No carbon monoxide (CO) alarm was fitted on a fishing boat on which the two crewmen were found dead in their bunks, a marine accident report has said.
Mark Arries, 26, and Edward Ide, 21, both died of CO poisoning on the fishing vessel Eshcol at Whitby in North Yorkshire on January 15 this year.
The pair had left the grill of a butane-fuelled gas cooker lit when they went to bed. The grill was being used to warm the wheelhouse and sleeping area, said the report from the Marine Accident Investigation Branch (MAIB).
The MAIB, which had published an interim report into the tragedy earlier this year, said in today's report:
:: The metal gauze in the grill was holed and corroded, causing extraordinarily high levels of CO emissions;
:: The cooker was four years old and had probably never been serviced;
:: The wheelhouse door and windows were closed and the sleeping area had no other means of ventilation;
:: No carbon monoxide alarm was fitted;
:: Neither the guidance for the installation of gas appliances on board small fishing vessels nor the cooker manufacturer's instructions had been followed when the cooker was fitted;
:: Prior to the accident, the deceased were extremely tired and cold;
:: The vessel was not equipped for overnight sleeping and the heaters provided on board did not work or were damaged;
:: The management of the vessel was ineffective.
The MAIB said recommendations had been made to the Maritime and Coastguard Agency which were intended to ensure that the accommodation areas in all small fishing vessels were fitted with a CO alarm.
MAIB chief inspector Steve Clinch said: "This is one of several fatal accidents recently investigated by the MAIB where fishermen or leisure boat occupants have been poisoned by carbon monoxide.
"Clearly, more needs to be done to raise awareness of the sources of the gas, its dangers and the precautions that must be taken.
"There is no question that the fitting of CO alarms in the accommodation areas of all small vessels would help to prevent further similar tragedies from occurring in the future."
A compromise deal to shake up Europe's controversial fisheries policy has been hailed as bringing real benefits for British fishermen - if it wins approval from MEPs.
Marathon talks between EU fisheries ministers ended at dawn with agreement on plans to correct decades of failed attempts to restore dwindling fish stocks.
But the proposals do not include the proposed blanket ban on "discards" - the dumping of some fish back in the sea, dead, to avoid breaching restrictions on the size of landed catches. Instead the deal bans from 2015 only the dumping of pelagic fish - those living near the surface.
The Government today hailed an EU agreement to introduce a blanket ban on dumping dead fish back in the sea.
Fisheries minister Richard Benyon called it "a historic moment".
"The scandal of discards has gone on for too long and I'm delighted that the UK has taken such a central role in securing this agreement," Benyon said after marathon talks in Brussels.
Earlier this month MEPs overwhelmingly backed the biggest-ever Common Fisheries Policy reforms, crucially including an end to so-called "discards".
In the UK, TV chef Hugh Fearnley-Whittingstall launched a "Discards Campaign" that has so far attracted more than 850,000 signatures on a petition.
The EU Fisheries Commissioner said almost one quarter of all fish caught in European waters is being dumped at sea due to discards.
The fishing industry in our region is to get more local control.
The EU Council has agreed that Britain should be allowed to meet quotas with neighbouring countries - instead of having to follow rules set by landlocked nations. The Council also said there should be a ban on the practice of throwing dead fish back into the sea once quotas have been met.
Fisheries minister Richard Benyon has been telling us how it will affect the industry in Whitby.
An agreement has been reached which could provide the East coast fishing industry with more local control.
At a meeting in Luxembourg EU Fisheries Ministers have agreed to ban the discarding of dead fish. The EU Council said a ban will come in to force, but the date at which this achieved is yet to be set.
The UK was also successful in getting the council to agree to let Member States develop their own regional plan to manage fisheries.
A crunch meeting is taking place in Brussels to push for more local control for our region's fishing industry.
Fisheries minister Richard Benyon is pressing EU ministers to allow Britain to meet quotas along with neighbouring countries instead of having to follow rules set by landlocked nations. He's also campaigning for depleted fish stocks to be replenished.