An inquest into the 2016 death of a forestry worker in Hawke's Bay has ended with a coroner signalling she will likely make recommendations.
Closing the inquest in Gisborne on Friday, Coroner Donna Llewell told the whanau of Niko O'Neill Brooking-Hodgson that in recognition of the five years it had taken to reach this point, she would undertake to prioritise her written findings for this case.
They would not have to wait another five years, or even another five months.
She said she was likely to make recommendations, which involved a process that took additional time but the whanau could be assured she would deliver her findings as soon as possible thereafter, while also doing the appropriate justice to Niko and the forestry activity (line retrieval) that was identified as having caused his death.
The coroner said she hoped Niko's 7-year-old daughter would one day remember these proceedings and the significance of them, and having sat alongside her "koro" (grandad) as he gave his evidence.
Niko was 24 when he was fatally injured on August 22, 2016, while working as a head "breaker out" for DG Glenn Logging Ltd in part of Esk Forest at Te Haroto, northwest of Napier.
He was on steep terrain, involved in retrieving a log hauler line so the hauler could be moved, when he was struck by the line and a 9kg metal D shackle attached to it.
The shackle and line had been snagged, but became free and jettisoned towards Niko after the hauler driver applied tension to the line.
Niko died at the scene from his injuries.
After investigating, WorkSafe declined to prosecute — a decision that deeply disappointed whanau.
Such decisions cannot be examined as part of an inquest — a coroner's court is not an appellate jurisdiction, that is, it cannot hear appeals against decisions by other courts in the judicial hierarchy.
Neither is it the role of a coroner to determine any civil, criminal, or disciplinary liability.
However, a coronial inquiry or a coroner's findings can be the basis for fresh enforcement proceedings that might otherwise be time-barred.
The inquest focused on four issues:
• The best practice for dealing with an obstruction during line retrieval
• Whether line (and block) retrieval is a different operation from line shifting
• What is a "straw line" and whether use of one would have avoided Niko's death
• Whether there are deficiencies in policy and guidance for line retrieval in the Approved Code of Practice for Safety and Health in Forestry Operations 2012 (ACOP) that require it to be amended.
Niko's whanau believe his death was caused by major systems failings and called witnesses to give supporting evidence.
One witness said it was unacceptable Niko's crew were not using a straw line in conjunction with the hauler line as the straw line could have been a safe way of clearing the snag, preventing Niko's death.
The coroner was also told by whanau witnesses that many forest workers have the ACOP on site and call it their "bush bible". It needed to be updated to include policy and best practice for line retrieval, and consultation should begin at ground level with the workers — the people who face that danger daily.
The industry needed a single, go-to document. It needed to be readily available in hard copy form, whanau witnesses said.
The lawyers for WorkSafe and DG Glenn made closing submissions. Counsel for the whanau elected to make written submissions later.
For DG Glenn, counsel Brian Nathan said Niko's death had a significant and salutary effect on the company, which considered itself at the leading edge of safety development in the forestry sector.
It was a well-resourced business with a strong focus on health and safety, but as this case showed even in that circumstance, there could still be situations with bad outcomes.
Niko was well qualified, a good worker, and a role model for others, yet things still went wrong, Nathan said.
The company had not identified line retrieval as a specific risk but it had policies in place dealing with rope movements and associated hazards, a number of which could have applied to line retrieval.
"This isn't a situation where there were no systems in place; DG Glenn had done their best — what was reasonably practicable to ensure Niko's safety and that is why of course WorkSafe reached the conclusion that it did (not to prosecute)," Nathan said.
The company would not dispute it was best practice to use a straw line in line retrieval but questioned whether it should be mandatory. There were difficult settings — like the one in which Niko was working — where great care would be needed to prevent excess tension on the line.
The company supported the ACOP being amended — DG Glenn was involved in the 2017 best practice guidelines for cable logging. But the new ACOP needed to be kept clear and concise, Nathan said. Over-complicating it would not solve this issue confronting the sector.
For WorkSafe, counsel Anna Longdill said that before Niko's death, the forest industry did not recognise line retrieval as a specific risk or provide training on it. There were no documented guidelines about it.
Line shifting was considered a much greater risk of harm.
However, the lack of guidance about line retrieval had since been addressed by a Competenz best practice guide for breaking out and cable harvesting, which was published in September, 2017, a few months after the WorkSafe investigation concluded.
She acknowledged witnesses' evidence that workers wanted the ACOP to act as a single go-to document, but there would need to be a balance between the two documents, Longdill said.
It simply was not feasible to put all that information into the ACOP without losing portability.
Longdill suggested three potential recommendations the coroner might consider: Improving the prominence and accessibility of the Competenz document; for content in that guide to be considered for a unit standard (something the whanau wanted), and for controls for line retrieval set out in the guide to be considered for inclusion in the ACOP and consulted on.
While the consultation process took time, the process in itself was a good way of getting knowledge out to the people on the ground, Longdill said.