Calling it “the most important thing [investigators] will do in their Coast Guard career” Capt. Jason Neubauer formally wrapped up the two-year Marine Board of Investigation probe into the sinking of the El Faro.

The 199-page report, which incorporated 289 hours of testimony from 79 witnesses, is dense and detailed. The board issued 39 safety recommendations -- 30 designed to prevent future tragedies, four administrative changes to enhance post-accident response, and four suggested civil penalties against TOTE Maritime.

In the simplest terms, the report placed primary blame on three entities: the ship’s master -- Captain Michael Davidson; the ship’s owner TOTE Maritime; and the American Bureau of Shipping (ABS), the agency to which the Coast Guard outsourced ship inspections. (To a lesser extent, the report also faulted the Coast Guard for failing to supervise ABS.)

Neubauer, who led the Marine Board probe, noted “the primary initiating event for this tragedy was the vessel’s close proximity to Hurricane Joaquin.”

REPORT: Crew exhaustion, poor supervision and an aging ship to blame for El Faro tragedy

The fact the ship was where it was, Neubauer said, was Davidson’s doing. “The Master misjudged the path of Hurricane Joaquin and overestimated the vessel’s heavy weather survivability, while also failing to take adequate precautions to prepare for heavy weather,” he said.

The path put the ship in harm’s way, and in the final hours, the captain did not respond to multiple calls from the bridge seeking guidance. Had the captain survived, Neubauer says, the board would have pursued a negligence claim against him.

Regarding Jacksonville-based TOTE Maritime, he said, “Their safety management system was ineffective ... and insufficient in supporting vessel operations.”

As for ABS, the agency charged with inspecting ships on behalf of the Coast Guard, Neubauer let the findings that followed the tragedy speak for themselves. Three ships approved by ABS, upon further inspection, were simply scrapped – deemed too dangerous to sail. Another 14 vessels had “varying levels of noncompliance."

“When we finally went aboard they were definitely in a substandard safety condition,” Neubauer told First Coast News.

He also expressed concern about the problem of older vessels being “grandfathered” into compliance, despite carrying outdated – and hardly stormworthy – lifeboats. New regulations that require ships to have closed-tops and motor power took effect in 1986, but the 40-year-old El Faro was allowed to keep the old, open lifeboats.

“The design of the lifeboats made them not an option for the crew,” Neubauer said, given the storm's 40-foot seas.

The report was released Sunday morning, the second anniversary of the worst cargo vessel disaster in 60 years. Family members of the victims plan to gather at the Seafarers Union Hall at 2 pm today, with Neubauer and other MBI members in attendance as well.