Myra Goldman
PFD Report
Partially Responded
Ref: 2014-0490
1 of 3 responded · Over 2 years old
Response Status
Responses
1 of 3
56-Day Deadline
5 Jan 2015
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
The inversion of the upper hinge pin is not an uncommon practice and is intended to prevent a gate from being easily lifted off its hinges. BS 1722-12:2006 specification for steel palisade fences which states that ‘hinges shall be designed so that it is impossible to remove the gates by lifting at the hinges when they are in the shut and locked position’. The standard gives examples of hinge arrangements and does not specifically preclude this method. In the opinion of HM Specialist Inspector (Mechanical Engineering) of the Health & Safety Executive who gave evidence at the Inquest ‘the common sense approach is to spread the load’ between hinges by orientating them the same way rather than putting the significant majority of the weight of the gate onto one hinge only and ‘to prevent the gate from being easily lifted off, a proprietary method should be used such as double
— lug hinge or anti-theft collars or split pins’. The preference of HM Specialist Inspector was for the standard to be ‘changed’. Any change can only be considered I implemented at a review meeting of the British Standards Institute.
— lug hinge or anti-theft collars or split pins’. The preference of HM Specialist Inspector was for the standard to be ‘changed’. Any change can only be considered I implemented at a review meeting of the British Standards Institute.
Responses
Response received
View full response
Dear Mr Nelson Inquest touching upon the death of Myra Goldman Thank you for your letter of 12th November 2014 concerning the death of Myra Goldman and setting out your concerns over the specification for hinge arrangements in steel palisade
•fences detailed in BS 1722-12:2006. Please accept our apologies for the delay in responding. V A British Standard is a collective work created by a committee of interested parties, such as manufacturers, government departments, trade associations, consumers and research bodies. BSI administers the functions of the committee in its development of a Standard, but the committee is responsible for reviews of and modifications to the Standard. A Standard is maintained by a standing committee and every Standard is reviewed at least once every 5 years. In this case, the committee of BS 1722-12:2006 recently accepted a proposal to review this Standard and the reviewed Standard is expected to be published in 2016. I have forwarded your letter to the chairman of the standing committee responsible for BS 1722-12:2006 to be included as part of their review. I have also asked the chairman to consider whether the proposed review of this Standard may be accelerated in light of the concerns you have raised. Please contact me directly should you require any further information.
•fences detailed in BS 1722-12:2006. Please accept our apologies for the delay in responding. V A British Standard is a collective work created by a committee of interested parties, such as manufacturers, government departments, trade associations, consumers and research bodies. BSI administers the functions of the committee in its development of a Standard, but the committee is responsible for reviews of and modifications to the Standard. A Standard is maintained by a standing committee and every Standard is reviewed at least once every 5 years. In this case, the committee of BS 1722-12:2006 recently accepted a proposal to review this Standard and the reviewed Standard is expected to be published in 2016. I have forwarded your letter to the chairman of the standing committee responsible for BS 1722-12:2006 to be included as part of their review. I have also asked the chairman to consider whether the proposed review of this Standard may be accelerated in light of the concerns you have raised. Please contact me directly should you require any further information.
Action Should Be Taken
The content of BS 1722
— 12:2006 specification for steel palisade fences be reviewed at the next meeting of the British Standards Institute with a view to the prevention of future fatalities.
— 12:2006 specification for steel palisade fences be reviewed at the next meeting of the British Standards Institute with a view to the prevention of future fatalities.
Report Sections
Investigation and Inquest
On the 8 th March 2013 I commenced an investigation into the death of Myra Goldman for whom the cause of death was given as being that of la) Traumatic Asphyxia and at an Inquest convened with a Jury at the Oldham County Court on the November 2014, the conclusion of the Jury was that of an ‘accidental death’ with the Jurors unanimously stating in answer to question 3 of the Record of Inquest that ‘her death was caused by a palisade gate falling on her due to fatigue of the lower right hand hinged eye bolt plus configuration of the lugs and hinge pins’.
Circumstances of the Death
The palisade style gate was at the entrance to a number of storage units. A diagram confirming the configuration of the hinges to that gate is annexed and shows that each hinge was formed by a hinge pin welded onto the gate post and an eye bolt bolted through the stile of the gate and fastened by two nuts. The lower hinge pin had been welded so that its pin was above its lug. The upper hinge was welded so that its pin was below the lug i.e. they were the inverse of each other and therefore the lower eye bolt would have been taking the majority of the vertical static load of the gate. Impingement of the gate on the gate post was the primary cause of insidious fatigue cracking in the lower eye bolt and when this failed, the gate dropped until the upper eye bolt was clear of its own hinged pin at which point the gate was free to topple sideways.
Copies Sent To
1. Spaces and Places Limited (DWF Solicitors)
2. Health & Safety Executive
3. The British Standards Institute
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.