The decapitation of a Nelson fisherman on a boat in 2014 was caused by the deterioration of a rope on board, an investigation has found.
The Transport Accident Investigation Commission (TAIC) report, released today, also found the management plan for the ropes was ineffective.
Leighton Muir, 27, was killed on the Captain MJ Souza, while fishing in the waters off Kiribati.
He died instantly when the rope, which had snapped three weeks earlier, broke and whipped back while a net full of tuna was being hauled in.
TAIC found that the rope was in a deteriorated condition and was further weakened by the knot that had been used to join it.
In its report, the commission also found that "the broken rope was about as likely as not to have begun its life in service at a lower-than-typical breaking load for a rope of that size and construction".
"However, it could not be determined why, because the rope management plan on board was not effectively managing the purchase, storage, inspection and retirement from service of the ropes on board," TAIC said.
It said the boat's safety management system had good guidelines for the management and use of ropes on board, but neither the crew, skipper or shore management were ensuring that the safety management system was being adequately followed.
The commission recommended improvements to the boat's internal auditing.
The boat's operator, Talley's, has already been fined $73,520 and ordered to pay $21,000 to Mr Muir's family.