The National Transportation Safety Board has released its findings for a deadly crash off Molokai that killed then-state health director Loretta Fuddy.

Fuddy was one of nine people, including the pilot, on board a Cessna plane, Makani Kai Air, when it lost power and crashed into the water off Kalaupapa, Molokai on December 11, 2013.

Autopsy results had determined that Fuddy died from acute cardiac arrhythmia, or an irregular heartbeat, due to hyperventilation. According to the autopsy report, witnesses saw Fuddy exit the aircraft with her flotation device and was “markedly afraid” while waiting for rescue personnel to arrive.

Now, the NTSB has determined that Fuddy was wearing an infant life vest that only partially inflated. One of two cartridges in the vest was punctured and empty, the NTSB report said.

“Review of the video, recorded by passenger 8, indicated that the fatally injured passenger, passenger 3, exited the airplane under her own power while wearing an inflated life vest. Passenger 3’s life vest was examined, and determined to be an infant life vest. One of the two CO2 cartridges installed in the vest was punctured and empty, and the other cartridge was full, consistent with a partially inflated life vest.”

Multiple passenger accounts also said pilot Clyde Kawasaki provided no safety briefing prior to the flight, and the pouches containing the life vests were difficult to open.

“Passengers 5 and 6, a married couple, reported that the pilot assigned them seats, but did not provide a safety briefing prior to the flight. The pilot asked them how many of them had flown over that morning, and then said, ‘you know the procedures.'”

“Passenger 4 added that the pouch that the life vest was stored in was difficult to open and that the vest was ‘very tight’ on his neck and difficult to remove when he got on shore. He said that ‘even with the life vest on I was surprised [at] how much effort was needed to keep my head above the waves and to avoid swallowing water.'”

As for how the plane went down, the report states that Kawasaki ditched the Cessna off Kalaupapa after hearing a loud bang, followed by a loss of engine power, approximately two minutes into the flight.

Although bleeding badly from hitting his head on the instrument panel during impact, Kawasaki ordered everyone to grab a seat cushion for flotation and exit the plane.

“He looked for life vests, saw one, and gave it to a passenger who said his wife did not have one. He did not take time to look for his own life vest as the airplane was filling with water. After checking to see that the cabin was empty, he exited through the door at the rear of the cabin. He told the passengers to swim away from the airplane because he was concerned that it would sink rapidly and drag them down. The current and waves, which he estimated to be 6 to 8 feet high, gradually separated the group.”

The report said Kawasaki was the last person to exit the plane, which remained on the water’s surface for about 25 minutes before sinking, and one passenger swam to shore.

Kawasaki and the other passengers were recovered by Coast Guard and other rescue personnel about 80 minutes after the crash, but by that time, Fuddy was dead.

We reached out to Makani Kai for comment, but have yet to hear back.