Recurring concern

Failure to ensure lift engineers are competent to install and service lifts

First to latest report 23 Mar 2015 — 11 Jan 2023

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

Includes failures in qualification, training, competence assessment, refresher provision or verification for personnel who install, inspect, maintain or service passenger, vehicle or stair lifts, including failure to ensure they understand applicable manuals, safety-critical settings, examination requirements and known defects.

What is not included
  • Excludes competence or training deficiencies for lift users or operators who do not install or service lifts.
  • Excludes generic staff training or equipment-use competence where lift installation, inspection, maintenance or servicing is not the bounded function.
  • Excludes failures in the design, type approval, physical maintenance or operation of lifts when no deficiency in the competence assurance of lift engineers is identified.
  • Excludes competence concerns for unrelated machinery, vehicles or clinical equipment unless the assertion specifically concerns personnel responsible for lift installation or servicing.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West London

    AI-generated summary

    Ashley Michel Bullard · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ashley Michel Bullard died after a Volvo S80 fell from a vehicle lift while he was working underneath it at Wheel Art Ltd. The lift’s freeplay and the alignment of its pads contributed to the pads moving from a structural part of the car to a non-structural part, causing the car to fall and fatally injure him. Concerns included inadequate maintenance, the use of unsuitable bolts, insufficient warnings and manuals, and risks associated with outer lift points and tolerated freeplay in two-post vehicle lifts.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure engineers read and understand the lift manual

    Wider context from the report

    “2. An experienced Liftmaster employee gave clear evidence that he did not read all of the installation and operating manual for the XPR9 lift, in spite of being said to have received refresher training from his employer less than 5 months before giving evidence. He said he was not required to read the manual when he was trained, even though he had also signed a letter confirming that he had in fact read the manuals for the XPR series. At the time of giving evidence, he was unaware of the torque table and the full extent of the lift maintenance requirements within the installation and operation manual, notwithstanding the fact that tightening of gear ring bolts was considered by all relevant witnesses, to be critical to the safety of the vehicle lift. That employee was said to be presently employed by Liftmaster and Liftmaster was said to presently install and service Bendpak lifts. ”

    Source location

    Ashley Michel Bullard · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent communication of manual use and gear ring bolt responsibilities to lift owners

    Wider context from the report

    “1. There was little evidence of consistent practice amongst Liftmaster workers regarding informing the owners of vehicle lifts of the need to read the installation and operation manual, or in highlighting the important parts of the manual such as the need to tighten gear ring bolts. Liftmaster workers were not always aware that ‘the tightening a ‘safety-critical’ component such as gear ring bolts, were the customer’s responsibility, and hence that was not communicated to customers. ”

    Source location

    Ashley Michel Bullard · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Kenneth Roy Bardsley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of formal minimum qualification standards for lift engineers

    Wider context from the report

    “1. The inquest heard that there are no formal requirements for a minimum standard of qualification for people to be lift engineers. In effect, anyone can advertise themselves as a lift engineer/maintenance company; ”

    Source location

    Kenneth Roy Bardsley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. London (East)

    AI-generated summary

    Joseph Allison · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joseph Allison died after the upper trunnion assembly of his Minivator 2000 stairlift failed, throwing him down the stairs and causing cervical vertebrae and head injuries. He subsequently died from bronchopneumonia. Concerns included inadequate training and equipment for service engineers, the absence of a nationally publicised safety recall, and insufficient communication to the stairlift industry about the risks of unimproved stairlifts.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to train in-house service engineers to recognise the Minivator 2000 defect

    Wider context from the report

    “(1) In-house service engineers have not been specifically trained to be aware of the defect in the Minivator 2000, nor issued with feeler gauges to implement the appropriate safety check ”

    Source location

    Joseph Allison · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind manufacturing members to continue providing field-safety training until affected products are traced and necessary action is taken.

    Verbatim wording from the response

    “1 and 2 - we are satisfied that Handicare has adjusted internal process and training to ensure that appropriate training is provided to the in-house engineers on an ongoing basis. BHTA will remind all its manufacturing members that if training is necessary to address a field safety issue the training must continue to be provided until such time as all the products have been traced and the necessary action taken.”

    Source location

    2015-0103-Response-by-BHTA
    Page 1 · response
    Published 23 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train service engineers to identify the defect, use feeler gauges for trunnion inspections, and check recall batch serial numbers, including through new-starter induction.

    Verbatim wording from the response

    “Handicare engineers have been made aware of the potential defect, issued with feeler gauges and have received a face to face briefing with regard to its use to carry out a trunnion inspection as detailed in Bulletin 66. The content of Bulletin 66 has also been issued to them.”

    Source location

    2015-0103-Response-by-Handicare
    Page 2 · response
    Published 23 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Handicare's adjusted internal processes and ongoing engineer training are considered sufficient to ensure appropriate training.

    Verbatim wording from the response

    “1 and 2 - we are satisfied that Handicare has adjusted internal process and training to ensure that appropriate training is provided to the in-house engineers on an ongoing basis. BHTA will remind all its manufacturing members that if training is necessary to address a field safety issue the training must continue to be provided until such time as all the products have been traced and the necessary action taken.”

    Source location

    2015-0103-Response-by-BHTA
    Page 1 · response
    Published 23 March 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026