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(CNN) - In January 2018, 102 people boarded a ferry from a remote island in the South Pacific. Only seven of them survived.
A report by the Commission of Inquiry on the disaster off the coast of Kiribati, made available to the public on Monday, found a litany of problems behind the sinking of MV Butiraoi, including a drunk crew and an incompetent captain.
The commission, established by the Kiribati government in 2018, found that most of the 95 victims, if not all, died of hunger, dehydration and hypothermia. A woman died while giving birth during the accident, the commission found.
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Although the commission discovered that the actions of the crew had contributed to the worst maritime disaster in the history of Kiribati, it discovered that there were no intentions or actions that would have led to the death of these people.
The commission made a series of recommendations, including that monuments should be erected to remember the dead.
This is how the tragedy happened
On the morning of January 18, 2018, 89 passengers and 13 crew members boarded the MV Butiraoi on Nonouti Island, one of 32 atolls in the Kiribati island chain, where some 109,000 people live.
The ferry was heading to the municipality of Betio on an atoll about 288 km away. According to the New Zealand authorities, the trip was expected to take two days.
But when the 17.4-meter boat entered the open sea, it experienced waves up to 2.5 meters high. After 30 minutes, the main structural transverse beams began to fail, and after two hours, parts of the boat collapsed inward. The ferry broke and finally sank.
The boat had two life rafts for 25 people and two aluminum work boats. However, one of the liferafts was pierced by the remains, so it was unusable, and the floor of the second liferaft failed, leaving only the inflated tubes for people to float.
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Approximately on the third day adrift, one of the aluminum boats overturned and sank. In the remaining boat there was hardly any food and water, and the survivors began to decrease in number.
A search and rescue operation began on January 26, eight days after the departure of the ferry.
Finally, on January 28, the aluminum boat was seen by an Orion patrol aircraft of the New Zealand Air Force. Only seven survivors were rescued, all suffered dehydration and a slight degree of malnutrition. Including two crew members and a 14 year old girl.
The authorities of New Zealand, Australia and the United States continued to search until February 3, while local Kiribati authorities continued until February 8. However, the other 95 people on board are still missing.
What went wrong
Concerns about the boat had arisen even before MV Butiraoi left the port, according to the commission.
Recently the ferry had been grounded twice and had already been damaged by "excessive repetitive overload and very poor maintenance."
The boat's radio license expired on January 1 and the maritime capacity document expired on January 20. In essence, this meant that the boat was not in a position to sail at the time of the accident on January 18, the commission said.
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This photo was taken by the New Zealand Royal Air Force P-3K2 Orion when the fishing vessel picked up the seven survivors.
On January 3, a marine surveyor checked the boat and discovered that there were not enough life jackets or space in the aluminum boats for passengers. Because of that, he issued an instruction that the ferry could not carry passengers.
The next day, the ferry experienced a mechanical failure after its propeller became entangled with a fishing net.
When the ship departed on January 18, it was overloaded with people and cargo, which put more pressure on the already damaged structure of the ship, the commission found.
The failures of the ferry captain
The commission discovered that the ship's captain had failed in several ways.
When the ship sailed, the captain ignored a warning from one of his colleagues about the bad weather in the open sea and continued sailing despite the high waves.
The captain refused to slow down when loud noises were heard inside the boat, and he did not play his role "during the chaos when the tragedy occurred."
"He was seen sitting in one of the overturned helmets along with some passengers obviously stunned, sorry and sorry," the commission found, adding that it seemed that everyone in the crew was fighting for their own lives. The captain, according to the report, "showed a complete lack of leadership."
When the boat sank, no one on land knew what had happened. The captain did not tell the marine guard before the ferry departed, did not send a distress message before the ship broke and did not activate the beacon that would have alerted others about his position.
That delay in the start of the search and rescue operation resulted in a significant loss of life, the commission found.
In general, there was no competence and experience of the crew and the captain, according to the commission. The captain was reckless and inconsiderate with the ship, the crew and the passengers.
"The overall management of the crew was very poor and, as a result, the safety of passengers on board was compromised," the report found.
The report also noted the use of alcohol by the captain and the crew during working hours, "giving each crew member who was drunk the feeling of greatness and power to make decisions alone."
Commission recommendations
The commission presented 15 recommendations to be implemented by the government of the island nation.
Among the recommendations included are that reports of damage during each trip should be sent to the Marine Division, and that alcohol consumption during working hours should be prohibited.
He also recommended that boats should have life-saving devices, such as vests, for each passenger on board, and that they should be inspected regularly.
The commission also established that a series of laws had been violated, including the fact that the ship had been taken to the sea when it was not safe. The commission recommended strengthening regulations to ensure stricter compliance.
Opposition lawmaker England Iuta said it would take some time for the contents of the report to be leaked into the community, because many locals don't speak English, according to Australian broadcaster ABC. Many people blamed the government and maritime authorities for the tragedy, he said
- CNN has contacted the office of the president of Kiribati to comment.
Tragedy in Kiribati