The workplace safety watchdog began research into the labour-hire industry safety within weeks of two temp workers being killed.
But it never investigated their deaths.
The family of Jake Ginders asked the regulator, WorkSafe, to investigate shortly after the Palmerston North 23-year-old died near Dannevirke in January 2019.
His employer, the country's largest labour hire firm, AWF, had arranged for him to travel with Floyd Harris to a job.
This was illegal: Floyd had only a learner licence, and AWF has acknowledged its responsibility for failing to check - "a terrible oversight", it said.
They spun out, hit a ute and both men were killed instantly.
The Ginders family never heard back from WorkSafe. Neither did the Harrises, the family told RNZ.
Among the many things WorkSafe did not tell the families was that it was about to launch research into risks within the labour-hire industry, to fill a "substantial" knowledge gap.
The agency commissioned the consultants MartinJenkins for the job in March 2019, and stated in the 2018 tender request:
"The labour-hire industry is a substantial employer ... hosted across many industries and each of WorkSafe's priority sectors (agriculture, construction, forestry and manufacturing).
"WorkSafe ... is looking to develop a profile of the labour-hire industry... and better understand the health and safety risks ... and how effectively they are being managed by both labour-hire firms and host employers."
A few months later, the research concluded that temp workers were at least at slightly greater risk of harm overall, and in fact their claims for severe injuries to ACC in 2017 were double regular rates.
Information had been hard to come by. However, the larger labour-hire firms usually had a lot of processes in place to manage risks, it said.
"Thirty of 37 participants described the way their own agency managed this risk as 'good', 'very well' or 'excellent'."
However, the industry had inherent problems around factors such as uncertain and high-risk work, economic pressures and workers having a say.
"Agency workers are wary of speaking out about health and safety issues, both to host firms and to their agencies, because of well-founded fears that they will not be offered further work," the 107-page report said.
Dead men felt under pressure, families say
The Ginders and Harris families knew nothing of these findings.
But Sharon Harris echoed them at an inquest in Palmerston North in March, regarding AWF arranging for her autistic son to drive to work.
"Floyd was too worked up and frightened to say no, and he drove that morning and he never made it to work alive," she told the coroner.
"Floyd told me that he would be given opportunities as he progressed through his [driver] licence, and that he would be more likely to get permanent work, which he told me he was looking forward to, and this is why he didn't say no to driving himself and others to the job."
The Ginders family said Jake felt under pressure, too.
In stark contrast, the employer AWF denied at the inquest that its workers ever faced any repercussions for turning down jobs.
AWF won a top industry award in 2021 for how it engages with workers, and told the inquest its own surveys found workers felt looked after.
WorkSafe never investigated or prosecuted AWF.
Without a prosecution there could be no court-ordered reparations.
Seven months after the crash, the Crown agency visited the company.
Its inspector looked at changes AWF had made to its driver licence checks and, within a month, approved them.
WorkSafe did not produce any report about this, according to a coroner's minute.
It never told either family it had done any of this.
The Ginders only found out months later from AWF.
Shortly after this, in September 2019, WorkSafe's research into the labour-hire industry came out.
The report had nothing to say about the risks temps faced getting to work.
It drew on a lot of Australian research, to conclude: "Agency workers are in a particularly vulnerable and precarious form of employment ...
"The issues raised in this report will need careful oversight by policymakers and regulators."
After WorkSafe's visit, AWF carried on arranging informal carpools until pausing the practice entirely just before last month's inquest.
Under its rules tightened after the 2019 crash, AWF told the coroner it would check driver licences if it was compensating workers for the travel, but not check the licence if it was not compensating them.
WorkSafe told RNZ it "regrets" not keeping the families informed.
It would not comment for this story, while the coroner had yet to report back.
However, the coroner has made clear that while she may yet ask WorkSafe to investigate, it is not within her mandate to look into what the agency did or did not do.