A forklift driver who died from a head injury after colliding with stacked pallets, was a victim of a "lapse in strict workplace procedure", according to a coroner's report.
The report has revealed Peter Delamare, 63, died as a result of "accidentally sustaining blunt force head injury from a workplace accident".
The Masterton man worked at Juken New Zealand at the Wairarapa Mill when the accident happened.
On August 24, 2009 he had started a nightshift about 8pm and was removing bins of waste timber by forklift from the laminating plant to a waste pile, by travelling on a roadway lined with stacked pallets.
Although yellow lines were painted on the sides of the roadway to designate where pallets should be stacked, at times pallets and waste bins were placed outside of these lines, said the report.
While returning with an empty waste bin, the forklift collided with stacked pallets and Mr Delamere became injured and disorientated.
No one saw the accident, but shortly afterwards he was seen by a colleague stumbling around and then falling to the ground, said the report.
Mr Delamere was taken to Masterton Hospital and later transferred to Wellington Hospital. He did not recover and died less than two weeks later on September 3.
Coroner Ian Smith said it was a "tragic accident" that had caused the company to review its safety procedures.
Investigations in the accident were carried out by the police, Department of Labour, and Mr Delamare's employer.
Department health and safety inspector Russell Young initially recommended a prosecution against Mr Delamare's employer because it "failed to take all practical steps to ensure the safety of Mr Delamare".
Following a further review this plan was dropped.
Instead, Junken and the Department of Labour agreed to use the incident to highlight the threat posed by workplace hazards, circulating a safety alert, and taking part in a national forklift driver competition.
Mr Young said injuries like Mr Delamare's were rare and did not warrant mandatory use of helmets for all forklift drivers.