, Timme added.

“We will absolutely look at that,” he said.

Brian Curtis, the NTSB director of the Office of Marine Safety, told Carbajal the agency is scrutinizing the old and current standards to determine if each adequately addresses “means of escape and crew responsibilities” on small passenger vessels.

“We’re taking a close look at all these regulations,” Curtis said, “to make sure this doesn’t happen again.”