Why a roading contractor was working in an area with heavy machinery when he was run over by a grader remains unresolved.

Fulton Hogan employee Walter Daniel Crosa died at the Port of Tauranga on August 15, 2011.

Walter Crosa was working at the Port of Tauranga when he sustained fatal injuries in 2011. File photo.

His cause of death being severe crush injuries he sustained with associated blood loss as a result of being run over by a grader, says a report released by Bay of Plenty Coroner Wallace Bain.

Walter was part of a large group of Fulton Hogan contractors working on a large outdoor site at the Sulphur Point terminal. His task was setting string lines across a large area of sandy ground that was to be levelled by a large grading machine.

He was working with another person doing the stringing. At the time the grader was reversing and was being driven by one person.

Walter was seen to stumble backwards two or three metres into the path of the reversing grader and got his foot caught underneath one of the rear tyres on the grader.

Attempts were made by his work colleagues to stop the grader driver from reversing, but by the time he was alerted the rear tyre of the grader had driven over Walter's body, says the Coroner's report.

Fulton Hogan denied there was any instruction at all given to Walter to complete stringing in a live bay – a bay where heavy machinery was operating.

Coroner Bain agrees with Walter's widow that he would not place himself in a position of extreme danger.

'We do not know precisely why he was where he was at the time he died, but the court agrees with his family view that he was quite pedantic in the way he organised himself,” says the Coroner.

'That would be the way he worked and the court agrees that he would be in the bay he was stringing because he believed he was supposed to be there, even though it's clear from the evidence that there is a clear direction not to be in a live bay.

'From the totality of evidence, however, it's the court's view that Mr Crosa was in that bay completing his work task because he thought he was supposed to be there doing it. No fault can be sheeted home to him, at best it is a misunderstanding. The Court accepts Fulton Hogan's rule that there is to be no work and the restrictions of no stringing in live plants.

'There is some evidence that he had been asked to do the stringing in that area because the employer had wanted a very good stringing job done on that area. That fits the description of Mr Crosa as a person in that he was meticulous, and would be doing the very best that he could to get the best result as required.”

The accident occurred in a large fenced off area being graded to be prepared as a container storage area.

It was a clear sunny day but very cold with good visibility.

Checking the area for height and levels was achieved by using a string line between or re-surveyed marker pegs and required two people on foot to carry it out.

It seems clear Walter Crosa didn't hear the beeper of the reversing grader, says Coroner Bain.

'Tahuri Blake, who was working with Walter Crosa, also didn't hear a beeper from the reversing grader.

'We do not know why he stumbled and fell, but that would not be unusual if you were walking backwards stringing it would seem.

'Fortunately there is now new technology where little ear pieces with radios in them that can be used and that seems to the court to be a major step forward in preventing deaths such as this in the future.

'It certainly is a matter that is raised on behalf of the family that they are wanting better systems in communication between machine operators and workers on foot.”