In 23 years as a scaffolder, Wally Noble came to rely on other people to fence off any hazard on a building site.
He expected no different when he turned up at a new job, building a penthouse apartment on top of a high-rise tower on the Auckland waterfront in March 2007.
As usual, his link to the job was third-hand. He and three employees had been called in as subcontractors to North Shore Scaffolding, which, in turn, had been hired by Alliance Construction. They were to be paid for the scaffolding, not by the hour.
"The faster we put it up, the faster we get out of there and make money," he says. "So being a subcontractor is not a safe way to be, because money rules over safety.
"So I walked into a safety induction briefing with the attitude that I've done it all before, and that's exactly what the safety inductor was feeling on the day too, he's done it all before."
The man's mobile phone rang and he answered it, effectively ending the induction.
Noble and his workers went up to look at the roof with a supervisor.
"When we were already just about up there, the inductor yelled out, 'don't forget about the hole upstairs!' I didn't hear him," Noble says.
There were no warning ropes. Noble stood on some black polythene and realised, too late, that there was nothing underneath it. He fell six metres to the penthouse floor.
"I was conscious but shocked," he says. "I first knew I had done something really serious when I brushed my hand against my leg and didn't feel the touch."
He was paralysed from the waist down.
"I was in shock for months and months," he says.
He was depressed and angry. His wife left him. Eventually he went back to school to do a social work degree. A month ago, he started work again as a needs assessor for disabled people at Taikura Trust.
Three of his sons, however, still work as scaffolders and are still at risk.
It's a tragic story - but all too common. About 100 New Zealanders die in workplace accidents every year, an annual death toll of about four in every 100,000 workers.
That's twice the rate as in Australia, three times the rate of Britain, and worse than all six other developed countries examined by a landmark taskforce that reported this week.
A further 500 to 800 Kiwis die every year from chronic diseases caused by workplace conditions, and the Accident Compensation Corporation (ACC) receives about 200,000 claims for work accidents a year.
"We have a system that has clearly been shown to be inadequate," says Shell-Todd Services general manager Rob Jager, who chaired the taskforce.
His taskforce, sparked by the Pike River coal disaster that killed 29 miners in 2010, has achieved a rare unanimity.
"For the first time in living memory, the employers, unions and government officials are in consensus on the fact that New Zealand needs to do better and how we are going to do better," says Dr Felicity Lamm of the Occupational Health and Safety Research Centre at AUT University.
Council of Trade Unions president Helen Kelly urges the Government to adopt Jager's recommendations "in full".
Employers and Manufacturers Association health and safety manager Paul Jarvie also wants "the whole package" implemented, and says employers are willing to pay even more than Jager's estimated price tag of $32 million in extra ACC levies each year.
"I think the budget that has been put in the taskforce document probably is conservative," he says.
"If we as a country - we as employers, and unions and all the other stakeholders - are committed to doing this, then we, as a country, need to bite the bullet and say if that's what it costs, that's what it costs."
Jager found there was "no single critical factor" that could turn around New Zealand's "appalling, unacceptable and unsustainable" record. The problem was "systemic". It's part-regulatory and part-cultural. Regulations set the ground rules. If we don't have them, contractors like Noble will keep feeling forced to work as quickly and cheaply as possible without adequate safeguards.
The Jager report describes our Health and Safety in Employment Act, passed in 1992, as "a much lighter version" of laws in other developed countries. Industry-specific regulations and codes of practice "have not been sufficiently developed and are often out of date".
Wellington lawyer Hazel Armstrong, a former Council of Trade Unions health and safety manager, says scaffolding is a classic example.
"There is a code of practice around scaffolding but there is not a regulation around the safe erecting of scaffolding," she says.
Even the regulations that we do have are inadequately enforced. Lamm says the former Labour Department's health and safety inspectors dwindled from 317 in 1988 to 168 in 1998 and just 130 in 2008. By 2011, we had only one mines inspector.
"As Pike River showed, you had a mines inspector who was pretty much desk-bound," she says.
Employers were prosecuted when serious injuries occurred, but fines were minimal. Alliance Construction (now in liquidation) was fined just $15,000 for not protecting Wally Noble.
Employers with more than 30 employees have been required since 2002 to have health and safety representatives, but ACC funding for training has been cut gradually from 6000 representatives a year to 1500.
Helen Parkes of the Institute of Safety Management says standards for health and safety managers have never been developed.
"In New Zealand health and safety isn't regarded as a high-value proposition, so it's not unusual for the health and safety portfolio to be given to a receptionist," she says.
Belatedly, changes have started. Last year's Budget used $9 million a year in unallocated revenue from the ACC employers' levy to restore the number of health and safety inspectors to 180 by 2015-16, and new Labour Minister Simon Bridges announced in February that health and safety would become a new stand-alone agency by late this year.
Jager recommends a further slight increase to 194 inspectors to match the Australian ratio.
He wants to replace the 1992 law with a completely new law, modelled on Australia's, extending health and safety coverage to contractors and everyone else on a worksite.
He wants the whole structure, from the board of the new agency downwards, set up on a tripartite basis representing workers as well as employers and government.
"We are recommending that there should be worker representation in every organisation where there is more than a certain threshold of workers," he says.
He would make company directors' health and safety duties "as strong as other fiduciary duties", and impose a duty of due diligence on every line manager.
Penalties would be raised to Australian levels - fines of up to A$600,000 ($722,800) and up to five years' jail for individuals, and fines of up to A$3 million ($3.6 million) for companies.
Companies would also become liable for criminal offences, including manslaughter.
As well as those "sticks", he proposes "carrots" in the form of much stronger use of differential ACC levies to reward businesses with effective health and safety systems.
But beyond all these regulatory measures, he also sees the need to change our culture.
Dutch-born, Jager has worked for Shell for 35 years and says New Zealand's approach to risk is more hands-off than even poorer nations such as Malaysia.
"It's part and parcel of what we are in New Zealand," he says. "We play rugby, we go hunting in the weekends, we do have this culture where I think we seem to be more accepting of risk."
Our high accident rate is not just at work. Our death rates on the roads and from accidents in all settings, are also much higher than in Australia or Britain.
Jager believes we can change this aspect of our culture if we choose to, just as we have chosen, through focused public campaigns, to wear seatbelts and to stop drink-driving, smoking and family violence.
"We are recommending a nationwide awareness campaign," he says.
He wants children to learn about health and safety from preschool onwards.
"It requires thought, but it is going to have to be another key building block," he says. "It's not one silver bullet."