JACKSONVILLE, Fla. – The 2015 sinking of the El Faro, which killed all 33 crew members, was a "tragic and preventable accident" and a wake-up call for the entire maritime community, according to a report released Thursday by the U.S. Coast Guard.
The report, which comes a week after the National Transportation Safety Board handed down its findings, found there were several factors that contributed to the disaster, but none more critical than the captain's decision to sail too close to Hurricane Joaquin.
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The cargo freighter sank near Crooked Island while heading from Jacksonville to San Juan, Puerto Rico, Oct. 1, 2015, after losing engine power in the face of the Category 3 hurricane. The wreck has become known as the worst maritime disaster in modern American history.
READ: Coast Guard's Final Action Memo on El Faro disaster
Like the NTSB, the Coast Guard assigned the bulk of the blame to Capt. Michael Davidson, who did not change course to avoid the storm's path, and TOTE Services, the cargo ship's owner. The final action memo recommended TOTE face civil penalties for multiple violations of industry rules.
Among other violations, the report cited failure of the crew to get sufficient rest on multiple dates before the fateful voyage, failure to comply with emergency procedures, failure to notify the Coast Guard of repairs to the ship's primary propulsion boiler a month before it left port for the last time.
The report also criticized the Coast Guard itself for a lack of oversight when it comes to safety inspections and for relying too much on private contractors to make sure ships are seaworthy.
The memo makes 31 safety recommendations, including the elimination of open life boats as well as the installation high-water alarms in cargo holds, warning indicators on watertight closures and closed-circuit cameras in the cargo holds that can be monitored from the bridge.