11 Jan 2023 Ashley Michel Bullard · Prevention of Future Deaths report West London
View report summary
Concerns raised 16 Excessive tolerated freeplay in 2-post vehicle lifts View source Failure to ensure engineers read and understand the lift manual View source Failure to keep lift inspection, maintenance and repair records View source Uncertainty about suitability of narrow vehicle lift points for frame contact pads View source Inconsistent communication of manual use and gear ring bolt responsibilities to lift owners View source Failure to maintain and verify required clearance around vehicle lifts View source Failure to require vehicle technicians to read the lift manual View source Failure to ensure lifts are maintained in accordance with manufacturer recommendations View source Lack of warnings about using outermost vehicle lift points View source Lack of clear gear ring bolt specifications in the installation and operation manual View source Failure to obtain confirmation that suppliers received all operational manuals View source Lack of consistent British Standards for tolerated freeplay in 2-post vehicle lifts View source Failure to ensure replacement of grade 4.8 gear ring bolts in existing lifts View source Lack of clear allocation of lift maintenance responsibilities View source Designation of unsafe outer vehicle lift points for 2-post lifts View source Lack of warnings about dangers of outermost lift points View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Excessive tolerated freeplay in 2-post vehicle lifts
Wider context from the report “1. Evidence was given that it could be possible to reduce the degree of freeplay in the Bendpak 2-post vehicle lifts. Given lift points positioned close to the edge of the vehicle may be in danger of allowing lifting pads / frame contact pads on the Bendpak XPR9 2-post vehicle lift and possibly other similar 2-post lifts, to move from a position under the structure of the vehicle, to a non-structural part of the vehicle, with a risk of the car leaving the vehicle lift, it appears the level of tolerated freeplay creates a risk of injury or death to those operating the lift .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to keep lift inspection, maintenance and repair records
Wider context from the report “2. There was no evidence that Wheel Art Ltd ever kept records of inspections, maintenance, or repair of the Bendpak XPR9 lifts in accordance with the Bendpak XPR9 installation and operating manual. Again, whilst Wheel Art Ltd may now use different vehicle lifts, this concern is not focussed on the make or model of lift but on the maintenance of relevant records.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about suitability of narrow vehicle lift points for frame contact pads
Wider context from the report “2. It is unclear whether a narrow vehicle lift point is suitable for 2-post vehicle lifts using frame contact pads , or whether a better fitted lifting pad adaptor is available. Evidence was provided by an HSE expert engineer, that some form of slotted vehicle lift pad would be better suited when using a 2-post vehicle lift to raise a car by way of the narrow outer lift points that are more often used with vehicle jacks.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain and verify required clearance around vehicle lifts
Wider context from the report “3. Photographs suggested the clearances recommended by the manufacturer, between the lift posts and the nearest obstruction, were not maintained at the time of the incident. Those clearances were said to be 13 feet at the front of the lift, 11 feet at the rear of the lift, and 5 inches from the sides to the nearest wall. Photographs taken very shortly after the incident, disclose the presence of a different vehicle within just a few feet of the rear of the lift used by Ashley in a neighbouring XPR9 vehicle lift / lift bay. It is unclear to what degree the recommended clearance requirements within the manufacturer’s installation and operating manual were considered or adhered to at installation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to require vehicle technicians to read the lift manual
Wider context from the report “1. There was no evidence that Wheel Art Ltd ever required vehicle technicians operating the Bendpak XPR9 lift, to read the installation and operating manual or to maintain the lift in accordance with the manufacturer’s recommendations. I am informed that Precision no longer owns any Bendpak XPR9 lifts, but instead uses Hoffman scissor lifts. This concern is not focussed on the make or model of lift but the use of lift operating manuals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure lifts are maintained in accordance with manufacturer recommendations
Wider context from the report “1. There was no evidence that Wheel Art Ltd ever required vehicle technicians operating the Bendpak XPR9 lift, to read the installation and operating manual or to maintain the lift in accordance with the manufacturer’s recommendations . I am informed that Precision no longer owns any Bendpak XPR9 lifts, but instead uses Hoffman scissor lifts. This concern is not focussed on the make or model of lift but the use of lift operating manuals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about using outermost vehicle lift points
Wider context from the report “3. There are no warnings on the Bendpak XPR9 2-post vehicle lift or in its installation and operation manual , that suggests caution or a prohibition on using a 2-post vehicle lift in conjunction with the outer most lift points on the underside of vehicles, that may be positioned on or near the sill or seam of the vehicle and often within a few inches from a non-structural part of the vehicle for lifting purposes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear gear ring bolt specifications in the installation and operation manual
Wider context from the report “6. The specification of the grade and size and torque settings of gear ring bolts provided by Bendpak prior to installation was not sufficiently clear within Bendpak’s installation and operation manual , and appeared to cause confusion amongst engineers tasked with installing the lift and those required to service or maintain the lift.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain confirmation that suppliers received all operational manuals
Wider context from the report “4. At the point of providing suppliers / installers with the lift, Bendpak did not require any form of written confirmation of acknowledgement that suppliers received all manuals that Bendpak intended to provide, and considered important to the operation of the lift.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent British Standards for tolerated freeplay in 2-post vehicle lifts
Wider context from the report “1. There appear to be no British Standards for the safe, acceptable and/or tolerated degree of travel or length of travel in terms of freeplay in 2-post vehicle lifts in the UK . Whilst evidence was provided by the HSE that the industry body SAFed suggested an acceptable degree of freeplay is the diameter of the vehicle lift’s frame contact pad, it is noted that various 2-post vehicle lifts have different diameter pads, and hence there is no consistency in the amount of freeplay tolerated in 2-post vehicle lifts . It was also noted that the diameter of pad in the present case, at 130mm, could allow a frame contact pad, to move from a position underneath the structure of a vehicle, to a position under a non-structural part of the vehicle, which can cause the vehicle to leave the lift. An HSE engineer’s expert evidence was that it might be more sensible for tolerated freeplay to not exceed half the diameter of the frame contact pad.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure replacement of grade 4.8 gear ring bolts in existing lifts
