"Serious systemic failings" in the Marine Department contributed to the Lamma ferry tragedy, the Commission of Inquiry into the disaster has found.
In its report, released yesterday, the commission pointed to a "litany of errors" at every stage of the design, construction and inspection of the Lamma IV, which contributed to the rapid sinking of the boat.
"What is required is systemic change, in particular a change in attitude to responsibility and transparency," the commission said of the department. "In [some] areas, what is required is action, and action now."
The commission, led by Mr Justice Michael Lunn, said it was "astonished and deeply dismayed" to learn that the department had not fully enforced a 2008 regulation stipulating that vessels should carry a number of lifejackets matching their capacity, as well as children's lifejackets equal to five per cent of capacity.
The key factors so many lives were lost were loosely attached seats on the upper deck of the Lamma IV that came off, throwing passengers towards the stern; passengers having trouble getting to and donning lifejackets; and no children's lifejackets.
The department has promised an internal investigation into whether any officer bears part of the responsibility for Hong Kong's deadliest sea tragedy in 40 years.
A total of 39 passengers died when the Hongkong Electric vessel Lamma IV, taking workers and their families to see the National Day fireworks in Victoria Harbour, collided with the ferry Sea Smooth off Lamma Island.
Sections of the report dealing with the responsibilities of the two coxswains involved in the October 1 crash - both of whom have been charged with manslaughter - was redacted to avoid influencing their trials.
Secretary for Transport and Housing Professor Anthony Cheung Bing-leung said he would lead a steering committee to oversee the reform of the department. He said he would appoint a directorate-grade officer as deputy director of the department to lead the reforms.
Director of Marine Francis Liu Hon-por said the department had appointed foreign experts to review its inspection procedures and compare safety regulations with those in Singapore, Sydney and Southampton.
Chief Executive Leung Chun-ying pledged that the government would handle any case of maladministration or human error impartially, and said disciplinary hearings could start.
Liu did not answer if he would apologise or resign. Cheung said he "felt sorry".
Ryan Tsui Chi-shing, younger brother of Tsui Chi-wai and uncle of Tsui Hoi-ying, 10, who both died in the crash, said he appreciated that the inquiry had shed light on a lot of facts. But he had doubts whether the reforms would succeed: "The director lacks the courage to even apologise, so how can I trust him to have a conscience in future?"