A man struck and killed by a falling crane would "in all likelihood" still be alive if a workplace safety regime had been followed, a coroner has found.
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Herman Holtz, 62, was killed in August 2016 when an overloaded mobile crane fell on him during the repositioning of a 10.3-tonne generator at the University of Canberra Hospital's construction site in Bruce.
The driver, Michael John Watts, repeatedly overrode safety mechanisms and ignored warning alarms to continue operating the crane. It tipped, crushing and instantly killing the grandfather.
In findings published on Wednesday, ACT coroner Ken Archer found Mr Holtz's death was "senseless", "tragic and unnecessary" and had been caused by failures to ensure a safe workplace.
"Decisions were made to use a crane that was not suited to the task at hand," he said.
The coroner found Watts "was not adequately trained in the use of the equipment, the workplace was unfamiliar to him, and the load was too heavy for the crane".
Watts received a 12-month suspended jail sentence in the ACT Supreme Court in 2020 for reckless conduct exposing a person to the risk of death or serious injury.
Action was also taken against Watts' employer, RAR Cranes, which was fined $300,000 in 2022 after it pleaded guilty to failing to comply with a work health and safety duty, thereby exposing Mr Holtz to the risk of death or serious injury.
Multiplex Constructions, which had employed Mr Holtz, was fined $150,000 in 2021 after pleading guilty to the same charge.
On Wednesday, Mr Archer found another employee had warned the crane company about the need to find a safer way to move the generator.
He also found workplace safety procedures had not been followed.
"Multiplex, through its employees, was supposed to sign documentation representing that the use of the crane to perform this task was safe. It failed to do so," Mr Archer said.
"The safety regime that was in place at the time, if complied with, would have meant that the accident would, in all likelihood, not have happened."
The Holtz family has raised concerns about how the prosecution process unfolded in the six-and-a-half years since the workplace death.
This included concerns about an inability to read victim impact statements in court, changing and dropping of charges, and delays.
The family also felt Mr Holtz's body was left under the crane for too long and should have been removed earlier.
They have also stated their view that justice has not been done.
Mr Archer said investigation after a death was "complex and must be undertaken with care".
The coroner said he was "satisfied" a balance was struck between the needs of coronial and criminal investigations, issues of safety and the need to ensure the body was treated with respect and dignity.
Mr Archer recommended the ACT government review the operation of the ACT Coroner's Court in cases that may involve related criminal proceedings.
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Mr Holtz and his wife, Rangimarie Nellie, had been married for 42 years before his death.
The coroner stated the marriage had been "filled with happy times spent with family and friends enjoying birthdays, holidays, weddings, family gatherings and trips together".
Mr Archer said Mr Holtz had been a hard-working man, who was deeply committed to caring for his family.
"His death is still profoundly felt by those who knew and loved him," Mr Archer said.
"He did not deserve to die in the way he did."
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