The Newark fire department's lack of training and familiarity with marine firefighting during a deadly cargo ship fire at the East Coast's largest port in July 2023 amounted to a “failure of leadership,” the head of the National Transportation Safety Board said Tuesday.

The board met publicly in Washington to unveil its findings about the inferno inside the Italian-flagged Grande Costa D’Avorio, which smoldered for nearly a week and resulted in the deaths of two Newark firefighters.

In addition to singling out Newark's fire department for criticism, the board also found that the fire ignited when cargo loaders used a Jeep that wasn't designed for such work to push vehicles into position. It also found that a carbon dioxide fire suppression system was ineffective because a garage door had to be closed for it to operate correctly, and could only be shut from inside, where the fire was raging in cramped conditions, with vehicles parked as narrowly as 4 inches (10 centimeters) apart.

“I hope that Newark fire department leadership is listening. This isn’t just a failure of communication. This was a failure of leadership. That’s what this was,” NTSB chairperson Jennifer Homendy said.

Board investigators said the department's chiefs “exposed firefighters to unnecessary risk," first responders were not familiar enough with marine firefighting and the department lacked a fire control plan for the ship.

“Staff feels that Newark Fire Division, responding land-based firefighters should not have gone into the space,” investigator Bart Barnum said Tuesday.

The need for more training, Barnum said, was his main takeaway from the accident.

"You have to be properly trained when you respond to a marine vessel fires," he said. “In this particular instance, if they had been, they should never have went inside.”

Messages seeking comment were left with the Newark Fire Division and with Ports America, the company overseeing cargo operations at the port.

The blaze ignited as the ship was being loaded with about 920 mostly used vehicles enroute to West Africa. Port workers were using a Jeep Wrangler to push nonrunning vehicles into the ship when a worker heard “clunking noises” and another operator reported seeing “flaming fireballs dripping” from the Jeep, according to the board. The Jeep had pushed 37 other vehicles on board by that point, investigators said.

Federal rules require that any vehicle used to push other vehicles onto a ship meets standards for such work. The Jeep didn't meet that Occupational Safety and Health Administration standard and was straining beyond its capacity, the board's investigators said.

“Maybe it was a readily available vehicle,” one investigator said Tuesday. “Maybe they overlooked OSHA requirements that it couldn't be used in that manner — just speculating.”

The fire began on deck 10 of the 12-deck ship, investigators said, and the ship's crew had activated the carbon dioxide suppression system, but it required the ship's exterior garage doors to be closed to operate effectively. Because the door on the top deck couldn't be closed except from inside the ship, it remained open, according to the board's presentation.

Newark firefighters quickly responded — and got lost inside the vessel, the board said, as dark smoke billowed into the sky.

“We cannot find our way out,” the board said one firefighter relayed. “We are lost.”

Newark firefighters Augusto “Augie” Acabou and Wayne “Bear” Brooks Jr. were killed. Firefighting boats ultimately blasted water cannons at the ship for days to extinguish the blaze.

Board members noted that relatives of the fallen firefighters were present at the meeting and expressed condolences to them.

The Port Authority of New York and New Jersey, which operates Newark's port, relies on local fire departments to assist with fires since it doesn’t have its own firefighting agency.

Authorities earlier declined to answer whether firefighters should have gone into harm’s way to put the blaze out when no lives appeared to be at risk, with the ship's 28 crew members safe and accounted-for. Fritz Frage, who was Newark's public safety director at the time, said the city and port authority have continuing conversations about training. He didn’t offer specifics.