An overloaded ferry that sank near the Pacific island archipelago of Kiribati in 2018, killing 95 people, was not allowed to carry passengers in the open sea and had twice run aground before its fateful journey, an inquiry has found.
Only five passengers and two crew members of 102 aboard survived the sinking of the MV Butiraoi ferry in January 2018, after many died of thirst and hunger while adrift for over a week in a lifeboat in the central Pacific Ocean.
The report commissioned by the government detailed a litany of failings that caused the tragedy.
The report found widespread use of alcohol by the master and crew during working hours, "giving every drunken crew (member) the feeling of grandeur and power to make decisions alone".
"It was obvious the master of the MV Butiraoi was reckless and inconsiderate of the ship, crew and passengers," it said. The ship's master did not survive.
The report found the catamaran began to fall apart 30 minutes into the journey and had split and sank after two hours.
It said there was no leadership from the crew, who had limited survival training.
It blamed the slow rescue response on a lack of information provided by the ship's crew, recommending stricter maritime policing to ensure reporting procedures were properly followed.
It also called for a tighter inspection regime and better boat building standards.
"With hardly any food and water, the survivors began to perish," investigators said in the report, ordered by the office of Kiribati's president.
The MV Butiraoi departed the Kiribati island of Nonouti, about 3000km southwest of Hawaii, on its way to Kiribati's capital Tarawa, 250km away on 18 January.
The vessel, loaded with almost 30 tonnes of dried coconut kernels called copra and 35 empty fuel drums, was not licensed to carry passengers in the open ocean.
The crew had also been drinking alcohol, the investigators found.
Facing strong winds and 2.5m waves, the boat broke apart and capsized two hours after departure.
The catamaran had been poorly maintained, according to the report, and had run aground previously, likely damaging its structure.
Two life rafts carrying a total of 50 people were launched but one became unusable after a puncture. As passengers reached for the one working lifeboat, its floor "failed" as well, the commission said.
Others clung to the capsized hull of the ferry.
Authorities did not commission a search-and-rescue operation until 26 January when the catamaran's arrival in Tarawa became clearly overdue.
That operation included help from US, Australian and New Zealand aircraft and lasted for six days.