The pilot of a small plane that crashed off Molokai, contributing to the death of former state Health Director Lorretta Fuddy, did not give passengers a safety briefing prior to the flight as required under federal law, the National Transportation Safety Board said in a report about the crash.

Fuddy died of acute cardiac arrhythmia due to hyperventilation after exiting into the ocean wearing an infant’s life vest, according to the report that was released Tuesday. The document is a factual report and does not give the probable cause of the crash.

The crash happened about 3:20 p.m. Dec. 11, 2013, about two minutes into the flight, which departed from Kalaupapa Airport and was headed for Honolulu Airport.

The pilot, age 60 at the time, said he heard a loud bang followed by an immediate loss of engine power. The pilot landed the Makani Kai Air Cessna 208B nine-passenger plane in the open ocean with a level, slightly nose-up attitude.

All eight passengers and the pilot exited the plane through the rear door and the plane, which was intact, remained on the surface for about 25 minutes before sinking. One passenger recorded a video that began with the airplane descending toward the water, showed the impact, and continued for about 15 minutes.

Two passengers, a married couple, both sustained serious injuries. The man sustained broken ribs and a gash on his head, and the woman sustained broken ribs and a broken sternum.

Several passengers said the pilot did not give a safety briefing before takeoff.

Federal rules state that before each takeoff, the pilot in command will ensure all passengers have been briefed on the location of survival equipment and use of flotation devices.

Deputy Health Director Keith Yamamoto told investigators he had to ask other passengers where the life vests were located. He said the life vest was “very tight” on his neck and difficult to remove when he got to shore. He weighed 175 pounds and had an adult’s life vest. He told investigators he stayed with Fuddy, who was “breathing very hard and fast,” but later closed her eyes and was no longer breathing hard.

Investigators inspected Fuddy’s life vest and found only one of two CO2 cartridges were deployed and determined the vest was meant to be for an infant. Fuddy weighed 220 pounds. Another passenger who swam to shore also inadvertently put on an infant’s life vest.

Factual Report Aviation by Honolulu Star-Advertiser