The distress call came in at 3:14 A.M. on Monday, September 2, Labor Day weekend.

“Mayday, Mayday, Mayday,” a man gasped into marine Channel 16—the VHF frequency designated for emergencies. His voice was labored and halting.

“Conception. Platts Harbor. North Side Santa Cruz.”

At Coast Guard Sector Los Angeles/Long Beach, one of the night watch standers returned the call, asking the vessel in distress its position and the number of people on board.

“Thirty-nine POB,” the man responded. “I can’t breathe.”

Then the radio went silent.

Five times the radio operator tried to hail the vessel. Finally, the watch stander issued a “pan-pan”—an alert to first responders and other mariners that, somewhere in the night, an urgent problem was unfolding.

The Mayday call came from Jerry Boylan, captain of the Conception, a 75-foot liveaboard dive boat owned by Truth Aquatics and chartered by Worldwide Diving Adventures. Twenty minutes later, Boylan made radio contact again. The boat was anchored just off Santa Cruz Island, some 20 miles from California’s southern coast and 90 miles as the crow flies from the Coast Guard station in Los Angeles. Distance made the radio connection patchy, so Boylan’s call was relayed by an intermediary. As a result, only the following record of the Coast Guard’s replies remains.

“What is the emergency? Over.”

“What is the emergency? Over.”

“Your vessel is on fire? Is that correct?”

“Roger. There are 36 people on board the vessel that’s on fire, and they can’t get off?”

“Roger. Can you get back on board the boat and unlock the doors so they can get off?”

“Roger. And there’s no escape hatch for any of the people on board?”

A few key details were inaccurate in these radio calls. There were actually 34 people still on board this triple-decker boat: a crew member, a dive leader, and 32 paying customers. They were all in the sleeping quarters, where narrow bunks were stacked three high. The doors into the boat, which opened to the galley and dining area, were not locked. There was an escape hatch, but it led into the main cabin, which was now engulfed in flame. Sleeping on the top deck, Boylan and four crew members were forced to jump off the ship. They used an emergency raft to get to a nearby fishing boat to make the second Mayday call.

But as it would soon become clear, the correction of these few factual errors wouldn’t have any impact on the eventual outcome.

In the minutes after that second Mayday call, the Coast Guard sector dispatched a helicopter from Point Mugu, about 40 miles to the east, and another one from San Diego, along with the cutter Narwhal, which had been conducting routine operations at the Port of Los Angeles. Five other city and county rescue vessels from the region began motoring out to the island as well.

At Coast Guard Station Channel Islands Harbor, in Oxnard, boatswain’s mate Logan Steinberger was in charge of the station watch. By the time he’d pieced together what was happening, he and his crew had just enough time to grab a portable pump and leap into their response boat. The station’s second craft would wait for a few county medics to arrive before heading out. They were the closest response team in the area.

“We knew from listening to the radio chatter that it was really bad,” recalled Steinberger. “We kind of knew going in that it may be hopeless, but you don’t treat it as hopeless until you’re really sure it is.”

Two or so miles east of Santa Cruz Island, he could make out the unmistakable glow of fire. It was the only light on the horizon.

When the response boat arrived, the Conception was completely ablaze. Steinberger and his crew swept the area, looking for survivors. Seeing none, they set up their pump. It has a limited capacity, so they had to get close to the burning boat. Steinberger steered the vessel from inside the cabin. Outside, his engineer was shouting directions to keep him oriented away from smoke and the worst of the flames. The coxswain could feel the heat as he leaned out to hear the engineer’s instructions.

One of the next boats on the scene carried a Ventura County fire captain, who let Steinberger and his crew know that their efforts with the pump were futile—it just didn’t have the capability of a real fireboat. So the crew of the response boat went back to circling for survivors.

