Maritime New Zealand's investigation into the Platino yachting accident that killed two people in 2016 has provided a wake-up call to skippers.
While it was a situation of chaos, questions have been raised over decisions made on board.
Skipper and owner Tory McKeogh, her husband Harry and Ross McKee all survived, rescued by a container ship.
But Nick Saull died instantly - the boom was swinging around and he was hit by a 2kg piece of rigging, hanging from it. Steve Forno also died after he was thrown overboard.
"The thing that could have been done was to get something overboard - that could have assisted him to stay afloat," said Maritime New Zealand (MNZ) director Keith Manch.
The MNZ report notes the boat was worth $4 million, and had just undergone a full refit. It was fully stocked with lifejackets, but Mr Forno wasn't wearing one.
He was not thrown a recovery module because it was thought to have been smashed - it wasn't. He was also not thrown an EPIRB that would activate on contact with the water and record his position.
And skipper Tory McKeogh failed to activate a chart plotter to record his location, most likely because a button was not held down for the required three seconds.
The survivors declined to comment on Thursday. But the report says one of them, Mr McKee, "believed the risk created by the swinging boom made it too dangerous to reach the equipment".
The crew described the object hanging from it as a wrecking ball that "quickly caused substantial damage to the rear of the yacht".
"The owner and the surviving crewmember… lay on the deck each time it swung past."
"The thing is we weren't there, and we know from the evidence that has been gathered that it was a totally chaotic situation," said Mr Manch.
The report says the autopilot system was gradually failing that day, and when they were hit by high winds and confusing seas the "yacht turned unexpectedly and dramatically to starboard".
The autopilot couldn't move the rudder and the crew couldn't turn the wheel. But GPS data shows, it's likely the Platino got close to Mr Forno and "passed within approximately 50 metres on at least two, possibly three occasions".
"On the one hand, saying that more perhaps could have been done seems like a good lessons to learn from this," said Mr Manch. "On the other hand, you do have to recognise it was an extreme, chaotic and difficult situation."
Among many recommendations, MNZ says care should be taken to ensure the master of any boat understands the level of responsibility associated with that position and are capable of exercising effective command.
But the report concedes: "The environment on deck was extremely dangerous. This limited the actions that could be taken by the crew."
"It was just a tragedy all round," said Mr Manch.
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