Oct. 1 (UPI) -- The U.S. Coast Guard has concluded mistakes by the captain of the El Faro led to the sinking of the cargo ship and the deaths of all 33 crew members in 2015.
The Coast Guard's final 199-page report was released on Sunday, two years to the day after the 800-foot vessel sunk near Crooked Island in the Bahamas.
Capt. Michael Davidson sailed through rather than around Hurricane Joaquin and "failed to carry out his responsibilities and duties as captain of the vessel during the last eight hours before it sank," the report concluded.
If the captain had survived, the Coast Guard would have filed negligence charges and attempted to have his license revoked, lead investigator Capt. Jason Neubauer told reporters during a Jacksonville news conference on Sunday.
Davidson "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 heavy weather," Neubauer said.
He added, "he failed to understand the severity of the situation, even when the watch standards warned him the hurricane was intensifying."
The crew's "complacency" and "lack of training" also contributed to the sinking, the report said.
Also, Tote, which managed the ship's operation, "did not ensure the safety of marine operations and failed to provide shore side nautical operations support to its vessels."
No criminal prosecution was recommended but Tote could be fined up to $80,000.
In a statement, Tote said the report "is another piece of this sacred obligation that everyone who works upon the sea must study and embrace. The report details industry practices which need change."
The investigation included 30 days of public hearings by 76 witnesses.
The Coast Guard also listened to 26 hours of voice recordings of the captain and crew from the El Faro's voyage data recorder. Similar to the so-called black boxes carried by airlines, the data recordings were retrieved from the ship's broken corpse, 15,000 feet beneath the ocean surface.
The El Faro sinking was "one of the worst maritime disasters in U.S. history," according to the report.
The report criticized the El Faro's design, the way its cargo was loaded, National Hurricane Service weather data and Coast Guard's own inspection procedure.
"The most important thing to remember is that 33 people lost their lives in this tragedy," Neubauer said. "If adopted, we believe the safety recommendations in our report will improve safety of life at sea."
The agency's 31 safety and four administrative recommendations include equipping ships with modern enclosed lifeboats.
The National Traffic Safety Board, which is conducting its own investigation, plans to issue its own safety recommendations on Dec. 12.