Albert Mason was found collapsed in his council flat in March, less than two months after council plumbers fitted a warm air unit in his kitchen.
Carbon monoxide was circulating through the flat because a fresh air duct and a sealing plate on the system had not been properly fixed.
The director of Labour-controlled Manchester's direct works department, Penny Badcoe, resigned after publication of the report, which found dangerous faults left in many of the 1,840 homes where the department was replacing obsolete heating systems at a cost of pounds 1.6m.
Some newly-fitted units incorporated the same dangers discovered in Mr Mason's flat at Hendham Vale. Others had loosely supported flues, unsafe joints on flue pipes, or poor ventilation to the gas heaters. Tape had been used instead of screws to fix connections, old electrical circuits had not been re-wired, and manufacturers' installation instructions had been ignored.
The council's plumbers had not been trained to do the job. 'Warm air systems were unfamiliar to almost the entire labour force - their experience had been on 'wet' systems associated with conventional radiators,' the report, by Arthur Sandford, the council's chief executive, said. Many workers were told they could 'pick it up as they went along'. Consequently, only about one in 10 new systems had been fitted safely.
Up to 70 council employees may be subject to disciplinary action, and some plumbers may have suffered long-term industrial illness. The report said asbestos lagging on old heating units was removed by some workers without proper training or supervision.
But inadequate records did not reveal where workers were deployed. The council still does not know who installed the heater at Mr Mason's flat. 'Something has gone dreadfully and seriously wrong with the direct works department,' Graham Stringer, the council leader, said.
An audit of heating systems in Manchester council housing is expected to begin soon. Ms Badcoe took up her post in March 1992, shortly before replacement work began. Her resignation was 'her decision and hers alone', Mr Stringer said.Reuse content