Seven passengers and nine crew members suffered minor injuries when the Coastal Inspiration rammed the dock at Duke Point on Dec. 20, 2011.
A safety board report released Tuesday said a problem in the propulsion controls was missed because crew members didn't follow the proper procedures for testing the equipment before docking.
"This meant that a malfunction in the controls went undetected until too late," said the TSB news release. "The investigation also found that the vessel's bridge crew was unfamiliar with the operation of this control in an emergency."
The report said there was no clear warning or alert to the crew that there was an equipment failure.
The ship's master corrected a loss of pitch control by increasing the pitch, rather than taking measures to fix the problem directly, the report said.
"Without an alarm specifically linked to safety-critical equipment that signals the equipment's malfunction, the crew may be unaware of the failure, putting the vessel, its passengers and the crew at increased risk," the report stated.
The vessel struck the berth at a speed of about five knots. Both the ferry and the dock sustained significant damage.
The crash put the ferry out of service for 23 days, while the Duke Point dock was closed for three months for repairs.
Last April, the TSB issued a Marine Safety letter to BC Ferries advising it the vessel's speed was a significant factor in the crash.
BC Ferries replied, saying it has since implemented a new standard operating procedure that highlighted all critical decision points during the passage for reducing speed.
BC Ferries also made numerous changes to prevent similar incidents, including a better warning system for malfunctions and a new emergency response drill for the crew.