A report into the death of a trawler skipper off Devon has revealed that his boat was overloaded and safety equipment did not function.
The Marine Accident Investigation Branch (MAIB) investigated the sinking last September of the Sarah Jayne.
Skipper and father-of-two Geoff Ingram, 51, from Exmouth, died after the heavily-laden trawler capsized.
Two waves washed over its decks, sending water through hatches and into the fish hold.
The report said:
- The trawler had about 20 tonnes of fish on board when 17 was the recommended amount.
- A life raft on board did not automatically inflate as it should have because it was obstructed by the boat's structure.
- An automatic emergency beacon did not function.
- None of the crew was wearing lifejackets.
Crewmen Matt Bull and Scott Chamberlain were rescued by a nearby fishing crew after the capsize about six miles off Brixham.
Sarah Jayne, built in 1979, was bought by Mr Ingram in 1998.
The report said the Sarah Jayne's crew had been fishing for sprats on 11 September when two large waves swamped the decks, leading to a "considerable amount of water entering the fish hold".
With the boat listing to starboard, Mr Ingram called the crew of Girl Rona, who were nearby, saying that he had a problem and asking them to stand by.
A few minutes later, at about 11:21 BST, he made another call saying that he thought he was "losing it", to which Girl Rona's skipper responded "Get out."
At this point, Sarah Jayne rolled slowly to starboard and capsized, said the report.
The two crewmen managed to get clear but the last sighting of the skipper was of him entering the wheelhouse.
Girl Rona's crew saw the Sarah Jayne capsize and sent a Mayday to coastguards.
The Sarah Jayne's crew managed to grab hold of a lifebuoy and shouted for Mr Ingram "but there was no sign of him".
The report said that landing catches of 20 tonnes was "routine" for the crew and "reinforced a belief that it was safe for Sarah Jayne to carry such loads".
It said: "Sarah Jayne capsized because, in her loaded condition, she had an insufficient reserve of stability to withstand the sudden flooding."
The report recommended that the Maritime and Coastguard Agency, consulting with the Sea Fish Industry Authority, should address hazards such as fish hold hatches being opened at sea.
Jim Portas, from the South Western Fish Producers Organisation and a member of Brixham's Fisherman's Mission, said the industry would "examine the report very closely and take on board its message for the future".
However, he added some factors could not be prepared for in what was the "most hazardous of peacetime occupations".
He said: "It is very, very, difficult to accurately gauge precisely the amount of fish caught when you are fishing for sprats.
"The difference between a 15-tonne haul and a 20-tonne haul would be quite difficult to judge."
He added the use of floatation devices by crews was "more commonplace".
South East Cornwall Conservative MP Sheryll Murray - who has campaigned on marine safety since her fisherman husband, Neil, was lost at sea in March 2011 - said life jackets were necessary because they also provided "peace of mind for crews' families".
Mr Ingram had served on the Exmouth lifeboat for more than 20 years until 1998.
He was awarded the RNLI's Vellum Service Certificate for bravery after entering the sea from the lifeboat in force seven winds and 8ft waves to rescue two girls who were in difficulty after a speedboat sank.