A woman died from a severe head injury last year in an accident involving a lift-like hoist structure which the state coroner found had not been tested by an authorised examiner.
Made up of a cage lifted by an electric chain hoist, the system was used to move items between a storage area on the mezzanine level and a food packaging area on the first storey of a building in Admiralty, where the accident took place.
The system was not compliant with Workplace Safety and Health (General Provisions) Regulations, said State Coroner Kamala Ponnampalam last Friday.
In an inquiry into Madam Zarimah Mohamad's death, the coroner noted that every hoistway used in a workplace must be protected by a "substantial enclosure fitted with gates".
When shut, such gates would "prevent any person from falling down the hoistway or coming into contact with any moving part of the hoist", said the state coroner, who ruled Madam Zarimah's death to be an "industrial misadventure".
The 57-year-old accountant was working for catering company Thyme Food and Services at FoodXchange@Admiralty when the incident occurred on June 25 last year.
Madam Zarimah had accompanied a colleague, Ms Chan Sook Chun, to the hoist system - also referred to as a "cargo lift" - at their Admiralty Street workplace to remove from it several items, including a warmer and a thermal box.
After the women removed the items, they found that the cargo lift was stuck. Ms Chan then stomped on the lift in a bid to get it to move. But it did not move. Both women were still in the lift when it abruptly dropped.
Ms Chan immediately shouted for help and a deliveryman who was nearby helped to call the police. Madam Zarimah was pronounced dead at 4.40pm that day.
The state coroner ruled that Madam Zarimah was killed after she fell and her head got caught between the frame of the cage and the lift landing.
Thyme Food and Services account director Hee Kok Hwa had said that the hoist was already present when he leased the premises, and that it was meant only for cargo use.
Last Friday, the state coroner said the company did not establish any safe work procedures for the operation of the hoist system.
The firm did not provide formal training on its use, although employees had been briefed not to use it to travel between the two floors.
The state coroner said: "Following this incident, MOM (the Ministry of Manpower) has issued an industry-wide advisory to alert to the hazards of an uncertified hoist system and the lack of appropriate maintenance. The need for specific risk assessment was also highlighted."
Thyme Food and Services has since removed the cargo lift with the hoist system and sealed up the shaft. It has also relocated its storage facilities to the ground level.