A weary crew, an aging ship, and poor weather forecasting are among the reasons the Coast Guard Marine Board of Investigation cites for the sinking of the El Faro cargo vessel two years ago today.

The Marine Board Investigators called the El Faro probe, "the most important thing they will do in their coast guard career."

The report identifies the factors that led to the deaths and includes recommendations to the commandant of the Coast Guard to ensure safety in the future.

“The most important thing to remember is that 33 people lost their lives in this tragedy,” said Capt. Jason Neubauer, the chairman of the Coast Guard’s El Faro Marine Board of Investigation. “If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

Why? And what now? Final report on El Faro tragedy due Sunday

Capt. Neubauer said multiple factors led to the sinking of the El Faro and that those factors were tied to four different responsible parties, which include:

1. Master of the vessel

2. The vessel owner (Tote)

3. The authorized class society

4. US Coast Guard

Capt. Neubauer said they determined the main reason for the ships sinking was its close proximity to Hurricane Joaquin. Joaquin was a powerful Category 4 hurricane at the time of El Faro's sinking.

"The master was ultimately responsible for the vessel, the crew and its safe navigation," Neubauer said. "The master misjudged the path of Hurricane Joaquin and overestimated the vessel's heavy weather survivability while also failing to take adequate precautions to monitor and prepare for the heavy weather."

The report stated Tote and Davidson did not do a proper job of identifying the heavy weather when making the plan for the voyage before departure.

When it came down to Tote's responsibility in the sinking of the El Faro, Capt. Neubauer said the company was responsible for the safe operation of their fleet of vessels.

"Tote failed to identify heavy weather as a threat to their vessels and failed to comply with important rest and regularity reporting requirements," Neubauer said.

Neubauer said after reading the report, Tote could be punished up to $80,000. According to the Florida Times-Union, Tote released the following statement following the press conference:

“The El Faro and its crew were lost on our watch and for this, we will be eternally sorry. Nothing we can do will bring back the remarkable crew, but everything we do can work to ensure that those who go to sea, serving us all, are in ever safer environments.”

As of right now, there are no recommendations for criminal prosecution in the sinking of the ship.

The 199-page Marine Board of Investigation Report of Investigation (ROI), released Sunday morning, comes after three, two-week public hearings and hundreds of hours of review. The report finds plenty of targets for blame in the tragedy. Among the findings:

  • TOTE did not ensure the safety of marine operations and failed to provide shore side nautical operations supports to its vessels.
  • The Master of EL FARO, Captain Michael Davidson, failed to carry out his responsibilities and duties as Captain by not changing course
  • The National Hurricane Center created and distributed tropical weather forecasts for Hurricane Joaquin that proved to be inaccurate
  • The cumulative effects of anxiety, fatigue, and vessel motion from heavy weather degraded the crew’s decision-making and physical performance of duties during the accident voyage.
  • The ship’s increase in cargo carrying capacity in a 2005-2006 conversion made the ship less stable but was not reviewed as a “major conversion” by the Coast Guard.
  • Once the ship’s hold began, flooding, the crew “did they have equipment or training to properly respond”
  • The captain failed to notify shore support of his order to abandon ship, delaying Coast Guard rescue response
  • The ship’s outdated open lifeboats were “completely inadequate to be considered as an option for the crew to abandon ship in the prevailing conditions.”

The report also finds violations of standards that could be subject to civil penalties. Among them:

  • There were numerous violations of crew rest hours standards
  • There was no safety orientation for the Polish riding crew, aboard to repair the ship’s boilers
  • TOTE failed to notify the Coast Guard of repairs to lifesaving gear
  • TOTE failed to notify the Coast Guard or regulators of repairs to EL FARO’s main propulsion boiler superheating piping on August 24, 2015.

Following is a statement from U.S. Sen. Bill Nelson (D-FL) on the Coast Guard report ohe sinking on the El Faro released today:

"Our thoughts and prayers remain with the families of those lost on the El Faro. This tragedy never should have happened, and the findings in this report will serve as a roadmap for how we can prevent this kind of tragedy from happening again."

Click here to read the full report.