KEY POINTS:
Maritime New Zealand (MNZ) director Catherine Taylor is adamant a wide range of factors caused the deaths of two men when their trucks tipped off a barge in Picton Harbour during loading in August 2005.
Allan Tempero, 58, and Tom Phillips, 62, both of Blenheim, died when their concrete trucks tipped off a barge during loading and slipped into eight metres of water.
The men worked for Firth and were delivering concrete to a construction job in the Marlborough Sounds.
Ms Taylor said today that an unforeseeable combination of factors caused the accident.
An MNZ report in October last year identified driver inattention was one of five "active failures" which led to the accident.
But Blenheim coroner Peter Radich's report, released today, has cleared the two men of fault.
Mr Radich said he could not accept many of the key findings in the MNZ report, including that the accident was not foreseeable or that driver inattention played any part in the accident.
Ms Taylor said it was difficult to know how Mr Radich reached a different conclusion.
"He may have been commenting on the fact that the operator of the barge should have perhaps realised. It's hard for me to know, he just reached a different conclusion."
MNZ and former director Russell Kilvington concluded there was no clear breach of the law, "and in reaching that decision he followed the solicitor general's guidelines", Ms Taylor said.
MNZ took the view that the barge operator had carried out more than 650 incident-free journeys, 80 carrying concrete trucks, She said.
The barge operator had carried a similar load only two days earlier.
"However, now we know there were different factors associated with this particular accident."
The trucks were larger, they were carrying heavier loads that would not have been permitted on the road.
An excess load in a third vehicle should have been pumped evenly between the two trucks, but was put into only one, significantly overloading it.
"What we also know is that the margin for error on the barge was very, very small," Ms Taylor said.
"There was lack of clarity in the communications between the concrete company and the actual barge operator as to just what was the weight of the truck.
"Some figures were quoted - they were assumed to be cubic metres, when in actual fact they were tonnes."
Mr Radich's report into the incident warned that unless workplace safety legislation was improved, including more flexibility for private prosecutions, more people could die needlessly, The Press said today.
"In my view this was a situation where procedures for dealing with health and safety were not adequate, unsafe practices developed and grew, the taking of responsibility fell between the cracks, people in good faith - but wrongly - went on doing what had been done before without adequately addressing the consequences and the tipping point was ultimately reached," Mr Radich said.
There was no unusual combination of factors and the hazards were there to be seen. His final findings were simply that the barge became overloaded and capsized, he said.
Ms Taylor said MNZ had instituted changes in the wake of the accident, including a safety bulletin to barge operators and a new set of barge stability guidelines.
"And we are currently developing a code of practice for barging operations in association with the barging industry that will published soon."
She said education and awareness could be as effective as a new rule.
- NZPA
