Ms Tilsley and Mr Wood, who was from Aylesbury in Buckinghamshire, were residents of Burdon Grange care home in Beaworthy when they took part in a day trip to the lake.
The MAIB reported they were strapped into their wheelchairs and drowned after the wheelyboat capsized and they were dragged to the bottom of the lake.
The report found water had leaked into the vessel and seals on the bow ramp had degraded which resulted in the capsize.
This, the MAIB said, was because the wheelyboat “had not been correctly maintained”.
The investigators recommended SWLT update its maintenance programme and employ a permanent member of staff to oversee upkeep at all its activity centres.
They also advised the trust to train staff in disability awareness and ensure instructors know how to evaluate the weight and load distribution when working with wheelchair users and watercraft.
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