The coroner's court on Tuesday ruled that two firemen had died by misadventure during an inferno at a self storage facility in Kowloon Bay in June 2016.
Wrapping up the 65-day inquest, Deputy Coroner Philip Wong said the senior firemen, Thomas Cheung and Samuel Hui, performed their duties courageously and responsibly during the fire at the Amoycan Industrial Centre.
He said they entered the hazardous fire scene to protect life and property and had acted lawfully, but an unexpected consequence caused their deaths. Therefore, he ruled that the two had died by misadventure.
However, Wong said the Fire Services Department should review its internal communication mechanism, noting that it didn't start an urgent rescue operation in time to save the firefighters.
He said high ranking officers should also take courses on fire scene management regularly before they become commanders for number three or higher alarm fires.
The coroner also said the Buildings Department should consider regulating mini storage units through a licensing system.
The court earlier heard that the partitioned facility was maze-like and built using metal plates that transferred heat quickly, while fire facilities were dilapidated.
Wong also proposed that tenants of industrial buildings be required to attend fire drills after a member of staff at the storage unit said he didn't know how to use a fire extinguisher.
The Fire Services Department said it would study the coroner's recommendations thoroughly.
It added it has rolled out a series of measures to improve safety for firemen and enhance their efficiency, and has been conducting inspections and taking enforcement action in mini-storage facilities since the tragedy happened.
The fire at the Amoycan Industrial Centre was put out after raging for 108 hours.