When Sanford bought San Granit in 2016 it had an "at sea safety report" done to identify risks on board and what could be done to fix them.
Dangers in the automated freezer system were identified as "high risk". However, it was not until Stewart's death two years after that that Sanford spent $450,000 making changes, including introducing an automatic shutdown system and revising its standard operating procedure (SOP) for clearing blockages.
The incident occurred shortly after 3.45am when Stewart entered part of the automated freezer system to clear a blockage. When the system activated he became caught and was fatally injured by moving parts of the system.
"On most voyages, the foreman or factory manager was to review the SOP with the freezer man. There are no records of this review kept by Sanford," he said.
Judge A.A. Couch said in his decision that having a written SOP at the time of the incident was of little value in practice because Sanford did not monitor compliance and management was either unaware or unconcerned that the procedures were not being followed.
Workers had developed their own work-arounds to clear blockages, including not calling designated personnel as required. In addition, the cage around part of the system was not always locked. This meant workers could enter the caged area to clear a blockage without the system being turned off, they said.
The factory supervisor checked workers every hour. However, the factory supervisor on Stewart's shift was unfamiliar with the automated freezer system and therefore limited in their ability to monitor and provide the supervision necessary to help keep workers safe.
They were also unaware of Sanford's fatigue management policy – San Granit's factory operated 24/7 when the ship was fishing.
Maritime NZ's investigation found that Sanford could have guarded machinery in the automated freezer system so blockages could be cleared without exposing workers to moving parts, the SOP was poorly worded and confusing, and monitoring and supervision of workers' safety was inadequate.
"It is positive that all these changes have now been made by Sanford. However, it is critical all employers consider carefully machine guarding equipment, processes, monitoring and supervision to avoid it taking a death or serious injury to learn these lessons," Dwen said.