Everywhere investigators looked, there were failures. Failures in inspections. Failures in maintenance of the vessel. Failures in communication.

In many ways, the cargo ship El Faro was doomed when it sailed from Jacksonville, Florida, more than two years ago directly into the path of Hurricane Joaquin.

All 33 people on board were killed, including four from Maine, in the worst U.S. maritime tragedy in more than three decades.

During a hearing Tuesday of the National Transportation Safety Board — the latest in an ongoing investigation into the El Faro’s sinking — officials said the incident had numerous causes.

Just as the Coast Guard concluded two months ago, the NTSB agreed that the ship’s captain, Michael Davidson of Windham, made decisions that contributed to the ship’s sinking, but that wasn’t the only factor. The structural integrity of the 40-year-old ship also played a major role, as did a lack of oversight from the company that owned the vessel, TOTE Maritime, and outdated weather information about the Category 3 hurricane.

Additionally, had the crew been able to launch its safety boats — they were unable to do so because of the ship’s list and extreme weather conditions — they likely wouldn’t have saved lives because they were open lifeboats, not closed.

The NTSB findings, 80 in total, led to 53 draft recommendations that it hopes will improve maritime safety and prevent a future tragedy, according to Chairman Robert Sumwalt.

“We have learned many lessons from the sinking of the El Faro,” he said during the hearing, held in Jacksonville.

The final voyage of El Faro has been well-documented at this point. The nearly 800-foot ship, loaded with cargo containers and vehicles, departed Florida for San Juan, Puerto Rico, two days before it sank off the coast of the Bahamas.

The crew, led by Capt. Davidson, was aware of Hurricane Joaquin and planned to alter its route slightly to travel around its path.

But at some point during its travel, the hurricane’s path shifted and the ship was relying on hours-old weather information.

Davidson, as the ship’s master, had several opportunities to turn the ship around but didn’t. Large cargo ships travel through inclement weather, including hurricanes, on a regular basis and he told crew members in the hours leading up to the sinking that the ship would be able to handle the hurricane.

Much of what has been revealed about the final 24 hours of El Faro was contained in the ship’s voyage data recorder, which was recovered from the ocean floor last August after a 10-month effort that cost roughly $3 million.

The data recorder included audio from the vessel’s bridge. That audio has not been released publicly but the NTSB and Coast Guard turned it into a transcript, which was released last December. Much of it, especially the final couple of hours before the ship went down, is harrowing.

Of the 33 who were killed, 28 were Americans, many from Florida, and five were from Poland.

Four crew members were from Maine, including Davidson, 53, Michael Holland, 25, of Wilton, and Danielle Randolph, 34, and Dylan Meklin, 23, both of Rockland. All four were graduates of Maine Maritime Academy in Castine, as was a fifth crew member, Mitchell Kuflik of New York.

Holland’s mother, Deb Roberts, told the Portland Press Herald in October that the Coast Guard went over the report in detail with the victims’ family members before releasing it to the public. Roberts said the key takeaway for her was that no single person or entity was solely responsible for the tragedy.

“There were times that the crew didn’t have accurate information that could have made a difference,” she said. “There were things early on, even before the accident, that the Coast Guard could have done differently. There wasn’t any one thing — it was several factors, sometimes seemingly small, that caused the tragedy to happen.”

The Coast Guard said the ship’s owner TOTE had violated safety regulations to ensure the crew was well-rested, and that the company had not replaced a safety officer management position. TOTE also had stopped employing port helpers who helped safely load cargo on the ships. The Coast Guard found that El Faro’s crew had difficulty keeping up with the brisk loading pace required to keep the ship on schedule.

The ship also had open-top lifeboats, unlike the closed-top lifeboats used on modern ships. While legal, the ship’s use of the older-style boats was only allowed because of an exemption to safety rules for older ships such as the El Faro.

Larry Brennan, a professor of maritime law at Fordham Law School and a retired U.S. Navy captain, said the NTSB’s findings could create a safer working environment for mariners in the future. For example, the board could help by calling for the removal of the safety exemption that allowed the El Faro to legally use old lifeboats.

“No one should use open boats in rough weather, or any weather,” Brennan told The Associated Press. “If the NTSB takes an aggressive course, they may be able to effectively change regulations and policies that will enhance safety at sea.”

This undated image made from a video released April 26, 2016, by the National Transportation Safety Board shows the stern of the sunken ship El Faro. (AP file photo)