The BC Ferries report on the sinking of the Queen of the Northblames human error for the accident, which claimed two lives when the ferry went down along B.C.'s North Coast in March 2006.
The report singles out three crew members in charge of navigation and steering on the night of the sinking, saying they failed to make a required course change at Sainty Point.
The ferry then proceeded straight on an incorrect course for four nautical miles over 14 minutes until it ran into the rocks of Gil Island.
The person at the wheel that nightwas the ship's quartermaster, a deckhand considered a "rating under training." The two people in charge of navigationwere the second and fourth officers.
The internal report says the ship's black boxshows the fourth officer failed to alter course, or at the very least, verify such a change in course was made.
It also says the two people on the bridge that night, the fourth officer and the deckhand, lost situational awareness sometime after Sainty Point. And it says they also failed to appreciate the vessel's impending peril prior to the grounding on Gil Island.
It states that theperson at the wheelonly became aware of trouble when trees were sighted on an island directly ahead.
At about the same time, the fourth officer shouted an order to disengage the ship's autopilot and alter course. But the person at the wheel apparently didn't know how to turn off the autopilot.
The ship hit ground and reports came in that the engine room was flooding.
The captain was off duty and asleepat the time. When he made it to the bridge, hesaid he was told by thefourth officer, "I'm sorry, I was trying to go around a fishing vessel."
Nothing wrong with ship
To back upits finding of human error, the report points out there was little wrong with the ship or its equipment that night;that there were no propulsion, mechanical or control defects on the ferry that night.
Itsays there is no evidence that the autopilot or steering system malfunctioned, and that all electrical navigational equipment in the wheelhouse was operating within normal limits.
The evidence obtained from the black box clearly demonstrates, according to the report, that the Queen of the North changed neither course nor speed during the final 14 minutes.
The report also points out the two officers did not co-operate with the internal investigation.
Crew didn't search all cabins
The crew of the sinking ferrybanged on the doors of all 55 passenger cabins, but only searched 53of them, according to the report.
Ninety-nine of the 101passengers and crew aboard the ferry managed to escape to safety. However, two passengers, Gerald Foisy, 46, and Shirley Rosette, 42, of 100 Mile House, B.C., are still missing and presumed dead.
Monday's internal report is not the final word on the tragedy. The National Transportation Safety Board still has to release its report on the sinking, which took place on March 22, 2006.
Last May, the board sent a letter to BCFerries president David Hahn also talking about human error.
The TSB said some of the crew may not have received proper training on the ship's new steering and navigational equipment.