Father of seven Palaamo Kalati was crushed and killed by a container at Ports of Auckland when a number of safety measures were not followed, according to Maritime New Zealand.
Maritime NZ has found the likely cause of the death was that a container fell and crushed Kalati when the stevedore and a colleague were working outside a safety zone onboard a ship.
"The crane driver was not aware of the workers' presence in the lift zone, and the supervisor failed to advise the crane driver of the presence of the workers in the lifting area," according to initial inquiries by Maritime New Zealand inspector Jason Lunjevich.
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He said based on events, it is likely Ports of Auckland was not ensuring compliance with procedures and safety measures to protect workers during the loading and unloading of ships.
The details of the tragedy are contained in an "Improvement Notice" issued by Maritime NZ requesting the ports company provide exclusion zones for workers to minimise the risk from falling objects by September 14.
A ports spokesman said the company had complied with the notice requirement to provide exclusion zones for workers, but could not comment on issues raised about the incident by Maritime NZ for legal reasons.
Maritime NZ is undertaking a formal investigation into the incident rather than WorkSafe because the incident happened on board a ship.
Maritime Union Auckland secretary Russell Mayn said Kalati was squashed by a container that had fallen off a crane while being unloaded from a ship.
"He should never have been working under the load and that is what happened that night," said Mayn.
The union supported Auckland Mayor Phil Goff's announcement today of an independent review of health at safety at the ports company following a series of deaths and serious injuries at the port.
The Herald understands the latest death at the port prompted a meeting last week where Goff and several councillors expressed concerns about management at the port.
As well as the death of Kalati, Goff said the death of another worker and a serious injury in recent years are a serious concern to him and other councillors.
In August 2018, Laboom Midnight Dyer was still killed when a straddle truck tipped over at the port. Months later a machinery operator suffered burns after a large fire broke out in a reach stacker.
In July this year, the port company was fined $424,000 after ocean swimmer Leslie Gelberger was involved in a tragic accident involving a Ports of Auckland pilot boat in 2017.
Judge Kevin Phillips said the death was not a factor in sentencing. Instead, the issue was over a "systemic failure" from continuous speeding breaches.
Goff said the independent review was needed to determine whether there is a pattern of failure in the health and safety measures at the port.
Labour councillor Shane Henderson said Ports of Auckland has the highest level of deaths and serious accidents of any port company in New Zealand.
"I want the review to root out any kind of systemic issues we might have. When we talk about health and safety we are talking about workplace culture. I want to see evidence it is there and is being followed appropriately.
""We expect when our loved ones go to work, we expect them to come home safely to their families," Henderson said.
Waitemata and Gulf councillor Pippa Coom said she understood the port had a long period with no fatalities and the review needed to look at all the factors at play creating an unsafe workplace in recent times.
"The management put in place the culture. That's what I want the investigation to uncover. There will, no doubt, be some recommendations around what needs to change," she said.
Ports of Auckland board chair Liz Coutts said: "The death of a stevedore late last month was devastating for his family, friends and workmates, and for the whole Ports of Auckland team.
"The wellbeing of our staff is paramount and POAL will co-operate fully with the independent review.
"The board has confirmed it is fully supportive and Ports of Auckland will co-operate with all aspects of the independent review," Coutts said.
The review's terms of reference are currently being finalised by Auckland Council, with the independent reviewer or panel to be appointed shortly by the Council. The costs for the review will be met by Ports of Auckland. The review is expected to be completed by the end of the year and will allow for stakeholder submissions.