Stevedore Don Grant was killed during a loading operation at Lyttelton Port, when he was buried under a load of coal on the deck of the ETG Aquarius, a bulk carrier, on 25 April, 2022. Photo: Supplied / Maritime New Zealand
An investigation into the deaths of two port workers within six days of each other last year has found a haphazard approach to safety, with poor regulatory oversight and a lack of industry-wide standards.
TAIC chief commissioner Jane Meares and chief investigator of accidents Naveen Kozhuppakalam spoke to reporters about the investigation.
Watch a video stream of their media conference here:
Meares began today's media conference by acknowledging the sorrow and trauma suffered by the whanau and friends of the two men whose lives were taken in the tragic accidents.
Meares said they existed to help prevent similar accidents in the future but only investigated accidents of the loading and unloading of ships.
Ōtara man Atiroa Tuaiti died shortly after 9am on 19 April, 2022 while working on a docked Singaporean container ship, Capitaine Tasman, after he moved under a suspended 40-foot container and suffered crush injuries.
Less than a week later, on 25 April, another stevedore, Don Grant, was killed during a loading operation at Lyttelton Port, when he was buried under a load of coal on the deck of the ETG Aquarius, a bulk carrier.
At the time, the Maritime Union, Rail and Maritime Transport Union, Council of Trade Unions and the Merchant Service Guild collectively asked for an inquiry into the industry.
The government directed the Transport Accident Investigation Commission (TAIC) to investigate the deaths on 27 April 2022.
In the just-released report, TAIC has highlighted several major safety problems for port workers requiring urgent attention.
The commission said both accidents revealed organisational weaknesses in risk identification and mitigation strategies, communication and supervisory oversight.
Wallace Investments, which employed the Auckland stevedore, had recognised suspended loads as a hazard and provided training procedures, which included regularly reminding them not to position themselves under a suspended load.
The commission said the presence of at-risk behaviour indicated "a desensitisation" to workplace hazards and a lack of effective supervisory oversight.
Lyttleton Port had also taken steps to improve safety of its port operations before the accident occurred, the commission said. However, it had not yet identified all the critical risks of the coal signalman's role.
Accidents chief investigator Naveen Kozhuppakalam said the report identified safety issues for the whole stevedoring sector in three areas - regulatory activity, cohesion in the stevedoring sector, and individual employers' management of safety.
"The commission wants regulators Maritime NZ and WorkSafe to do more to promote future safety across the sector. They need to take a 'just culture' approach, provide insight, promote information sharing and maturity in risk management, and encourage continuous learning," Kozhuppakalam said.
"If regulators can do that, then it's more likely that stevedoring will be able to make progress towards operating more like businesses in other high-risk industries, where training, qualifications, and adherence to standards are part of business-as-usual."
Lyttlelon port. (File image) Photo: 123rf
Among other recommendations, the commission said Maritime NZ should work with the stevedoring industry on training standards and sharing of information safety.
"We need to move on from stevedoring organisations deciding for themselves how they will meet safety requirements.
"They receive insufficient regulatory oversight, lack industry-wide safety standards, and lack the formal safety management oversight and monitoring required of other industries.
"There is minimal proactive gathering and sharing of safety information, and too few appreciate the benefits of a good safety culture."
'If proper codes aren't implemented, accidents will happen'
Kozhuppakalam said today the stevedoring industry had minimal proactive gathering and sharing of safety information and too few stevedoring companies appreciated the benefit of a good safety culture.
"Where the threat of prosecution is always imminent frontline workers tend not to report safety-related information within their own organisations and safety leadership is less of a priority."
The commission wants regulators Maritime NZ and WorkSafe to do more to promote future safety across the sector.
"While both stevedoring operations were working to improve their safety systems at the time of these accidents, both were weak in risk identification, mitigation, communication and supervisor oversight," Meares said.
