The commission said the ferry should never have left Kimbe for the last leg of its journey to Lae because of the following reasons:

• The ship was not suitable to operate in force 7 or above weather conditions;

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• the ship was not manned and operated by a competent and appropriately qualified crew;
• the ship was not maintained in accordance with a considered and recorded maintenance plan;
• the ship was routinely carrying more passengers than specified by its survey certificate;
• the crew did not carry out effective safety training drills;
• the crew was not provided with appropriate procedures and guidelines in the form of a safety management system;
• the passengers were not mustered and provided with information about the ship, its lifesaving equipment and emergency signals after departure;
• the ship did not carry lifejackets suitable for use by all of its passengers (ie children and infant lifejackets were not carried);
• Rabaul Shipping and the master did not consider the most appropriate weather forecast information either before the ship sailed, or during the voyage;
• the master did not make regular contact with Coastal Radio as required; and
• The master did not check the ship's stability before leaving port.

Overcrowding was long suspected to be a contributing factor to the capsizing of the old Japanese-made passenger ferry, which occurred after it was struck by three up to 4m-high waves in gale force conditions.

While the ferry was certified to carry up to 310 people, including 295 unberthed passengers and crew, the commission ultimately found there were at least 392 or possibly up to 411 people on board at the time of the disaster.

Rabaul Shipping owner Peter Sharp was a key witness at the inquiry. He did not convince the commission that the accident was an act of god.

If any of the inconsistencies in his testimony were deemed to be in breach of the COI Act, he could face up to 14 years in jail. The commission is not designed to investigate criminal liability and whether Sharp faces criminal proceedings is up to PNG police.

Of the 34 key recommendations, the following applied to the general maritime industry in PNG:

• While the legislation does not currently require it, the commission considers every ship operator in PNG should ensure that all of its ships capable of carrying passengers are fitted with an Emergency Position Indicating Radio Beacon (EPIRB) which has Global Positioning System (GPS) capability;
• While the legislation does not currently require it for all ships, the commission considers that every ship operator in PNG, particularly those operating ships capable of carrying passengers, should introduce and implement a safety management system for any ships operated by it, in line with the requirements of the International Safety Management (ISM) Code;
• There needs to be proper and effective enforcement of the merchant shipping laws and these laws need to be respected and complied with by all ship owners and operators within the PNG maritime industry. There has been a practice of ignoring the laws, including the Merchant Shipping Act 1975 and its subordinate regulations, which the commission considers will only change if the law is taken seriously by shipping companies and rigorously enforced by the regulator;
• Ship owners and operators in PNG must ensure they are familiar with the lnternational Maritime Organisation (IMO) document "Revised guidance to the master for avoiding dangerous situations in adverse weather and sea condition" (MSC.1/Circ.1228), and other relevant IMO advice, and develop simple instructions for the masters of their ships to assist them in reducing risk;
• Owners and operators of ships operating in PNG should ensure that lifejacket storage is clearly signposted, in English and Tok Pisin, and strategically located to facilitate easy access by passengers. The location should be close to exits on the route to muster stations, but clear of doorways. A proportion of lifejackets should be stowed in float free lockers on deck so that, if not accessed prior to a ship sinking, they will be available in the water for anyone who was unable to obtain a lifejacket before entering the water;
• All masters and crews of passenger ships should wear a form of distinctive uniform to distinguish themselves from passengers so, in an emergency, passengers will know who to turn to for advice.

The full COI report, which includes accounts of bullying behaviour against the National Maritime Safety Authority, is available at http://mvrabaulqueen.com/Commission_Report.htm