The crew - and the Commanding Officer - of the Navy ship Manawanui were under trained and the boat was not up to the task it was doing when it grounded on a Samoan reef.
Multiple failures of the crew, the ship and the Navy itself have been identified in a damning report by a Court of Inquiry into the sinking of the coast of Upolu in October which occurred after it was left in autopilot and could not turn.
The report also contains a full transcript of the dramatic night. Including the captain telling the crew they would survive if they abandoned ship.
The Manawanui has been conducting hydrographic surveys of the reef ahead of the Commonwealth Heads of Government meeting, something neither the ship nor the crew were properly equipped to do, when it ran aground.
Photo: Profile Boats / supplied
There was no one on board who was qualified enough to carry out the hydrographic surveying that the ship was tasked with doing and the ship itself was not cleared for that work, the court found.
There were not enough people on board to be able to have an effective watch rotation to prevent fatigue during the prolonged survey task, the Court found.
Out of 45 people on board, there were "20 personnel deficiencies," it found.
There were weaknesses in training - that enabled some people to hold posts on the ship without the necessary levels of proficiency or experience.
The report details the Captains word to her crew as they prepared to leave the ship after it had grounded several times and it was clear it had to be abandoned.
"This isn't a great situation, however I have faith that you all know what you need to do. We'll get to our liferaft stations, we'll get in our liferafts and we'll survive this and then we'll wait for help to arrive."
The person in charge of the ship at the time of the incident was "distracted", which the Court of Inquiry found contributed to a lack of situational awareness.
Meanwhile, the role of the supervisor was "not clearly defined" and they had inadequate situational awareness and understanding of how the ship operated, it found.
The ship sailed a day later than scheduled, because of an azimuth thruster defect prior to sailing.
The Court of Inquiry found time pressure influenced the way the survey task was conducted and "that time pressure could have been avoided if the task had been properly planned."
"The risk management culture was found to be deficient and weighted heavily on achieving the mission without the necessary balance to ensure the mission was completed safely," it found.
The Court found no errors with the ship's engines during the grounding.
"At the time of the grounding, there is no evidence that the ship had a loss of power or a steering/control failure," it said.
Speaking to media a short time ago, Chief of Navy Rear Admiral Garin Golding said the Navy will have a "relentless focus on continued improvement."
"I want to assure everyone, including most importantly, the Navy and the wider Defence Force, just how seriously on taking the response to this report," he said.
"The safety of our people and the missions we undertake are my main priority."
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