Sugar manufacturing giant Tate & Lyle was fined £270,000 today after a contract worker "tragically" drowned in the Thames.
Because an access ladder was out of action, Keith Webb was forced to sit in the cab of a digger as it was lowered by crane into the hold of a ship moored at the company's refinery at Silvertown, east London.
But as he was swung between the jetty and vessel, vital chain "lugs" on the vehicle snapped.
The 53-year-old and the nine-tonne machine promptly fell, striking the side of the ship and plunging into the fast-flowing river, London's Southwark Crown Court was told.
An inquest jury subsequently returned a verdict of accidental death.
The company pleaded guilty to two breaches of health and safety at work regulations.
As his widow, Avril, sat in the public gallery, Judge James Wadsworth, QC, said it was "very clear" father-of-two Mr Webb was "a good workman and a very good husband and family man who is desperately missed".
He said his death on March 2, 2004, was a direct result of the company "failing to discharge its duty".
It had not "provided and managed a proper means of access to ships being unloaded".
He said it had also "failed to manage and control its staff properly to prevent being carried in vehicles lifted by crane".
Although there were guidelines in place regarding the use of ladders "the unavoidable conclusion is that the actual practice on the site was that instructions were sometime ignored".
"This is a serious failure of management and supervision for which the company must bear responsibility, and I sentence on that basis."
The judge added Tate & Lyle would also have to pay £90,000 costs.
Mark Harris, prosecuting, said Mr Webb's 6.45am death came just a day after another worker jumped or fell into the hold, injuring his back.
Although the company immediately issued a "safety bulletin" which father-of-two Mr Webb - who worked for sub-contractors Acclaim Logistics Ltd - read before starting work, it referred only to the dangers of jumping on the sugar.
It made no mention of the "prohibition of riding into the hold".
Mr Harris said those like Mr Webb who unloaded sugar consignments "frequently encountered problems with access to holds because ladders were blocked with sugar as the easily accessible material was removed by a crane and grab, leaving a considerable drop to the sugar below.
"The designated method for dealing with this was to clear the sugar manually from the ladders using a scraper....but this could be a time consuming and ineffectual process, particularly if the sugar had gone hard.
"Although Tate & Lyle supervisors were aware of the problems, it was a common theme of those engaged in the unloading work that no, or no adequate, guidance was given to them on how to overcome the access problems, many saying that they had never been shown written procedures for gaining access to ships' holds."
As a result Mr Webb and others operating the "tracked loading shovels" sat in the vehicles' cabs as they were lowered into the holds.
The barrister, who said it was clear there had been "inadequate supervision" of the unloading work, told the court the caterpillared shovel Mr Webb had ridden in was recovered from the river and examined.
Experts discovered the lugs had been "married" up to the wrong chain shackles.
In addition, the crane's brakes and gears were not working properly and would have caused "uncontrolled movements" and extra stresses during the lifting operations.
"The risk created by the breaches was significant and foreseeable and the risk created by the breaches was high," said Mr Harris.
Prashant Popat, QC, defending, said Tate & Lyle "first and foremost wanted to express its remorse and deep regret" for what had happened.
"It fully accepts its responsibility for its failings."
Since Mr Webb's death the company has done "all it practicably could" to improve safety.
The barrister said his client's success in this regard was clearly reflected in its subsequent record and the fact independent auditors had concluded it "now managed safety very well".
He added: "Of course, it is striving towards zero incidents."Reuse content