On whether the deaths would have been preventable had the companies followed safety protocols, Meares said she suspected many deaths are preventable but "we can never know exactly what happened in an accident, we can look at circumstances and causes surrounding the event".
"It's impossible for us to say if these safety standards had been followed to the later that this accident wouldn't have happened."
Lyttelton Port company have taken a number of safety actions which was very heartening, Meares said.
Asked if it was concerning to find out if the companies didn't even know how they were applying their administration rules, Meares said it was always concerning to find out that an entity that should be responsible for safety did not know what was happening within the company itself.
"Part of a mature safety culture is to ensure that not only are there rules and administrative controls and processes and procedures but that they are actually being adhered to in practice and that's what we're recommending that the safety culture needs to change to make sure these things from being simply written to being implemented."
Meares said it was not for them to outline how a company or entity should implement that safety culture "that's for those entities to do within the framework of the law and regulations".
"If proper codes aren't implemented and safety culture learnt across an organisation, accidents will happen."
Meares said they had not received a response from Wallace Investments about what safety actions it has taken since the accident happened.
Lyttelton Port and Wallace Investments
Lyttelton Port Company chief executive Graeme Sumner said the port agreed with all the recommendations in the report and was committed to implementing them.
They had also already taken steps following the death of Grant, Sumner said.
"We also welcome the recommendation relating to greater regulatory oversight of the port industry and look forward to working with Maritime New Zealand (MNZ) in this regard.
"Our thoughts are with the family of Don Grant and with his friends and fellow team members. This report is a reminder of the very significant loss of a much-loved family man, work colleague and friend."
Sumner said it was not appropriate to say more at this stage while there was a case before the courts.
Wallace Investments said it would be inappropriate to comment while the matter was before the courts.
Maritime NZ partially accepts two recommendations, fully accepts other two
In a statement, Maritime NZ said health and safety were priorities for the national maritime regulator.
Director Kirstie Hewlett said the regulator partially accepted two of the recommendations (regulators aim to take a more proactive role in driving safety on ports), and fully accepted the other two.
"We agree that there is always more opportunity to work proactively and we welcome the additional funding that comes with our designation extension from 1 July 2024, so we can carry out more proactive monitoring on ports."
Maritime NZ and WorkSafe are currently sharing designation overseeing health and safety at ports, but from 1 July 2024, Maritime NZ will take over the designation as the sole regulator on ports.
"Any incident on a port is one too many, and everyone at Maritime NZ extends their thoughts to those who have been injured at ports, as well as to the friends and families who have lost loved ones," director Kirstie Hewlett said.
Earlier this year, the Port Health and Safety Leadership Group - made up of port and stevedoring companies, unions, the Port Industry Association, Maritime NZ and WorkSafe NZ representatives - released an action plan to make ports safer.
Maritime NZ said "significant progress" had been made on implementing some of the group's action plan since it was released.
List of actions under PHSLG:
- completion of a platform where people can access new safety technologies
- development of a work programme on good practice guidance
- develop more consistent safety standards on ports
- Approved Code of Practice for loading and discharging cargo on ports and on ships (which is currently out for consultation)
- improve workforce training, capability and understanding of risks
- Looking at whether future standards will be backed by the regulator (Maritime NZ), as recommended by TAIC (Decisions on this potential backing will need to be made by the relevant ministers.)
Maritime Union of New Zealand national secretary Craig Harrison said the union endorsed the findings of the report and its recommendations.
Many of the issues noted in the report were the outcomes of decades of industry deregulation, where the voice of workers had been silenced in favour of commercial priorities, he said.
Harrison agreed with the national maritime regulator, saying the development of a national Approved Code of Practice for port operations was another major step.
A Stevedoring Code of Practice was already in place at Port of Auckland, that had been put together by the port, two private stevedoring companies, and the Maritime Union.
This progress went some way to meet the TAIC report call for industry collaboration and benchmarking improve safety standards, Harrison said.