Investigators have made a series of recommendations in a bid to prevent further tragedies like the one that claimed the lives of four disabled people on the Leeds-Liverpool Canal at Gargrave.
Marine accident investigators also called on British Waterways to set up a reporting system for canal boat accidents and near-misses during an inquest in Skipton yesterday, which recorded accidental death verdicts on the victims.
And father and son rescuers Stephen and David Grimm, who were in a neighbouring narrow boat, were praised by the coroner for launching a rescue bid in Stegneck Lock.
The new recommendations include narrow boats having emergency escape routes other than the front and rear doors, possibly in the middle of the boat.
Rope defenders at the front of the boats should have an emergency escape link so they snap and break away if trapped.
Captain Simon Harwood from the Marine Accident Investigation Bureau told the inquest that British Waterways should also set up a reporting system. After the hearing a spokesman said the authority was considering the recommendations and the industry was looking at ways of improving the advice it gives.
Fur people drowned when their narrow boat became jammed in a lock gate and on side masonry. They were Beverley Wilson, 33, Eric Jones, 43, and John McGill, 49, all of Barrow-in-Furness and Peter Burgess, 42, of Dalton-in-Furness who all suffered learning difficulties. They had been on a week long cruise from the Mill Lane Centre at Walney, Cumbria.
Paul Robinson, a health and safety inspector said that the disaster was unique. Nobody would know exactly what happened but he believed that the front fender on the narrow boat Drum Major, which had been hired from Silsden, became wedged on the lock gate and on the masonry as the lock was being emptied.
The rear tilted backwards and also listed to one side until the 2.9 tonne vessel splashed back down causing the black, oily water to flood through the boat.
"It was inevitable that it would sink," he said.
Michael Barrett a British Waterways safety engineer, said there had been no record of a similar accident despite five million lock movements every year.
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