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One of the 23 people on board was killed and six others were injured after jumping overboard to escape smoke churning out of the ship’s cargo hold about 27 kilometers (17 miles) north of the Dutch island of Ameland. The remaining 16 people were rescued using helicopters.

During the mission by Dutch maritime rescuers, 鈥渢he focus for too long was on firefighting instead of saving the crew,鈥� the report said.

It added that poor information sharing between different rescuers and emergency services on land meant authorities were not fully prepared when 16 survivors who also required medical help were flown to shore, causing delays in transferring them to hospitals.

鈥淚n order to be well prepared for future incidents at sea, the emergency assistance system must be put in order as soon as possible. Various improvements are needed for this, both at the Coastguard and at the relevant safety regions,鈥� the report said in recommendations to the government.

The Dutch report did not look into or comment on the cause of the fire. Maritime authorities in Panama were investigating the cause because the ship was flying under a Panamanian flag.

The fire burned out of control for a week as the stricken freighter floated near shipping lanes and the shallow Wadden Sea, a UNESCO World Heritage-listed migratory bird habitat. It was eventually towed to a port in the northern Netherlands for salvage.