Coronial
QLDother

Jones, Katherine Alison

Deceased

Katherine Alison Jones

Demographics

54y, female

Date of death

2005-12-10

Finding date

2006-12-04

Cause of death

Severe multi trauma due to gate falling on deceased

AI-generated summary

Katherine Alison Jones, a 54-year-old cleaner, was fatally crushed by a 900kg automatic sliding gate that fell from its track at a shopping centre on 10 December 2005. The gate had a broken safety stop that had not been repaired, and the control system failed to detect the gate's position after the motor was forcefully manipulated by security staff the previous night. The security officer who manipulated the gate did not test its operation afterwards or warn of the malfunction. Key preventable factors included: inadequate design of temporary extension arms and safety stops, lack of regular inspection protocols, failure to warn of known defects, and lack of proper staff training. The coroner found no criminal negligence but recommended national standards for automatic gates, mechanical backup systems for electronic failures, and mandatory maintenance registers.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Error types

systemproceduralcommunication

Contributing factors

  • Lack of safety stop to prevent gate travelling beyond supported position
  • Safety stop on eastern gate had broken off and was not repaired
  • Absence of regular inspection system that would have detected missing stop
  • Gate control system not programmed to sense gate positions, relied on rack and pinion engagement
  • Electric motor malfunction caused by forceful manipulation with steel pipe by security officer
  • Security officer failed to test gate operation after manipulation
  • Security officer failed to place warning or danger tag on defective gate
  • Design and attachment of extension arms and metal stops were inadequate and temporary
  • Extension arms and stops not installed in accordance with manufacturer instructions
  • No proper structural or safety assessment was conducted
  • Absence of danger tag or warning system for malfunctioning equipment
  • Access to motor control box by non-qualified persons without proper training
  • Employees not properly trained on procedures for gate malfunction

Coroner's recommendations

  1. A copy of these findings be sent to the Australian Building Codes Board
  2. An appropriate standard for automatic sliding gates should include provisions of stops including a central stop where gates meet at a central point on all sliding gates as a safety feature to be incorporated in design and manufacture
  3. All electronically operated gates above a minimum weight should have some form of mechanical backup system so that in the event of any electronic malfunction the gates do not have to be moved manually in order to operate
  4. The occupier of premises be required by legislation including WorkCover to keep and maintain a register of malfunctions of any automatic sliding gates
  5. On a regular basis certification from a suitably qualified person that the gates have been inspected and are in good working order be required

Further listening

Coronial podcast — Episode 52

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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