Don Grant died when he was struck and killed by coal, on the deck of a cargo ship.
He was hit when coal was being moved from the port via a conveyor belt, and loaded onto the ship by a jet-slinger. The jet-slinger propels coal into the ship's hold.
At the time of the incident, Grant was working as a "hatchman", and was stationed on the deck of the ship.
Grant was following LPC's procedures, and was standing in the position he was trained to.
Maritime NZ director Kirstie Hewlett said investigations found several safety failings by LPC in the management of risks for workers involved in the loading of coal.
"Included in the range of issues identified by the investigation was the hatchmen being located within the potential firing line of the jet-slinger. This meant if it was re-positioned, or moved without their knowledge, they'd be at risk of being struck by the coal."
There were steps the company should have taken to provide a safe working environment, Hewlett said.
"Loading coal is a known high-risk activity for LPC, and there were a lack of controls and policies in place around this specific activity.
"There should have been more controls in place to reduce the potential of harm when coal was being loaded onto vessels at the port."
Since the incident, LPC has made changes to reduce the risk of hatchmen being struck by coal, including hatchmen standing in a designated safe zone, rules around when the coal can be poured to keep workers safe, and increased CCTV.
"Since April 2022 there has been significant work across the ports sector to improve health and safety," Hewlett said.
"While this doesn't change what has happened. We want to assure those working on ports and their families that improving health and safety on New Zealand's ports has been a major priority."
Lyttelton Port Company (LPC) has been ordered to pay a fine of $480,000 and $35,000 in costs to Maritime NZ.
The judge also made an adverse publicity order requiring LPC to publish a statement about the incident.
