Worksafe have found that nobody was deemed responsible for the death of a Wellington man died of crushing injuries while repairing a lift in the city.
However, just how Otis lift service technician Brendon Scheib died will remain a mystery.
Scheib was an experienced member of the Otis team and had phoned his bosses at 3.05pm on January 14 this year to say his repair on the lift at T&G Building, Grey St, Wellington, had been completed.
A Worksafe report into the incident reveals that Scheib was still there carrying out repairs at 3.30pm when he was last seen by an associate of the building owner.
At 5.29pm the lone worker alarm - which is the sound of a barking dog - was activated, sending an automated alert to the Otis call centre. Scheib was found dead by a co-worker, having been crushed between the lift car and shaft.
The lone worker alarm sounds after two hours of non-activity on the worker's cellphone.
After investigating, Worksafe states that it will remain unclear exactly how Scheib's death occurred.
"From the evidence available it is unclear how this situation arose."
WorkSafe found it was likely Scheib either thought he had engaged the top pit switch when he hadn't, or had knocked it accidentally, causing the lift to restart.
The report said Scheib had 27 years experience as a level 4 service technician for Otis. He had also completed the most recent courses and meetings.
A toxicology report came back negative to any substances in his body.
The lifts that operated in the building were almost silent, meaning there would be little audible warning when the lift cars were moving.
At the point where Scheib was trapped there was only 165mm clearance between wire mesh and lift cars.
Otis was not prosecuted after the incident and the company stated that no changes were made to their existing policies and procedures.
Service technicians were aware that the potential harm of working in a lift pit was severe injury or death.
Under the Voluntary Code of Practice for Health and Safety Issues in the New Zealand Lift Industry it states that "entry into the pit will only be permitted when two independent means of shutting off the elevator are available and used. Where a redundant means of protection is not available ... [the lift must be locked out]".
A similar guide is also in Otis' employee handbook, stating technicians working in lift shafts should either shut the lift off completely in the machine room, or use two independent means to stop it, including using a pit switch, located at the entry to the lift's pit.