The inquest finally concluded after the case was adjourned last October until January 10 for a report to be prepared on the boom articulation and rope issues.

The accident happened when a team of workers from crane and haulage company Elliott Bros went to Margate to move a 6.5t (7USt) boat. The boom hit Keith Mitchell, 44, as it tipped over while lifting the load.

Coroner Ian Matterson said: “I believe that downhill articulation was the reason this crane fell over, and it was merely due to an unfortunate miscalculation.”

He added: “I recommend that this model of crane be recalled and fitted with an amended capacity chart which shows load derating when operated on gradients which exceed 8.75% and articulation angles which exceed 10 degrees.”

He went on to suggest that an inclinometer be fitted in the operator’s cabins of these cranes and that such a device should be ‘redlined’ to show an operating exclusion zone beyond 8.75% gradient in any direction.

Matterson concluded: “I also recommend that a formal approach should be made to Standards Australia for AS1418.5 Mobile Cranes Code and AS2550.5 Safe Use of Mobile Cranes to be amended to include inclinometers and gradient derating charts as mandatory requirements on this type of crane regardless of capacity.”

According to Matterson’s report, on the day of the accident Greg Smith was the rigger, Shane Geappen was the crane driver and the deceased, who was a fitter with Elliott Bros, attended in the role of truck driver.

With the lift underway, there was a hand signal from Smith to Geappen that signified the boat was articulated a couple of degrees to the right. Moments later, the stop signal was given.

The next move was to wire the boat down onto the trailer. The deceased was asked if the stern of the boat was in position, and he gave a positive answer. They then went to get some rubber matting from the truck to put between the boat and the trailer.

At some stage Smith noticed Mitchell jump clear of the trailer as the boat moved slightly towards the direction of the crane. Smith signalled for the driver of the crane to wire it down, at the same time as Geappen felt the crane tipping over to his right.

Smith ran away from the boat at a diagonal angle as he gave that signal. The boat was wired down as quickly as possible, it then rested on the trailer, but the crane continued to tip over. Smith was struck on the head by a small part, but the boom of the crane struck Mitchell across the back of his shoulder area, pinning him face down, which Matterson believed, killed him instantly.