WASHINGTON -- The Coast Guard today released the Final Action Memo regarding the loss of the S.S. El Faro and its 33 crewmembers during a 2015 hurricane near Crooked Island, Bahamas.

In the Final Action Memo, Commandant of the Coast Guard, Adm. Paul Zukunft, approves the findings of fact, analysis, and conclusions detailed in the Marine Board of Investigation's Report of Investigation, essentially marking it as the official Coast Guard position on the cause of the marine casualty.

Read the Final Action Memo here.

Following the Commandant's review of the ROI and comments received from Parties in Interest and families of the crew, he concluded that the primary cause of the casualty was the decision to navigate El Faro too close to the path of Hurricane Joaquin.

Contributing factors include:

(1) an ineffective safety management system within the operating company, TOTE Services, Incorporated;

(2) American Bureau of Shipping's failures to uncover or otherwise resolve longstanding deficiencies that adversely affected the safety and seaworthiness of vessels on multiple occasions; and

(3) failure of the Coast Guard to adequately oversee the third party in this case, and the investigation reveals that the Coast Guard has not sustained the proficiency and policy framework to do so, in general.

“As the pace and complexity of maritime commerce and operations have increased, third parties have enabled the regulatory regime to evolve and keep up with increasing demand,” the memo said. “Third party programs, such as the Alternate Compliance Program (ACP), have transitioned from an option to a necessity upon which both the Coast Guard and the maritime industry rely. Responding to the recommendations on the 1983 capsizing and sinking ofthe S.S. Marine Electric, the Commandant dissented with the MBI and concluded that the poor quality of surveys aboard that vessel could not be justifiably expanded to condemn the entire system ofthird-party delegations. The same is true in this case. The Coast Guard relies far more heavily on third parties today than at the time of the Marine Electric casualty. Now, more than ever, the system requires reform. The Coast Guard must, and will, establish a risk-based and enduring policy framework that is simpler to execute and enables more robust oversight of delegated functions.”

"The loss of the El Faro and its crewmembers was tragic and preventable. The Coast Guard will take appropriate action on all that we have learned from this investigation," said Zukunft, in a news release. "I thank the members of the Marine Board of Investigation for their exhaustive work and independent recommendations. El Faro's heartbreaking story points to the need for all maritime stakeholders to zealously recommit to both the safety of our mariners and to professionalism of the maritime industry."

The Final Action Memo also outlines the final agency actions that will be taken in response to the Board's recommendations. Rear Adm. John Nadeau, the assistant commandant for prevention policy, will lead the Commandant's efforts in response to the recommendations.

"The tragic story of the El Faro points to the need for a strong and enduring commitment from all elements of the safety framework: vessel owner, Authorized Class Society, and the Coast Guard," said Nadeau. "As the lead agency of the U.S. Flag Administration, the Coast Guard is ultimately responsible to monitor the performance of third party organizations entrusted with the safety of U.S. ships. The Coast Guard takes the implementation of the safety recommendations in the Commandant's Final Action Memo very seriously and is committed to providing sustainable policy, oversight, and accountability both internally and externally."