The Transport Accident Investigation Committee (TAIC) says a lack of regulation in the stevedore industry led to the deaths of two port workers last year.

Stevedores are people employed to load and unload cargo ships and, in April of last year, two stevedores were killed while at work in Auckland and Lyttelton.

Atiroa Tuaiti died while working at the Ports of Auckland on April 19, while Donald Grant died at the Port of Lyttelton less than a week later.

Tuaiti died after he was crushed by a falling container being loaded off a ship, and Grant was found deceased after he fell, hit his head and suffered a medical event before being buried beneath coal that was being unloaded.

At the time of Tuaiti’s accident he was not in sight of either the crane operator or the second hold operator, who was positioned on a different level of the container stack. As the crane operator was manoeuvring a 40ft container, Tuaiti unexpectedly moved under the suspended load and suffered crush injuries followed by a fall when the container was lowered.

TAIC found it was likely that the crane operator did not notice Tuaiti moving under the container, and that by working on different levels without sight of one another the risk of a crush injury was heightened.

There was an overall “desensitisation” to risk at the site, TAIC found.

Atiroa Tuaiti, a stevedore for contracting company Wallace Investments, died after a fall from numerous stacked containers in April.

In Grant’s accident, he was in charge of monitoring the flow of coal from a conveyor belt into the hold. He was not in the sightline of either of the operators and lost radio contact with them. Towards the end of the loading, TAIC found Grant almost certainly fell from the platform he was standing on and hit his head, causing his helmet to come off. He was subsequently buried under coal.

• 'Heartbroken': 26yo new dad revealed as victim in fatal fall at port - 4th death in 5 years
• Rare prosecution: Ex-Auckland port CEO denies charges over worker's death

At some point during the incident, Grant had also suffered a medical event but TAIC could not ascertain at which point these events fell in a sequence.

TAIC found that Grant and other staff did not wear chinstraps with their helmets, which almost certainly contributed to the severity of his head injury - and the reason he and others did not wear the straps was due to a lack of minimum standards and training for stevedores.

The report also found a more comprehensive medical fitness assessment would likely have identified Grant’s pre-existing health condition and allowed for a health and safety assessment as to his suitability for the job.

Donald Grant is remembered as a loving family man and respected workmate.

Maritime New Zealand has already issued Auckland stevedoring company Wallace Investments with one charge in relation to the fatality and Lyttleton Port Company with two charges. Each charge carries a maximum fine of $1.5 million.

Today, TAIC released its full findings from the investigation into the two fatalities and has recommended the industry “move on from deciding for themselves how they will meet safety requirements”.

Both port companies were in the process of improving their safety systems at the time of the incidents, but TAIC found there were deficiencies across both companies.

“The risks associated with work activity were primarily managed with administrative risk controls, yet robust safety assurance processes to ensure that these controls remained effective were lacking.”

As well as this, the stevedoring industry as a whole lacked cohesion.

“With no best practice guidelines, no minimum training requirements and few safety-related information-sharing platforms, leadership from within the sector was found lacking.”

There have been 18 deaths among port workers since 2012 in New Zealand, and the number of fatalities across a 10-year period has remained consistent, averaging 1.8 deaths per annum.

As a proportion of the workforce, stevedore fatalities occur at a rate of approximately 20 deaths per 100,000 workers, which is the second highest rate of any sector within New Zealand.

TAIC’s chief investigator of accidents, Naveen Kozhuppakalam, said there are broad safety concerns for the whole stevedoring industry across three areas - regulatory activity, cohesion in the stevedoring sector, and individual employers’ management of safety.

“The commission is recommending that Maritime NZ work with the stevedoring industry to develop and implement a risk management code of practice, minimum training standards, and ongoing improvements such as sharing of safety information among industry players.”

This would include implementing an Approved Code of Practice for managing health and safety risks, establishing minimum training standards for stevedores and establishing a programme to facilitate continuous improvement of stevedoring safety standards - including the sharing of safety information amongst industry stakeholders.

For Wallace Investments, TAIC recommended the company prioritise a review of its safety systems to ensure all risks are identified and all stevedores’ safety responsibilities are clearly defined and understood.

Wallace Investments has not responded to the report or the recommendations.

It also recommended that Lyttleton Port ensure all workers are medically fit to undertake work by updating its medical screening. Lyttleton Port has acknowledged the recommendation and introduced mandatory screenings in response, which chief executive Jane Meares said was “commendable”.

“While both stevedoring operations were working to improve their safety systems, each was weak in risk identification and mitigation, communication, and supervisory oversight,” said Kozhuppakalam.

“And while both companies relied on administrative risk controls, like rules and guidelines, to manage workplace risks, neither company knew how well workers were applying those rules.”

Vita Molyneux is a Wellington-based journalist who covers breaking news and stories from the capital. She has been a journalist since 2018 and joined the Herald in 2021.