Paul Amaral was at home when he got word of the distress call that night via a TowBoatUS radio-dispatch center. Captain of a TowBoatUS craft, he sped to his Ventura office, grabbed a grappling hook, and raced to the scene. The sea and sky were as dark as Amaral had ever seen them. He, too, was listening to the radio on his way to the Conception, hoping someone had made a terrible mistake when reporting the situation. And then, there it was on the horizon: the worsening fire.

Other fireboats arrived, one after another. They sprayed the Conception continuously for hours. The flames began to abate in places. But big hot spots remained. One burned through the boat’s anchor line. Amaral watched as the boat drifted into the jagged rocks encircling Platts Harbor. He knew his small vessel was the only one that could get in close, so he pushed up against the hull of the Conception, right next to the sleeping quarters. He didn’t hear a sound. Amaral knew no one could be alive.

The fire had decimated patches of the Conception’s hull. Amaral threw the grappling hook onto the bow and let out 50 feet of line. He pulled the burning boat off the rocks and tried to hold it in deeper water while two fireboats continued to pump water.

As the sun began to break, the bowline of the Conception wallowed lower and lower on the waterline. The Coast Guard began setting up gear to pump water out of the boat, hoping to keep the Conception stable enough to tow ashore. But before it could get the equipment ready, the stern disappeared below the water. Moments later, all but the bow had vanished. As it sank, the boat turtled. Debris quickly gathered on the surface above—charcoal, a pool of diesel fuel, charred remnants of the boat itself. No one really wanted to think about what else could be there.

First responders from over 14 state and federal agencies had aided in the rescue and recovery efforts. They retrieved 20 of the 34 victims by the end of the day. It took nearly two weeks before the rest of the casualties were recovered and identified.

As the international diving community mourned, crew members and victims’ families began looking for answers. Federal agencies, including the National Transportation Safety Board (NTSB) and the USCG, started to investigate. All indications suggest those answers may never come—that we may never know what caused one of the worst maritime tragedies in modern U.S. history, or how to prevent it from happening again.

The Conception was one of three boats belonging to Truth Aquatics, a dive and charter company founded in 1974. Owned and operated by Glen Fritzler and his family, the Santa Barbara–based organization was widely considered one of the best in the business.

These were family boats, where the crew and passengers ate meals shoulder to shoulder, often still in their wetsuits. Clients chartered the Fritzlers’ boats for field trips and family reunions. Customers felt safe on the dives. They felt secure living and sleeping on board.

The Conception was built for Truth Aquatics in 1981. Records obtained by Outside show that the boat passed its annual USCG inspections from 2016 through 2019, with just a handful of violations. These included, in 2017, an expired fire extinguisher, some minor electrical issues, and a failure to document both fire and abandon-ship drills, and, in 2018, expired items in a first aid kit.

Other than these citations, the vessel met USCG standards. It maintained mandatory fire-suppression systems, including fire extinguishers and above-deck hoses. Fritzler had installed smoke detectors on board. In addition to the narrow stairway leading from the fore end of the galley to below deck, the sleeping berths also had an emergency escape hatch—a square of plywood above one of the uppermost aft bunks that also led into the galley.

Truth Aquatics did have a few major safety incidents over the years. In 1992, its boat Vision ran aground in the Channel Islands while carrying divers. In nearly 40 years of service, three customers (out of an estimated 450,000) drowned while diving. For most of its patrons, however, their experience was overwhelmingly positive—one reason Fritzler was awarded the California Scuba Service Award, a lifetime-achievement commendation, in June 2019.

Every day hundreds of similarly compliant dive boats around the world depart for multi-day trips, only to return all passengers safely and happily to the dock. But it’s also true that catastrophic accidents aren’t entirely uncommon. In a simple Google search, I found reports of at least 11 fires on liveaboard dive boats since 2000. Most of those incidents did not receive widespread coverage, like the Sea Queen II, which caught fire in the Red Sea in 2004, killing an American teacher and two students. Or the Mandarin Siren, which incinerated in 2012 off the Indonesian coast while its customers were diving directly below (they were all rescued).

