Revealed: Shocking catalogue of failures that led to deaths of 39 in Lamma ferry crash

The Marine Department failed to uphold the law, document its decisions or conduct proper inspections, yesterday's report into the Lamma ferry tragedy says.

The Commission of Inquiry said the department never fully implemented a 2008 requirement that the number of lifejackets carried should be equivalent to a vessel's capacity, and that the number of children's lifejackets should be equivalent to 5 per cent of capacity.

Its report also said the department's inspectors missed several chances to spot that the doomed Lamma IV did not have the watertight bulkhead door stipulated in its design.

A marine official told the inquiry there was a "policy" within the department not to apply the law to vessels already operating, but that the reasons for the decision were never documented.

"It appears that the 'policy' was disseminated by word of mouth only among Marine Department officers," the report said. "Without such records … discerning what those matters and reasons were is left to the frailties of human memory."

The lack of records jeopardised transparency and exposed officers to the danger of corruption, it said.