The Tokyo District Court on May 11 found Mr. Toshihiro Kobayashi, former president of gas water heater maker Paloma Industries Ltd., and Mr. Wataru Kamatsuka, former chief quality control officer of the company, guilty of causing the death of an 18-year-old university student and the injury of his brother in a Minato Ward, Tokyo, apartment in November 2005 by carbon monoxide poisoning.

Although their sentences were suspended, the ruling is rare and significant. The company officials were found guilty of professional negligence resulting in death and injury, not because of product defects, but because of their failure to take sufficient safety measures to cope with maintenance service providers’ prevalent practice of deliberately deactivating the safety devices of gas water heaters.

Seven types of Paloma gas water heaters sold in and after 1980 often failed to ignite. To ensure ignition, maintenance service providers deliberately deactivated the safety devices; deactivation led the heaters to operate with exhaust fans off.

The court determined that 15 people died of carbon monoxide poisoning in 13 cases between 1985 and 2001 in which safety devices were improperly altered. Because the two officials were aware of 12 of the 13 cases and 14 of the 15 deaths, and because there was a strong possibility that improperly modified heaters continued in use, the two officials were in a position to be able to predict the occurrence of fatal accidents, the court said.

The court ruled that the two failed to warn consumers about the dangers and to check and recall all products as needed and that this negligence caused the death and injury in the November 2005 accident — the only case in which the statute of limitations for professional negligence had not expired.

The ruling is a strong reminder to company executives that they must put priority on protecting consumers and never cut back on safety measures. The government, on its part, must improve the Consumer Agency’s system of collecting information on accidents involving products and publicizing them to alert both consumers and makers.

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