No one operating the chartered Robben Island ferry, which partially sank in choppy seas and high winds in September while carrying more than 60 passengers, considered the weather conditions that day, a preliminary investigation report into the incident has revealed.
And, while the skipper and several crew members claimed that members held a safety briefing before leaving the island, others disputed this.
"The crew member identified as having given the safety briefing stated that no safety briefing had been held. This was also corroborated by passengers," the preliminary South African Maritime Safety Authority (Samsa) report stated.
Samsa on Monday announced that it had concluded a preliminary probe into what happened. It had investigated the incident from September 15 to November 23.
News24 has obtained a copy of the report, which details several apparent shortcomings in the operation of the chartered ferry, named Thandi.
On September 15, the weather had changed suddenly and the Thandi started to sink about 3km from the V&A Waterfront, with 64 passengers and five crew members aboard.
A dramatic rescue operation ensued and everyone was brought safely ashore.
The Samsa report revealed just how dramatic events on the ferry were.
It said three crew members tried using a hand pump and a bucket to bail out water washing on board.
The port engine stopped and could not be restarted.
Life raft swept away and roof blown off
The report also revealed that, at one point, the skipper instructed the crew to launch the main life raft.
"The life raft was launched but was swept away by the sea and wind," it said.
A smaller life raft was then launched.
The report stated that the wind blew the roof above the wheelhouse off.
"It was blown towards the upper deck seating and a number of passengers and the crew member on the upper deck attempted to hold the dislodged roof in position... the roof became lodged between seats."
The Samsa report detailed the weather conditions that day.
"There was... clear indication that the weather conditions in Table Bay were unlikely to be suitable for the operation of the Thandi on the day in question," it said.
A section of the report contained comments by attending surveyors and detailed what they found.
'No one monitored the weather'
"Neither the skipper, owner nor (Robben Island Museum) monitored the appropriate weather forecast or took the prevailing weather conditions into account...
"As a small passenger vessel, it is of paramount importance that due cognisance is taken of the prevailing and forecasted weather conditions and the possible effect on the operation of the vessel," it said.
A statement by Samsa on Monday said that, when leaving Robben Island, the ferry "was moving into rough weather", which included strong wind and high seas.
This means a warning contained in a Robben Island Museum report about the ferry was not taken into consideration.
News24 reported in September that the Robben Island Museum appeared to have overlooked a warning contained in one of its own reports that the Thandi, "only be used in fine weather conditions".
Asked at the time about the report, Regine le Roux, speaking on behalf of the museum, said: "We [are] not aware of this."
This report, a proposal request for a new high-speed passenger ferry, is available on the government's online tenders site and is dated 2016.
'No passenger records kept'
The comments in the Samsa investigation report also said that no records of people aboard the vessel were kept.
It said the final passenger list was only provided by the Robben Island Museum on September 20 - five days after the incident.
The comments also said neither the skipper, nor crew members, were able to identify the engine room vent dampers.
It said the engine room vents may have been where water entered the vessel into the engine compartment and shutting these may have reduced the amount of incoming water.
"In the event of a fire in the engine compartment, familiarity with the vent closing arrangement is essential."
'No harbour master'
The report also found that unlike previous years, there was no harbour master at Robben Island.
"Having a harbour master on the island may be of benefit provided he is able to manage the arrival and departure of vessels appropriately," it said.
"The added benefit would be to monitor compliance with reporting of persons on board prior to departure."
'Significant amount' of water washing onto ferry
According to the report, a possible sequence of events had emerged.
It said the ferry was moving into rough weather when leaving Robben Island.
"There was a significant amount of water washing onto the bow of the vessel, likely more on the port side," the statement said.
"Water could have leaked into the chain locker space at a faster rate than could drain out."
It appeared water washing up on the port side may have leaked into the front below deck compartment.
Water may also have entered the port engine compartment space via electrical cable ducting.
The statement said water could have run through the engine room vent into the engine compartment.
Waves smashed windows
"The port engine compartment bilge alarm was triggered. The skipper stopped the port engine and then could not restart it," it said.
"As the vessels list increased to port and trimmed further by the head, the front windows, port and starboard were broken by waves coming over the bow."
Water then washing through the windows could have added to the water on the port side.
'Weather conditions were favourable'
Thandi is owned by Yacoob Yachts, which is run by Esa Yacoob.
In response to News24's questions in September, Yacoob Yachts said the Thandi was surveyed by Samsa on September 12 - three days before the incident.
"On the morning of the incident, all vessels were operating as weather conditions were favourable. All vessels, including the other Robben Island ferries, were operating," the response by his company had said.
"Our skipper did sea trials before commencing operations."
The response had also said "no directive had been given that the weather conditions were unfavourable".
On Monday in a statement, Samsa's chief operating officer Sobantu Tilayi said the owners of the Thandi indicated the ferry would be repaired.
He said remedial steps would be continued "to avert a similar crisis" as to what happened on September 15.
Possible injuries to passengers
The Samsa statement said no one was injured.
However, Beverley Schafer, chairperson of the Western Cape Provincial Parliament's standing committee on economic opportunities, tourism and agriculture, issued a statement at the end of October, calling on the Robben Island Museum to contact each passenger involved.
She said one of them, Bill Slade of Canada, said he and other passengers had not received compensation "for their injuries".
"The passenger, who sustained a cracked rib, a severe chest infection as a result of hypothermia, as well as damage to his camera, was instructed by the South African Maritime Safety Authority to direct his claim for compensation to the Robben Island Museum (RIM)," Schafer said.
The museum made use of its own ferry, as well as hired ferries from other companies.
In September, the Robben Island Museum said it needed to make use of chartered vessels as it alone could not cater to the number of tourists it attracted.
"We do not have the capacity in house to meet the tourist demand," the museum's chief executive officer Mava Dada had told News24.
He had said a chartered ferry needed a maintenance plan to do business with the museum.
Dada had told News24 that Robben Island Museum monitored the weather and checked each vessel to see if it could be used in specific weather conditions.
"If the weather conditions are not suitable to safely transport our passengers they inform the Robben Island representative and all tours are cancelled," he had said.