Most of 95 people killed in Kiribati ferry disaster died from hunger, dehydration and hypothermia, inquiry finds

A January 28, 2018, photo released by the New Zealand Defense Force shows a wooden dinghy, left, carrying seven survivors from a missing ferry.

(CNN)Last January, 102 people boarded a ferry from a remote island in the South Pacific. Only seven of them survived.

A Commission of Inquiry report into the disaster off the coast of Kiribati, made publicly available on Monday, found a litany of problems behind the sinking of the MV Butiraoi, including a drunk crew and incompetent captain.
The commission, which was set up by the Kiribati government last year, found that most -- if not all -- of the 95 victims died from hunger, dehydration and hypothermia. One woman died while giving birth during the accident, the commission found.
Although the commission found that the actions of the crew had contributed to the worst maritime disaster in Kiribati's history, it found there were no willful intentions or actions which had led to the deaths.
    It made a number of recommendations, including that monuments should be erected to remember the dead.

    How the events unfolded

    On the morning of January 18, 2018, 89 passengers and 13 crew boarded the MV Butiraoi at the island of Nonouti, one of 32 atolls in the Kiribati island chain, home to about 109,000 people.
    They were bound for the township of Betio on an atoll some 288km away (179 miles). According to 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 of up to 2.5 meters (8.2 foot) high. After 30 minutes, the main structural cross beams began to fail, and after two hours parts of the boat collapsed inwards. The ferry broke apart and eventually sank.
    The boat had two 25-person life rafts and two aluminum work boats. However, one of the life rafts was punctured by the wreckage rendering it unusable, and the floor of the second life raft failed, leaving only the inflated tubes for people to hang onto.
    On about the third day of drifting, one of the aluminum boats capsized and sank. On the remaining boat, there was hardly any food and water -- and the survivors started to dwindle in numbers.
    A search and rescue operation was launched on January 26 -- eight days after the ferry departed.
    Finally, on January 28, the aluminum boat was spotted by a New Zealand Air Force Orion patrol plane. Only seven survivors were rescued, all suffering from dehydration and a mild degree of malnutrition. They included two crew members, and a 14-year-old girl.
    New Zealand, Australian and United States authorities continued searching until February 3, while local Kiribati authorities continued until February 8. Nevertheless, the other 95 people on board remain unaccounted for.

    What went wrong

    Concerns about the boat had been raised even before the MV Butiraoi left port, the commission found.
    The ferry had experienced two recent groundings and had already been damaged by "repetitive excessive overloading and very poor maintenance."
    The boat's radio license was set to expire on January 1, and its sea worthiness was set to expire on January 20. In essence, this meant that the boat was not seaworthy at the time of the accident on January 18, the commission said.
    Imagery that was taken from Royal New Zealand Air Force P-3K2 Orion as the fishing vessel picked up the seven survivors.
    On January 3, a marine surveyor checked the boat and found there were not enough life jackets or space on the aluminum boats for passengers. Because of that, he issued an instruction that the ferry was not allowed to take passengers.
    The next day, the ferry experienced mechanical failure after its propeller became tangled with a fishing net.
    When the boat set off on January 18, it was overloaded with people and cargo, which put more pressure on the boat's already damaged structure, the commission found.

    The ferry master's failings

    The commission found the boat captain had failed in a number of ways.
    When the boat set off, the captain had failed to heed a warning from his colleague about bad weather in the open sea and continued to sail despite high swells.
    He refused to slow down when loud noises could be heard from within the boat, and he did not perform his role "during the chaos when tragedy struck."
    "He was seen sitting on one of the capsized hull with some passengers obviously dazed, regretful and sorry," the commission found, adding that it appeared that everyone in the crew was fighting for their own lives. The captain, the report said, "showed complete lack of leadership."
    When the boat sank, no one back on land knew what had happened. The captain did not tell the marine guard before the ferry set off, didn't send a distress message before the vessel broke apart, and didn't activate the radio beacon which would have alerted others to their position.
    That delay in starting the search and rescue operation resulted in significant loss of life, the commission found.
    In general, the competency and experience of the crew and captain was lacking, the commission found. The captain was reckless and inconsiderate of the ship, crew and passengers.
    "The overall management of 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 master and crew during work hours, "giving every drunken crew the feeling of grandeur and power to make decisions alone."

    What the commission recommended

    The commission laid out 15 recommendations to be implemented by the island nation's government.
    Those included that reports of damage during each voyage should be sent to the Marine Division, and that drinking alcohol during work hours should be prohibited.
    It also recommended that boats should have life-saving appliances -- such as life jackets -- for every passenger on board, and that these should be inspected regularly.
    The commission also laid out a number of laws that had been broken, including that the vessel had been taken out to sea when it was unsafe. But the commission recommended that the regulations needed to be strengthened to ensure stricter compliance.
      Opposition lawmaker England Iuta said it would take some time for the report's contents to filter into the community, because many locals did not speak English, according to Australian broadcaster ABC. Many people blamed the government and maritime authorities for the tragedy, he said.
      CNN has reached out to the office of the Kiribati President for comment.