Shaw, Alan Macklin- non-inquest findings
Deceased
Alan Macklin Shaw
Demographics
86y, male
Date of death
2020-09-11
Finding date
2022-10-20
Cause of death
Traumatic Subdural Haemorrhage
AI-generated summary
An 86-year-old man died from traumatic subdural haemorrhage after being struck by a malfunctioning roller door at his apartment complex. While attempting to push a bin into the garage, the remotely-controlled door descended uncontrollably and struck him on the head. Independent forensic engineering analysis identified two critical design flaws: the safety sensor was positioned offset from the door's path and failed to detect the bin obstruction, and the motor continued driving the door downward despite the obstruction, causing the door to unspool from its shaft and fall uncontrollably out of its guide channels. The coroner accepted recommendations for design modifications including repositioning sensors or installing light curtain-type sensors with multiple detection beams, and implementing mechanical safeguards to prevent door movement outside guide channels. This case highlights the importance of comprehensive safety design in automated systems used in multi-residential premises.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Inadequate sensor positioning – offset from door path, failed to detect bin obstruction
- Motor continued driving door downward despite physical obstruction
- Door unspooled from shaft creating uncontrolled falling hazard
- Sensor beam positioned at vehicle wheel height, inadequate for detecting objects at varied heights
- Door pulled out of guide channels in uncontrolled manner
- Lack of preventive mechanical safeguards to stop door movement outside guide channels
- Lack of maintenance – roller door not serviced since February 2019 despite annual requirement
Coroner's recommendations
- Distribute findings to increase knowledge of potential risks of roller doors
- Implement design modification A: reposition sensor in line with door path to detect obstructions directly in closing path
- Implement design modification B: install light curtain type sensor with multiple detection beams for more rigorous detection across height range and within or adjacent to guide channels
- Implement design modification C: install mechanical safety device to prevent door movement outside guide channels, such as sensing device on guide channels to inform control of door closing edge position
- Preferred recommendation: combination of light curtain sensor (Modification B) with mechanical safeguard to prevent unspooling (Modification C)
- When designing roller door systems, consider highest-risk scenarios including small children, not just common use cases like vehicles
- Ensure regular maintenance and servicing of roller door systems in multi-residential premises
Full text
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