The State's investigation into the sinking of the fishing vessel Tit Bonhomme last year with the loss of five lives has found crew fatigue to have been the "single overriding causal factor".
The Marine Casualty Investigation Board (MCIB) report has been unable to establish who was on watch when the vessel ran aground on Adam's island at the mouth of Glandore harbour in the early hours of January 15th, 2012.
However, examination of the hull by Naval Service and Garda diving teams established that the 21-metre vessel was on autopilot and the engine in gear with a course set for Adam's island, and there was no "off course" alarm system.
The report also rules out a delay in the Irish Coast Guard Shannon-based helicopter's departure as a factor in the loss of life.
None of the crew had time to put on an immersion suit which might have increased chances of survival in the water, and only one of the five who drowned was wearing a personal flotation device (PFD).
The sole survivor, Egyptian crew member Abdelbaky Mohamed (43), was in shorts and t-shirt and was trying to put on a lifejacket when he was washed out of the wheelhouse and managed to swim to shore.
Skipper Michael Hayes (52) from Helvick, Co Waterford, crewmates Kevin Kershaw (21) from Clonakilty, Co Cork, and Wael Mohamed (35), Attaia Shaban (26) and Saied Ali Eldin (22), all from Egypt, died in the sinking.
It prompted an extensive search over 26 days by the statutory agencies, the local community and volunteers, until all five bodies were eventually recovered.
The MCIB investigation found that in the 40 hours between the twin-rigged trawler's departure on a fishing trip and its return to Union Hall, all of the crew had less than four to five hours sleep.
The vessel had decided to return to port early, after an initial problem with a bilge pump and a leak from the top of a lubricating oil pump. It was making the approach to Glandore in a strong south-easterly gale when it hit rocks on Adam's island.
No mayday was sent by VHF radio. The vessel's emergency indicating position radio beacon (EPIRB)did not issue a signal until 20 minutes after the sinking.
The alarm was raised by a 999 call from Kevin Kershaw's mobile phone, believed to have been made when the trawler was running aground, which was relayed to the Irish Coast Guard.
The Toe Head Coast Guard and Baltimore lifeboats were first on scene, while the ICG Shannon-based rescue helicopter was also tasked and its Waterford counterpart put on standby.
However, the Shannon helicopter had a fuelling problem which delayed it by eight minutes, and the Waterford helicopter was despatched ahead.
The MCIB investigating team analysed all response times, due to concerns raised by the skipper's wife Caitlín Uí Aodha.
However, it concluded that all units responded within procedural targets, except for the Shannon helicopter, and that this would not have made a difference to the outcome.
The investigation team found that the vessel was certified for five crew, and didn't have sufficient lifesaving equipment for six.
At least two of the crew had not undertaken basic safety training, and musters and drills had not been carried out on board.
The MCIB recommends that the Minister for Transport enforce existing regulations on safety of fishing vessels, and considers making bridge navigation and watchkeeping alarm systems mandatory.
It says he should also take steps to ensure that skippers alert shore authorities if there is a problem at sea.
Caitlin Uí Aodha said she had no comment to make on the report, as she had only received it on Wednesday night.
The inquest into the deaths of the five crew is due to be held later this Spring.
Last year, the High Court approved a settlement of €40,000 for the family of Kevin Kershaw, who had just started working on the Tit Bonhomme when it sank.
The full MCIB report will be available at www.mcib.ie on Monday.