Wider context from the report “5. There was no evidence as to whether all Bendpak XPR9 2-post vehicle lifts with grade 4.8 bolts had been recalled or whether grade 4.8 bolts had been replaced in all existing XPR9 lifts, nor any evidence as to what efforts had made to contact customers that might still have such lifts in operation , in order to replace grade 4.8 bolts in lifts manufactured after 01.01.2014.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear allocation of lift maintenance responsibilities
Wider context from the report “7. It is not clear within Bendpak’s installation and operation manual as to which components and bolts in particular, are the subsequent lift owner’s responsibility to maintain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Designation of unsafe outer vehicle lift points for 2-post lifts
Wider context from the report “1. Volvo (and/or other manufacturers) appear to designate lift points towards the edge of vehicles , that are near, on, or outside the sill or seam of the underside of the vehicle. Lift points in a position so close to the edge of a vehicle frame, appear to be in danger of allowing frame contact pads on a Bendpak XPR9 2-post vehicle lift, and possibly other similar 2-post vehicle lifts, to move from a position under the structure of the vehicle, to a non-structural part of the vehicle, due to tolerated freeplay within the vehicle lift, leading to a risk of the car leaving the vehicle lift. Whilst multiple lift points are identified in manuals and/or on Autodata, no warning is given with regards to any danger of using 2-post vehicle lifts on the outer most lift points.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about dangers of outermost lift points
Wider context from the report “1. Volvo (and/or other manufacturers) appear to designate lift points towards the edge of vehicles, that are near, on, or outside the sill or seam of the underside of the vehicle. Lift points in a position so close to the edge of a vehicle frame, appear to be in danger of allowing frame contact pads on a Bendpak XPR9 2-post vehicle lift, and possibly other similar 2-post vehicle lifts, to move from a position under the structure of the vehicle, to a non-structural part of the vehicle, due to tolerated freeplay within the vehicle lift, leading to a risk of the car leaving the vehicle lift. Whilst multiple lift points are identified in manuals and/or on Autodata, no warning is given with regards to any danger of using 2-post vehicle lifts on the outer most lift points .
” Open source report
10 May 2016 Peter William RICHARDSON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to record lift tolerance levels for comparison by subsequent examiners View source Failure to record vehicle-lift operator training View source Failure to ensure lift users are appropriately competent to maintain the lift View source Lack of formal guidance on safe tolerances for safety-critical elements of two-post lifts View source Failure to provide guidance on required torque for safety-critical elements of Bendpak two-post lifts View source Use of foreign objects between two-post lift pads and vehicles during lifting View source Failure to provide guidance on safe tolerance levels for supplied two-post lifts View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter William RICHARDSON · 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
On 27 September 2015, Peter William Richardson was working beneath a car on a two-post vehicle lift when the car became dislodged and fell onto him, causing fatal head injuries. The substantive concerns included the absence of formal guidance on safe tolerances and torque levels for safety-critical lift components, inadequate recording and training arrangements, and the practice of placing foreign objects between lift pads and vehicles to provide clearance.
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. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record lift tolerance levels for comparison by subsequent examiners
Wider context from the report “c) Safe tolerance should be considered at a LOLER ‘Thorough Examination’ however there is no guidance to be followed and there is no requirement for such tolerance levels to be recorded and as such the levels are not available to any subsequent examiner .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record vehicle-lift operator training
Wider context from the report “d) Mr Richardson who operated the lift only received training on the specific lift at the point it was installed in 2012. All other users were subsequently trained by him in its use, which was not recorded and all users of the lift were expected to maintain the lift properly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure lift users are appropriately competent to maintain the lift
Wider context from the report “d) Mr Richardson who operated the lift only received training on the specific lift at the point it was installed in 2012. All other users were subsequently trained by him in its use, which was not recorded and all users of the lift were expected to maintain the lift properly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of formal guidance on safe tolerances for safety-critical elements of two-post lifts
Wider context from the report “a) No formal guidance exists as to safe tolerances of safety critical elements of two-post lifts . The Court heard from two HSE witnesses and a ‘Thorough examiner’ who examined the lift for the purposes of complying with LOLER 1988, who gave differing views on what was a safe tolerance or ‘play’ for an extended lift arm . Further, it was accepted that this was an issue of concern to the HSE, but as yet remained to be dealt with.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on required torque for safety-critical elements of Bendpak two-post lifts
Wider context from the report “b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not supply guidance as to the required torque for safety critical elements of their two-post lifts and neither do they provide guidance on safe tolerance levels.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Use of foreign objects between two-post lift pads and vehicles during lifting
Wider context from the report “e) It is a known practice for a variety of different objects (for example a piece of wood) to be placed on top of the lift pads between the pad and the vehicle when it is lifted in order to provide clearance and to assist with difficult jobs such as removing a car under-shield.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Liftmaster Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide guidance on safe tolerance levels for supplied two-post lifts
Wider context from the report “b) The supplier of the Bendpak Lift in the UK, Liftmaster, do not supply guidance as to the required torque for safety critical elements of their two-post lifts and neither do they provide guidance on safe tolerance levels .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations