''The cadet was not wearing a safety harness attached to a fall arrestor while working close to the edge of the log stack, despite a company requirement to do so. The commission found that the crew on Mount Hikurangi routinely did not follow company procedures by working on top of log cargoes without the required safety harnesses.
''There was little evidence of a strong safety culture on board Mount Hikurangi at the time,'' the report said.
Safety actions taken by the ship's operator and Maritime New Zealand negated the need for the commission to make any recommendations.
All crew members must now wear safety harnesses, preferably connected to fall arrestors, when working at height. A strong safety culture must be established and promoted from the highest levels of management on a ship.
''It must be encouraged, monitored and enforced throughout all levels of the organisation so that best safety practices are followed,'' the report concluded.
The man fell about 9.15am. Navy divers found his body three hours later - a navy ship happened to be in port at the time.