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."