The board's incident review committee is required to examine all accidents where a license could be revoked, even though Cota had already voluntarily retired.
The committee concluded that the accident was caused by pilot error, including failure to exercise judgement in deciding to get underway, failure to consider reduced visibility, failure to resolve concerns about the ship's radar and proceeding at an unsafe speed.
On a recording played at Thursday's hearing, Cota can be heard shortly after the incident saying, "so yeah, it's foggy, I shouldn't have gone. I'm not going to do well on this one."
But the ship's crew and the Coast Guard are also to blame for failing to warn Cota of the ship's position, Cota's attorney John Meadows told the board.
"Had that been done, we wouldn't be here today," Meadows said.
The report will now be read by every pilot and pilot trainee.
"So people have a file of lessons learned over the years," board executive director Patrick Moloney said. "You don't get underway when you can't find your way out,"
The bar pilots and the Coast Guard worked together to quickly make changes to guidelines following the accident. There are now clearer guidelines about visibility requirements.
The National transportation Safety Board investigation and a criminal case are still pending.
