What led to death at port may never be known

Walter and Robyn Crosa with children from back Jazmin, Michel, Daniel, Graciela and Javier.

How a Tauranga man came to stray into a "live" workplace area where he was run over and killed by a grader may never be known, a coroner says.

Dr Wallace Bain was addressing the family of Walter Daniel Crosa at the conclusion of the inquest into his death at the Port of Tauranga on August 19, 2011.

At the opening of the day-long hearing in the Rotorua Coroner's Court on Monday, the Crosa family's lawyer, Genevieve Denize, said they were deeply distressed that the then Labour Department (now WorkSafe NZ) and Mr Crosa's employers, Fulton Hogan, had treated his death as "simply an accident ... that he was in the wrong place at the wrong time".

She said the only outcome from Mr Crosa's death had been a warning to site workers to be safe around heavy vehicles.

"This doesn't sit right with the family. He was a methodical, safety-conscious individual. His close-knit family is devastated he didn't return that day. Instead they received the call no family wishes to receive, saying he'd died at his place of work."

The court heard Mr Crosa had been laying string lines when he was struck and crushed by a reversing grader.

Fulton Hogan and the Labour Department concluded he'd strayed into an area where lines had already been laid and heavy vehicles were working.

In a deposition, Sergeant Scott Merritt, of the Tauranga police, said Mr Crosa had been seen to stumble two or three metres backwards into the path of a reversing grader.

His foot became caught under a rear tyre and although a workmate attempted to attract the driver's attention, by the time he did the rear tyre had driven vertically up Mr Crosa's body and on to his chest.

Although the grader driver and others performed CPR, Mr Crosa could not be revived.

Through Ms Denize, his family claimed there had to be a better way for those on site to communicate with drivers other than by eye contact.

They suggested the company installed RTs in drivers' cabs or have a man on the ground operating a flag system.

Fulton Hogan national health and safety reform manage John Smith responded that technology had advanced considerably since Mr Crosa's death.

Drivers now wore ear pieces and a flag system wouldn't be practical, he said.

He described Mr Crosa as a very experienced stringer and that when he was killed, the worksite would have been very noisy with graders and rollers beeping as they reversed, making it possible he had not heard the grader approaching.

"Everyone is struggling to answer why he went back to the live area. He was a meticulous worker. Maybe he went back to check on his work," Mr Smith said.

The Labour Department advanced the theory Mr Crosa could have been affected by hypothermia on the day he died because it was extremely cold and he hadn't been wearing a jacket.

However, army doctor and hypothermia specialist Major Charmaine Tate disputed this.

Constable Lani Jackson, assisting the coroner, asked Mr Smith if it was common practice for workers to go into a 'live' zone. "That is the million-dollar question ... why was he there?" Mr Smith responded.

Dr Bain reserved his decision until lawyers for all those involved have made further submissions by mid-June.

He told the Crosa family he did not intend to criticise anyone but reminded them Mr Crosa had been in a 'live' area.

"We don't know why but it will be factored into my findings," he said.

Outside the court and speaking through Ms Denize, Mr Crosa's widow Robyn said she had pushed for a formal inquest into her husband's death after learning it was to be dealt with as an in-chambers matter.

"I felt I had to do it for my five children, so we all got to have a better understanding of what happened. It was very important for us to do that."