The man who fell off a party cruise and drowned in Lake Ontario in 2015 had been drinking before he set foot on the Northern Spirit I, something that security guards missed when they allowed him to board and then continue to buy alcohol until he went overboard, the Transportation Safety Board of Canada has found.

The board's report, released Thursday morning, also found that the crew aboard the Mariposa Cruises ship had never practised what to do in the case of a passenger falling in the water, although they had done other safety drills.

"The crew's response to the emergency was not co-ordinated and did not align with the company emergency procedures," the report said.

Keith White, 34, drowned in Lake Ontario after falling off a Mariposa Cruises boat in June 2015. (Keith White/Facebook)

Keith White, 34, was found dead in the water near Humber Bay on July 1, 2015. He was a lifeguard and a strong swimmer, his family told CBC News at the time.

Some of the 400 passengers on the vessel told CBC News that staff waited to throw life-saving equipment toward White and that the ship kept moving away from him.

The rescue itself had been delayed because no crew member had sent out the signal that someone had fallen in the water — and because the emergency response boat had been tied on a different side of the cruise vessel, according to the TSB.

'Lost his balance'

A spokeswoman for the cruise line would not agree to an interview. Instead, she sent a statement that said the TSB report "clearly vindicates" the firm and confirms that White fell overboard because he was intoxicated.

The Mariposa Cruises statement makes no mention of the report's findings that the crew neither followed the company's safety procedures, nor had they run a drill about what to do in the case of a man falling overboard.

The company also did not respond to the report's finding that the security guards who screened White when he got on the boat failed to notice he had been drinking — and that bar staff continued to serve him.

"Unfortunately, Mr. White, who was intoxicated by nearly 2 1/2 times the legal driving limit, leaned too far over the railing and lost his balance," the statement said.

While the board found gaps in training and in the response of the crew that evening, it's an independent body and cannot assign blame to either the company or the people involved. Someone else could enter the findings as evidence if they filed a civil suit, but the board cannot decide whether someone can be held criminally or civilly responsible.