A coroner has said he would recommend random breath-testing for navy personnel following the shooting dead of an officer by a drunk submariner on a nuclear-powered submarine.
Southampton coroner Keith Wiseman said at the end of the inquest into the death of Lieutenant Commander Ian Molyneux that he would write to the Royal Navy about 18 areas it should look at.
The officer was shot dead by Able Seaman Ryan Donovan, who was at least three times the drink-drive limit while on guard duty on HMS Astute in April 2011.
The hearing has previously heard that Donovan had drunk 20 pints of cider and lager, cocktails and vodkas in the 48 hours before he was put on duty armed the SA80 rifle.
Police investigating the murder were so concerned about binge drinking by the crew while ashore that the senior officer wrote to his chief constable to highlight the issue and it was passed to military authorities.
The navy has since tightened its rules on alcohol consumption before duty.
At the time sailors were allowed 10 units in the previous 24 hours with no alcohol in the 10 hours before duty, which has now been changed to five units.
Wiseman said it would never be known why the attack took place.
He said it was "a miracle" no one else had died during the gun rampage during a civic visit by Southampton's mayor and schoolchildren, who had just left when Donovan started firing. Donovan fired seven rounds in 13 seconds in the control room area of the sub.
The coroner said he would incorporate recommendations from Molyneux's widow, Gillian, which included random breath-testing of crew; breathalysing all those going on armed sentry duty; a look at alcohol allowances while on board; work to tackle the culture of binge drinking in the navy and the issuing of handheld breath-testing devices to all personnel.
Recording a narrative verdict, Wiseman said the officer was unlawfully killed and he will now write to the navy citing the issues under what is called a Rule 43 letter.
"Random testing has some value. Anyone being drunk, or anywhere near drunk, on duty has, in my view, got to stop.
"It is an unfair responsibility to be given to someone carrying out little more than a spot check. In my view the routine use of the appropriate machinery to at least establish the absence of alcohol in the system is necessary as I'm not convinced that the concept of heavy drinking on leave periods is likely to alter very much.
"On an intense personal note this criminal action has left one family bereaved in the most appalling circumstances."
Donovan, 23, was jailed for a minimum of 25 years after pleading guilty at Winchester crown court to the murder of Molyneux.
The navigator yeoman also pleaded guilty to attempting to murder Lieutenant Commander Christopher Hodge, 45, who was shot in the stomach.
The court heard that his real targets, whom he also admitted to attempting to murder, were Petty Officer Christopher Brown, 36, and Chief Petty Officer David McCoy, 37.
On the day of the killing, Donovan said he was going to kill someone but the person who heard it thought he was joking. Donovan was facing disciplinary procedures for disobeying orders and a transfer for an operational tour on RFA Cardigan Bay was cancelled.
He was issued the SA80 weapon by Brown before the shooting, but the petty officer said he was unaware that Donovan was under the influence of alcohol at the time. Toxicology tests showed that Donovan would have had an alcohol/blood level of 139mg per 100ml, the two-week inquest heard.
Molyneux, 36, died from a single gunshot wound to his head, fired from 5cm away.
The Home Office pathologist Dr Basil Purdue said the position in which the officer was found, lying face down on the floor, was consistent with him rushing forward to tackle the gunman.
Molyneux received a posthumous George Medal for his actions.
The Royal Navy has undertaken what the coroner said were thorough inquiries into the incident that has also implemented new alcohol consumption guidelines and is looking at tackling the culture of binge drinking while ashore.