According to the official Department of Labour report, Ken Callow was the "architect of his own demise".
OPINION: The 34-year-old father of two young boys was crushed by a pine tree he was attempting to fell in the Wharerata Forest, just over two years ago. After his saw sliced through the rotten trunk, he decided to move on to the next tree - but the weakened tree collapsed on him. His was the third death in that forest, south of Gisborne, in 20 months. They were all employees of forestry contracting firms.
"Basically, what they are saying is that he killed himself," his mother Caroline says of the Labour department investigation.
Although she agrees Ken made a terrible mistake, Caroline, and her husband Roger, blame the high pressures and working conditions in the forestry industry. Meeting deadlines and fulfilling contracts, in a competitive market, overtook the welfare of workers.
The Callows agreed to be filmed for a Council of Trade Unions video What killed Ken Callow? earlier this year. Over the roar of logging trucks in the forest, they recalled how their son often worked six days a week, 5am to 6pm, and would come home bone-tired. After one long shift, he was so exhausted he couldn't make it past the garden gate to the front door with his chainsaw.
"I think he felt getting home every day, and getting through the day, was a bonus without getting injured," Carol says.
The short film was part of a campaign for safer forests launched in February, which noted that 23 workers had died in accidents since 2008. Ten months later, a further six have perished, with more than 90 serious injuries.
The death of 63-year-old David Charles Beamsley last week brought about a remarkable watershed: Labour Minister Simon Bridges acknowledged the tragedy in a press release noting the safety record was "not acceptable".
However, despite calling for the industry to "get its safety house in order" Bridges is refusing to lead an inquiry.
He believes it is not necessary, arguing a new code of practice will improve safety, along with a new crown agency to deal with all workplace health and safety issues. The Government is also looking at a form of corporate manslaughter legislation.
And yet the chief coroner has already launched a series of inquests and a union-backed industry-led safety investigation is in play.
Bridges is occasionally touted as a future leader of National, so his handling of this - and recent controversy over oil drilling off the coast of Raglan - is under the microscope.
In black and white, productivity pressure, and squeezed and exhausted employees working in an already dangerous environment, often in bad weather, appear to be the root causes.
Forestry, like mining, is one of National's hopes for economic growth. It directly employs 20,000 people and contributes an annual gross income of $5 billion. In September the Government invested $2.5m in technology research to boost productivity.
It seems a no-brainer for the Government to get on board with a safety inquiry, especially after the failures of self-regulation that led to the Pike River disaster.
Labour's Shane Jones has already pointed out that if Remuera lawyers were dying at a rate of five a year, the Government would sit up and take notice.
As Ken's father Roger says: "I don't know why it should be so dangerous . . . something is not right."
- Sunday Star Times