An electrical fitter crushed by a factory crane was operating in a work system which was defective and unsafe, an inquest has found.
Training given to the co-worker at FG Wilson's engineering firm in Larne, Co Antrim, who was controlling the appliance that fatally injured 55-year-old Roy Montgomery was also inadequate, the nine-member jury decided.
Mr Montgomery had been fixing an electrical fault on the overhead mobile crane moments before the accident happened in October 2008.
His colleague Stephen McNeill was on the ground below testing the repair from a control pad. But as Mr McNeill was moving the crane along its tracks, Mr Montgomery stood up out of the cab and was hit by a fixed roof girder.
As the crane passed beneath, the Newtownabbey-born fitter was wedged into a 4.3in gap between it and the girder.
While he was able to walk away from the incident, he had suffered a serious injury to the carotid artery in his neck which would ultimately cut off blood supply to his brain.
He died fours days later in Belfast's Royal Victoria Hospital.
Earlier this year, FG Wilson was fined £90,000 plus costs after pleading guilty to two breaches of health and safety legislation in relation to the incident. Civil proceedings are ongoing.
On the second anniversary of his death, Mr Montgomery's widow Linda was joined by other family members at the Coroner's Court in Belfast's Old Townhall to hear a senior safety inspector outline the failings that contributed to the tragedy.
The jury of six women and three men unanimously agreed with the evidence of Louis Burns, principal inspector at the Health and Safety Executive NI, and found faults in the work system, training provision and risk assessment procedures.