SINGAPORE - A 58-year-old cleaner working at the Singtel Comcentre in Exeter Road died on March 25 last year after he was wedged between a cargo lift car and the lift landing on the first floor.
The cargo lift was unfit for operation as its fail-safe devices were faulty. Before the incident it was last certified safe for use from November 2013 to April 2014.
On Thursday (Feb 25), State Coroner Marvin Bay found Mr Mak Weng Yeow's death to be "an unfortunate misadventure".
"This case does call to attention the importance of maintaining a scrupulous and thorough regime of inspections and certifications for all passenger, cargo and utility lifts, with special care being taken to ensure that installed fail-safe devices are fully operable," he said.
The coroner's court heard that in the afternoon of the day of the incident, Mr Mak and a colleague, who worked for CSP Maintenance, had collected some trolleys of rubbish from the basement of the building and pushed them into the cargo lift.
Mr Mak then went to the first floor to retrieve the trolleys, to push them to the rubbish collection centre, while his colleague went to collect more trolleys.
At about 4pm, as Mr Mak stepping out of the lift, his colleague, unaware of this, pressed the button to send it back down. Mr Mak was 1.67m tall, while the lift entrance was 1.56m high and 1.52m wide.
When the lift did not come back down shortly after, the colleague went to the first floor, where he saw Mr Mak's body caught in between the lift and the floor. He was unconscious, but breathing.
The lift had two buttons, for moving up and down, and an emergency button, to stop it. The colleague pressed the 'up' button, along with the emergency button, but the lift did not budge.
Rescuers arrived shortly after, but could not detect any signs of life on Mr Mak. The Singapore Civil Defence Force's Disaster Assistance and Rescue Team later extricated his body through a hole they cut on top of the lift car. A paramedic pronounced Mr Mak dead at about 6 pm.
An autopsy found fractures to his spine and ribs, among other injuries.
A technician, who carried out maintenance on the lift two days before the incident, had found that some switches on the basement and first floor, which controlled the external doors of the lift, were not functioning or missing.
These switches, installed at the bottom of the lift's roller shutter on each floor, are safety devices. If any one of the shutters is open, the switch prevents the lift from moving.
But the technician found that the lift could still function when the external shutters were open.
He had found the same faults after a check in December 2014, and reported them to the building management. But no repairs had been done, pending a quotation approval.
Another cleaner, who had been working with Mr Mak at the same building for 20 years, meanwhile said that he never felt completely safe using the lift.
He had experienced the lift descending by itself on two occasions, even though the roller shutters were open. Mr Mak was present both times. They stopped the lift by pressing the emergency button.
Just a month before Mr Mak's death, a 54-year-old security guard working at Singtel's Pickering Operations Complex in Pickering Street died after he fell into a lift pit while trying to prise open the lift doors at a first-storey lobby.