An experienced vineyard manager crushed to death in a machine used to take netting off vines had skipped a fall-back safety process, a coroner ruled today.
David John McIntosh was working at Greenhough Vineyard near Nelson on his 42nd birthday when his leg became caught in netting and he got dragged in to the machine.
He suffered serious leg, head and chest injuries and managed to call out for help before he passed out.
Two passers-by heard his cries before bosses alerted emergency services.
Mr McIntosh, who'd worked at the vineyard for nine years and lived in nearby Wakefield, died later that day, April 21, 2010, in Nelson Hospital.
In a finding released today, Coroner Carla na Nagara said Mr McIntosh was known as a conscientious and methodical worker who was proficient and experienced in the safe operation of the NetWizz automatic net roller.
An investigation into his death was launched by the then Department of Labour, now part of the Ministry of Business, Innovation and Employment.
It found that Mr McIntosh typically either turned off the tractor hydraulics or disengaged the spindle motor when the net was fully retrieved, which locked it off.
"However, on the day of the accident, he had not done this, and thus he relied solely on the net sensor being properly locked off," the coroner said.
"Tragically, it seems that the net sensor latch plate was not fully engaged and slipped out, allowed the sensor handle to fall which started the net rolling."
Mr McIntosh was leaning over the net when the machine re-started, tipping him onto the ground.
The net swept over his body, caught on his boot, and pulled him in.
"Mr McIntosh became entrapped, and subject to the forces of the roller as it rotated."
Given that there was no evidence of prior knowledge that the sensor lever latch plate could fail, there had been no modifications made to the NetWizz machine.
No prosecution was sought under the Health and Safety in Employment Act in respect of Mr McIntosh's death. However, the death prompted Coroner na Nagara to raise the problem of the sensor handle latch plate not engaging fully with the machine's importer.
The manufacturer has also updated owner manuals so that the operator is instructed to disengage the spindle motor before tucking in the end of the net.
"I am satisfied that appropriate steps have been taken to reduce the chances of deaths in similar circumstances in the future, and accordingly make no further recommendations," the coroner said in her finding.
After Mr McIntosh's death, Nelson Winegrowers set up the David McIntosh Memorial Scholarship in his memory, as a former committee member.
It is awarded annually to a local person involved in the wine industry to give them the opportunity to further their experience with organic grape and wine production.