Witnesses described the Christena as routinely overcrowded, especially when it was the only passenger vessel operating between St. Kitts and Nevis. The Ministry responsible for the vessel had written several letters about overcrowding, passenger counts and the need for better records. According to the inquiry, these warnings produced little or no effective action from the responsible administrative officers or the vessel’s command. The inquiry highlighted the concentration of passengers toward the stern, cargo and baggage stored in various areas, and passengers moving across the vessel. It exposed a wider breakdown in regulation, enforcement, passenger accounting, vessel operation and maritime safety oversight.