On October 26, 2019, less than two months after the Conception fire, the Red Sea Aggressor I, owned by Aggressor Adventures, based in Augusta, Georgia, departed Egypt’s Marsa Alam for a multi-day diving trip in the Red Sea. On November 1, just after midnight, passengers below deck awoke to the smell of smoke in their forward cabins. Smoke and heat prevented them from exiting the main staircase. They tried to use the emergency hatch but could move it only a few inches—as best as they could later surmise, a crew member had placed a thin mattress beside the hatch and fallen asleep against it. As they tried desperately to wake him, Michael Houben and his dive partner were waking up in their cabin, located in the aft of the vessel. Houben says he spent 20 or 30 seconds trying to find his glasses before abandoning the search and exiting the cabin, followed by his roommate. They made it to the emergency hatch, which had been opened once the crew member awoke. Houben estimates that, had he spent another few seconds trying to find those glasses, he probably wouldn’t have survived.

One passenger didn’t: Patricia Kessler, 54, a former naval officer and an experienced diver serving with the Justice Department at the American embassy in Tanzania. Her cabin was next to Houben’s, who speculates that she must have taken just a few seconds longer than he did before she exited.

I corresponded by email with Wayne Brown, CEO of Aggressor Adventures, in November. He said that his company has not yet received expert confirmation regarding the origin of the fire and is cooperating with local authorities in their investigation. He also said that while Egyptian codes do not require a standing watch, his company has implemented mandatory night watches on all of its vessels in the wake of the Aggressor fire. It’s also begun testing smoke detectors with artificial smoke to ensure their reliability, and guests are now invited, as part of their orientation, to test the devices and practice using the emergency exits.

“We hold our boats and crews to the highest standards of safety and service,” wrote Brown. “We’ll continue to do everything in our power to ensure guests enjoy their adventure with us, safely.”

But Houben, who has been perhaps the most outspoken of the Aggressor survivors in terms of the mistakes that he alleges were made on board, says that doesn’t go nearly far enough to ensure these types of disasters don’t occur again. Houben says he’s doubly disturbed because he heard there were similarities between what happened aboard the Aggressor and the Conception.

Worldwide Diving Adventures chartered the Conception for a Labor Day weekend trip—one that company head Kristy Finstad regularly led that time of year, often aboard a Truth Aquatics vessel. Fritzler’s crew handled logistics, meals, and the boat.

Finstad, 41, and her husband, Dan Chua, 42, took the reins of the company from her father, Bill, in 2004. For Finstad, it was a return home. She’d grown up in the water, surfing in Baja, Mexico, and diving with her dad by the time she was eight. After graduating from college, she worked in community-based coastal restoration in Southern California.

The diving industry was—and in a lot of ways remains—a male-dominated realm. Finstad fought hard against that, says Chua. “There were times abroad on trips where women leaders didn’t get the respect they deserved because of their gender,” he says. “She would battle through it by being smart and kind and thinking out of the box and knowing her shit.” In time she became a role model and certified dozens of new female divers.

In the years before the accident, Finstad and Chua took their business international, with trips to places like Borneo, South Africa, Indonesia, and French Polynesia. Those excursions weren’t cheap, but clients were guaranteed some of the best adventure diving out there.

The Channel Island excursions, by contrast, were structured to be affordable—unlimited tank refills and multiple daily dives, family-style meals in the galley, and spartan sleeping quarters down below. It wasn’t fancy, but it was fun.

Finstad’s 32 customers boarded the Conception the night of Friday, August 30. Some, like Sunil Singh Sandhu, 45, an electrical engineer originally from Singapore and living in Silicon Valley, were brand-new to diving. Others, like Kendra Chan, 26, and her dad, Scott, 59, both from the Bay Area, were veterans to these Channel Island excursions.

