The report also cites failures of the crew to follow standard risk management methods and the command climate at the guard's San Diego station, but places primary blame on the driver of the boat, Petty Officer 3rd Class Paul Ramos, who was demoted and sentenced to three months in the brig for dereliction of duty for the crash.
The 33-foot Coast Guard patrol vessel was going as fast as 42 knots—or 48 mph—when it struck the 24-foot pleasure boat shortly after the Festival of Lights holiday fireworks show in the bay crowded with kayaks, canoes and other watercraft, according to eyewitnesses and a video taken within 100 yards of the wreck.
Thirteen people were aboard the boat. Eight-year-old Anthony DeWeese was killed and 10 others injured.
The report comes after a thorough investigation by the National Transportation Safety Board and a military trial for Ramos and two other crew members, but was intended by the Coast Guard to find ways to prevent similar collisions.
"No words or deeds can atone for the death of a young boy, or for the pain caused to his family," Vice Adm. John P. Currier, the Coast Guard's vice commandant, said in a statement accompanying the report. "We can only affirm our resolve to ensure nothing like this happens again."
The crew was rushing to help a grounded sailboat, but investigators said it was in no danger of taking on water and there was no need to reach it so quickly.
The report recommends better training for boat operators and commanders, including reviews of risk management policy and case studies of collisions like this one to make sure its lessons are ingrained in students.
The NTSB investigation was sharply critical of the lack of oversight of San Diego Coast Guard command, with board members saying it was especially unfortunate that an agency charged with enforcing sea safety would take part in such dangerous boating.
The crew members delivered emotional apologies to DeWeese's family in court. Ian Howell, the highest-ranking member of the patrol boat crew, told Deweese's parents he wished it had been him who was killed instead of their son.