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The recent revelation that 21 people have died of carbon-monoxide poisoning caused by malfunctioning gas water heaters points to a lack of awareness and slow action on the part of the parties involved — the manufacturer and its parent company, Paloma Industries Ltd. and Paloma Co., the Ministry of Economy, Trade and Industry, and the police.

The 21 who died were among more than 50 people affected in 27 incidents of carbon-monoxide poisoning that took place in Hokkaido, Akita, Nagano, Tokyo, Kanagawa, Osaka, Nara, Fukuoka and other prefectures between 1985 and 2005.

The ministry didn’t go public with news of the cases until July 14, when Paloma Co. held its first news conference. Illegal modifications of the products, possibly by installers in many cases, are believed to have led to 15 of the 27 malfunctioning incidents. On July 19, Paloma firms placed ads in newspapers stating that they would examine, repair or recall the types of gas water heaters involved.

The gas water heaters in question were manufactured from 1980 through 1989, and about 260,000 were sold. A fan on the heaters is designed to draw air from inside the building and expel exhaust fumes outside. When ventilation is inadequate, a safety device is supposed to automatically stop the burning of gas.

The ministry acted only after the Metropolitan Police Department this month asked it to provide information on carbon-monoxide poisoning cases involving Paloma gas water heaters. The ministry checked its records between 1985 and 2005 and found that many incidents attributable to malfunctions of the water heaters’ exhaust fans occurred during that period. It explained that although it had been aware of individual cases, it had not drawn a connection among them.

The MPD was investigating the death of an 18-year-old university student who died from carbon-monoxide poisoning in a condominium in Minato Ward, Tokyo, on Nov. 28. It found that the safety device of the gas water heater installed in the condominium, which measures the temperature of the exhaust fan, had been purposely deactivated. Such a modification allows the heater to operate without the exhaust fan on.

The police may have waited too long to take action. In March 1996, a 21-year-old man was found dead in a condominium also in Tokyo’s Minato Ward. The MPD announced that he had died of cardiac arrest. His mother, who learned of the possibility of carbon monoxide poisoning from a medical examiner, asked the MPD many times to reinvestigate the case. She was told by the MPD early this month that the police now thought that her son may have died of carbon-monoxide poisoning due to a malfunction of a gas water heater.

Inconsistency in the explanations by Paloma Industries has deepened suspicion of whether it was aware of its responsibility as a maker of products whose malfunction could have caused deaths and how well it kept reports on incidents and related communication inside the firm. Paloma originally claimed that the first time it was aware of a death occurring from carbon-monoxide poisoning was in 1991. Later, however, it revised the year to 1987, and still later to 1985. In its first news conference, Paloma seemed to be trying to emphasize that it had no responsibility because the deaths were not caused by defects in its products but by illegal modifications done to them. In some cases, however, age-related deterioration rather than human tampering caused the safety device to malfunction.

An illegal modification of the safety device was found to have caused the first two deaths from carbon-monoxide poisoning, which occurred in Sapporo in 1985. Two years later, a similar cause was attributed to the deaths of two people in Tomakomai, Hokkaido. In 1988, Paloma sent written instructions to its branches throughout the country, prohibiting workers from carrying out modifications that disabled safety devices. It said that if such modifications lead to accidents, those who carried them out may have to take responsibility. But the firm did not alert the public at that point.

Nonetheless, carbon-monoxide poisoning accidents continued. In 1992, when seven incidents resulted in five deaths and injuries to 12 people, Paloma told the then Ministry of International Trade and Industry that it would strictly prohibit modifications of its products and conduct an earnest search for modified products. Paloma also notified the ministry of similar incidents resulting in death in 1997 and 2001. If Paloma and the ministry concerned had alerted the public sooner, many deaths and injuries might have been avoided. A radical change in the attitudes of Paloma employees and ministry officials toward safety is needed, as is a better system to file and utilize accident records. Communication among all the parties involved must be improved.

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