The report lays out a timeline of events, detailing mistakes that were made, and suggests things that need to change for the future.
"It was quite a tragedy," said Alameda resident Floyd. "It seems like it should have been avoidable."
Many Alameda residents are still upset over the Memorial Day drowning of a suicidal man and how rescue workers responded to the incident.
"Just stand around and watch him die is unconscionable," said James, an Alameda resident.
Residents who visit Crown Beach regularly say they don't believe the Memorial Day drowning had to happen. Those residents aren't surprised by the findings in an independent report released on Friday.
The review details the missed steps by city officials. Rescuers watched on shore as Raymond Zach, 52, drowned.
The review faults the city of Alameda for not having a water rescue crew. The review, conducted by a former state fire marshal, also cites police and firefighters for failure to immediately call for a shallow water rescue boat from Oakland.
City officials say they were unable to help Zach because their water rescue program had been discontinued.
According to the report, 31 minutes passed between the arrival of the first officer on the scene until the time Zach died of hypothermia, just one of several major issues identified in the report.
Alameda Police Chief Mike Noonan said he believes the independent review was fair.
"I do think it was fair, and I think it was thorough," said Noonan. "We've made a lot of changes before the recommendations even came out."
As chief, he says it's his job to alleviate the fears of the community. Immediately following the Memorial Day drowning, measures were put into place to avoid a possible repeat of inaction by first responders.
"By mid-next month, every officer, jailer and dispatcher...will have received crisis intervention training," Noonan said.
The entire report will be made presented to the Alameda city council on October 11.