Inquiry into the fire at 58 Surveyor Street
Demographics
male
Date of death
2014-12-04
Finding date
2017-06-30
Cause of death
Ignition of liquid petroleum gas pooled in bedroom by cigarette lighter
AI-generated summary
Mr Bowdi Latham suffered catastrophic 75% total body surface area burns when LPG pooling in a bedroom ignited from a lighter on 4 December 2014. Investigation revealed an open copper gas pipe in the granny flat had been disconnected from a heater by unknown prior tenants. The gasfitter, Mr David Williams, conducted a defective pressure test that failed to detect this critical safety hazard before certifying the installation. He did not gain access to the interior of the premises to inspect appliances as required by regulation, making assumptions based on a 30-year-old compliance plate. The property agent, Mr Andreas Haas, failed to identify the open pipe during pre-tenancy inspections despite previous photographs showing the heater location. The explosion was preventable through proper inspection and certification procedures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Open non-standard 3/8 inch copper gas pipe with no seal or stop mechanism
- Failure to inspect gas appliances before certification
- Defective pressure test that did not comply with Australian Standard
- Failure to gain access to interior premises for mandatory inspection
- Assumptions based on 30-year-old compliance plate rather than current inspection
- Property agent failure to identify open pipe during pre-tenancy inspection
- Removal of gas heater by previous tenants without rendering pipe safe
- LPG gas pooling at floor level below resident's awareness
- Possible desensitization to gas odour from smoking and occupational exposure
Coroner's recommendations
- Department of Fair Trading consider applying new Australian Standard AS5601-2013 to all new gas installations in NSW
- Department of Fair Trading issue advice to Licensed Plumbers and Gasfitters emphasising need to strictly comply with Gas Supply (Consumer Safety) Regulation 2012, particularly stressing need to physically inspect gas installation in addition to pressure testing before certification
- Department of Fair Trading advise letting agents through Real Estate Institute of NSW of need to carefully inspect properties for hazards including gas hazards, with consideration to amending inspection records to prompt recording of potential hazards
- Department of Fair Trading sponsor amendment to Clause 28(a) of Gas Supply (Consumer Safety) Regulation 2012 to require gasfitters to inspect (not just test) the whole gas installation as defined
- Department of Fair Trading consider options to mandate periodical testing of pressure test equipment such as manometers to ensure continued accuracy and calibration
- Department of Fair Trading ensure gasfitters are using most recent LP Gas Certificate of Inspection and consider amending form to require identification of type and duration of pressure test performed and pressure used
- Minister for Regional NSW, Skills and Small Business review Certificate III in Gasfitting course to ensure compliance with legislation and Australian Standard are emphasised, particularly understanding what certification of gas installation entails and strict compliance with Regulation
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