The boat departed Santa Barbara at 4 A.M. that Saturday. Chua was out of cell range in Costa Rica for much of the weekend. But he says that if the trip followed the typical schedule, most of the passengers would have slept through a good bit of the slog out to the islands. When they woke up, there’d be a continental breakfast and a safety briefing, then a morning dive and second hot breakfast. Guests could take multiple afternoon dives and, if they hadn’t been drinking at happy hour, there was usually the opportunity for a night dive. Each day they’d repeat that pattern.

The waters off the Channel Islands are coarse, filled with rocky reefs and dense kelp beds. Water temperatures are in the sixties. But divers get the chance to swim with sea lions and harbor seals, spearfish for halibut, and harvest lobster.

“It’s wonderful diving, but it’s not easy,” says Chua.

Sunday night, September 1, Captain Boylan anchored the boat off Santa Cruz Island. After the night dive, everyone stayed up late, celebrating the birthdays of three passengers: Vaidehi Campbell, a water-conservation specialist just two days shy of her 42nd birthday; Michael Quitasol, who was celebrating his 63rd with his wife, Fernisa Sisan, and three adult daughters—Evan Michel, Nicole, and Angela Rose; and Tia Salika-Adamic, whose parents had booked the family trip to commemorate her 17th birthday. Traveling with Salika-Adamic was Berenice Felipe, 16, one of her best friends. The daughter of Mexican-American immigrants, Felipe had lost her father when she was seven years old. Her mother, Yadira, raised her and her sister alone. Salika-Adamic and Felipe were regular volunteers at the animal shelter in Santa Cruz, California. And when Felipe expressed an interest in diving, the family took her on trips to places as far-flung as Bonaire, in the Caribbean, where they worked on reef-restoration projects.

What happened after the cake and ice cream is murky. (Boylan and the four surviving crew members have refused interviews due to ongoing investigations). What can be pieced together based on reports given to the NTSB is that 34 people, including Finstad and 26-year-old deckhand Allie Kurtz, descended the narrow ladderway in the galley near the bow of the boat to the bunks down below.

The captain and remaining crew members, including Ryan Sims, a newly hired boat steward, eventually settled into their wheelhouse quarters (the other crew members haven’t been named). A former attorney for the Fritzler family said in September that one of the crew members checked the galley as late as 2:30 A.M. This detail, however, could not be confirmed with the family’s new attorney, who directed inquiries about the fire to court documents.

The preliminary NTSB report said that Captain Boylan and four crew members were sleeping in the wheelhouse, on the top deck of the vessel, when the blaze broke out. Just after 3 A.M., an unidentified crew member woke to a loud noise. He says he opened the door, looked down, and saw a fire billowing out of the aft end of the dining area on the main level. He then woke the others. Boylan ran to make the first Mayday call. The others tried to descend to the main deck but could not because the ladder was on fire. With no other choice, they jumped 20 feet or so down to the main deck. Sims broke his leg in three places and injured his back and neck. With Sims unable to move, the other three crew members say they tried to open both the double doors at the dining area of the salon and the fore windows but couldn’t access either. As the smoke began to overtake them, the entire crew jumped overboard. Next, Boylan and two others say they swam to the aft of the boat, reboarded via a ladder, and checked the engine room for fire but saw none.

They then launched the Conception’s tender and collected the other two crew members, including Sims, who were in the water. There was only one other boat in the vicinity: the Grape Escape, a 60-foot fishing boat owned by Bob and Shirley Hansen, a couple who had anchored nearby for the night. Using the raft to reach the other boat, they woke the Hansens and deposited Sims, who the Hansens say was groaning in obvious pain, and Boylan, who then made the second Mayday call.

By then over 20 minutes had passed since the crew member first noticed the dining room was engulfed in fire. Later, in a press conference, Santa Barbara sheriff Bill Brown would say there was no indication that anyone on the lower level made it up through the flames.

“It was lit from one end to the other. There wasn’t a part of that boat that wasn’t on fire,” says Bob Hansen. “The flames were 30 feet high.”

A fire of that magnitude and in the sleeping quarters on the lower deck below the hull would mean an instant, deadly crisis for anyone down below, says Dr. Douglas Arenberg, a pulmonologist and critical-care professor of medicine at the University of Michigan Health System.

“With a fire on a modern craft, there’s a lot of plastic and materials that are going to release lethal chemicals,” says Arenberg. Burning plastics release cyanide, he explains. The polyvinyl chloride used on the flooring and seat covers would have created poisonous plumes of hydrogen chloride. Even just the particulates in that smoke could have obstructed airways before anyone could escape.

Accessing the emergency hatch on the Conception would have required 34 people to hop from their respective beds and orient down a dark, smoke-filled walkway to the aftmost set of bunks. Then, one by one, they would have had to climb a ladder to the top bunk, lie on their back, push open the hatch above their head, and then contort themselves up into it—if they woke up in time.

The fire would have rapidly depleted the quarters of oxygen, replacing it with lethal levels of carbon monoxide and toxic smoke. Indeed, medical examinations of the victims, a sheriff’s-office spokesperson told me later, indicated they died of carbon-monoxide poisoning.

“It’s a nightmare scenario,” says Arenberg.

Three days after the fire, representatives from the NTSB held a press conference in Santa Barbara, not far from a memorial to the victims of the Conception fire.

The vessel had not yet been raised from the ocean floor, but NTSB member Jennifer Homendy reiterated a comment one of the crew members had made to the Hansens the night of the fire that had since been widely reported by newspapers.

“There was a lot of photography, videography, cameras, cell phones that were charging on the vessel itself,” Homendy told reporters.

Later that week, the USCG issued a marine-safety bulletin urging boaters to “reduce potential fire hazards and consider limiting the unsupervised charging of lithium-ion batteries.”

These statements and bulletins have done much to encourage the theory that the Conception fire was caused by an overheated lithium-ion battery in one of the passenger’s devices and plugged into one of the ad hoc charging stations in the dining area or one of the outlets in the sleeping quarters.

There is precedent for this in the aviation world. A recent Federal Aviation Administration report lists 252 recorded incidents involving lithium-ion battery fires on board commercial airlines since 2006. The batteries store an enormous amount of energy in a very confined space, explains Feng Lin, a professor of chemistry at Virginia Polytechnic Institute and State University. And if multiple people were charging their devices simultaneously and in close proximity, Lin says you could have a “temperature escalation that would reduce safety features.”

“It’s a complicated chemical reaction made even more complicated by everything else contained in the seawater,” Lin says.

Chua says he gets that. But with no evidence to substantiate the battery theory other than speculation, he thinks making that supposition public was a callous and irresponsible move while the boat was still on the ocean floor and one victim had yet to be recovered.

“It was a random guess, with no evidence at the time, and was a slight to all the people who died and their families,” he says. “It seemed like victim blaming to me.”

Fires such as these are notoriously difficult to investigate, because evidence that could be used to determine a specific cause is incinerated. Even if it weren’t, days sloshing around on the seafloor would render much of it difficult to analyze. Without any such specific evidence at hand, one certified fire investigator told me, the boat fire may ultimately be classified as of “undetermined cause.”

Nevertheless, in a press conference a day after the fire, Homendy stated, “I am 100 percent confident that our investigators will determine the cause of this fire, why it occurred, how it occurred, and what is needed to prevent it from happening again.”

I spoke with her by phone two months later, and she stood by that statement.

“This is what we do. We investigate a lot of tragedies. And after accidents, sometimes there’s a lot of evidence and sometimes there’s little evidence,” she said. “There’s no doubt in my mind that, at the end of the day, we’ll have a probable cause and recommendations to vote on when we consider the final report.”

One reason for her confidence may be the fact that the NTSB considers not only the actual mechanism that ignited the fire but also human behavior and environmental factors. For instance, when fire destroyed the Florida-based Island Lady in January 2018, the NTSB determined probable cause to be an ineffective preventative-maintenance program, along with insufficient guidance for the crew on how to operate the vessel in an overheated-engine situation. As for those lithium-ion batteries, she said the crew’s statements about the charging stations are factoring into their investigations, but so, too, are other matters like electrical wiring and galley equipment.

“We’re not ruling anything out,” Homendy told me.

The NTSB will not speculate on the cause of the fire, as the investigation is still ongoing, but one finding in the agency’s final report could be the lack of a standing night watch—a violation of UCSG rules—since the NTSB’s preliminary report found that all crew members were asleep when the blaze broke out. If the final report confirms that the ship did not have a standing night watch, the captain or vessel owner could serve up to ten years in prison, according to U.S. code.

Regardless of the cause, the NTSB could also make recommendations concerning the size and egress of emergency hatches, the types of onboard fire alarms, and the use of personal electronics. But Homendy reiterated that these recommendations could really include anything, and the goal of the recommendations is to ensure an event like this doesn’t happen again.

In the meantime, it’s up to both the criminal and civil courts to decide what happens next for the owners, crew, and surviving family members of the Conception.

Three days after the fire, the Fritzlers evoked a maritime statute from the 19th century that limits financial liability to the value of the vessel (which is currently zero) and mandates that all claims be filed within six months of the accident, making it difficult for some surviving family members to seek compensation. In January, four of the victims’ families, including Kurtz’s, filed claims challenging the Friztlers’ effort to invoke the obscure law. Among the safety violations the filing alleges is that Truth Aquatics failed to provide a safe way to store and charge lithium-ion batteries, as required by the USCG.

Meanwhile, Sims has sued Truth Aquatics for pain and suffering, alleging that the Conception was not properly maintained and outfitted with safety equipment. Sims also alleges that he and other crew members were not adequately trained for emergencies such as the one that led to his injuries. A similar lawsuit has been filed by the widow of Justin Dignam, 58, who died in the fire. Her suit alleges that the vessel didn’t have adequate smoke detectors or firefighting equipment, it lacked enough emergency exits, and a required night watch was not on duty when the flames broke, according to the lawsuit filed in federal court. (Truth Aquatics and its attorneys did not respond to multiple requests for comment regarding the allegations made in the two lawsuits and claims filed by victims’ families.)

On Capitol Hill, congresspeople are pointing fingers at the Coast Guard. The agency is responsible for creating and enforcing safety standards, inspecting vessels, and launching rescue and recovery operations. In November, after the Los Angeles Times revealed that the Coast Guard rejected recommendations to improve fire safety, the House Committee on Transportation and Infrastructure’s subcommittee on Coast Guard and maritime transportation called Rear Admiral Richard Timme, the assistant commandant for prevention policy, to testify. Members chided him for what they saw as a “track record of inaction” when it came to requiring changes suggested by the NTSB, particularly those following maritime tragedies.

In December, California senator Dianne Feinstein, along with representatives Julia Brownley and Salud Carbajal, introduced the Small Passenger Vessel Safety Act, which endeavors to shore up safety measures by requiring multiple egresses (which exit into different parts of the vessel), strengthening requirements for integrated fire-alarm systems, and restricting the use of lithium-ion batteries on board.

“The Conception boat fire was a tragedy that could have been prevented had stronger safety measures been in place,” said Feinstein. “We must ensure that small passenger vessels have the right safety measures in place to prevent disasters at sea.”

Chua says he’s all for common-sense regulations. But he doesn’t want to see elected officials insisting on knee-jerk changes just to make people feel better. Any new regulation, he says, has to make sense and promote safety.

In the meantime, he’s trying to put his life back together. Kristy Finstad wasn’t just the love of his life, she was also the heart and soul of their business. Worldwide Diving Adventures has been on hiatus since the fire. Chua says he’ll run the trips already scheduled for 2020, but handling both logistics and grief has been hard. After these trips are done, he doesn’t know what’ll be next.

“It was always a team effort on trips between Kristy and myself, and it’s really hard to not have your partner next to you,” he says. “Sometimes I look to my side and just see an enormous empty space where she would have been, and my heart just aches.”