BOSTON (AP) – A carnival ride accident that threw a man to his death last month was caused by a chain reaction that started when the safety bar holding the man and his companion in place failed, causing their weight to shift and snapping two bolts.

The state Department of Public Safety released its final report on Friday about the accident that threw Andrew R. Fohlin, 38, to his death and injured two others at a fair at St. Mary’s Parish in Shrewsbury.

The report also said Jaro Amusements Inc., the company that owned and operated the ride, didn’t keep maintenance records which could have pointed to problems with the two bolts, and didn’t perform required maintenance – a claim which a company spokesman denied.

“This tragic accident was completely preventable and never should have happened,” said Public Safety Commissioner Thomas Gatzunis. “We are working with the Worcester County District Attorney’s Office to make sure those responsible are held accountable.”

The accident on the afternoon of Sept. 19 threw Fohlin and David Mills, 48, to the ground during the church fair filled with families. Diane Derosier, 44, suffered minor injuries when she was hit by flying debris. All three lived at a nearby state-run home for the disabled.

Preliminary reports on the accident pointed to the two bolts, but the final report included new details about why they failed.

Investigators found that a nut that secured the lap bar restraining Fohlin and Mills had fallen off, though it was not clear when the nut worked its way off. The bar was supposed to be secured with a locknut; the nut in use did not meet specifications of the manufacturer, Wisdom Manufacturing Co. of Merino, Colo., according to the report.

When the lap bar failed, the weight of the two men – about 350 pounds – shifted to the outside side panel of the car, causing the car to tilt.

The head had been removed from a bolt on the outside panel of the car. When that bolt failed, all the weight in the car shifted to a 3/8-inch bolt on the car’s side. The undersized both then sheared off, flinging Fohlin and Mills from the car, the report said.

Jaro owner Jack Keough also told investigators that the ride did not receive maintenance, and that Jaro could not produce any maintenance records for the ride. Manufacturer specifications indicated that the first nut which failed was supposed to be inspected daily. Without maintenance logs, investigators had no way of knowing if the inspections ever occurred.

Jaro spokesman Alan Ramsay said that the ride had received maintenance, and that the report was wrong in its finding that Jaro had not maintained the car.

He said the report’s blame of Jaro was not surprising, given past comments from public safety officials, but otherwise declined to comment.

“Until we take the time to review this with the owner of the ride and with his attorney as well, it’s very difficult to make comment on this report,” he said.

Worcester District Attorney John J. Conte is using a grand jury to subpoena records in his investigation of the accident. He said about a week ago that his investigation could lead to negligence or even manslaughter charges.

The Department of Public Safety will call Jaro to a hearing by year’s end on whether to suspend or revoke the company’s license to operate carnivals in Massachusetts. Jaro has not operated any carnivals in Massachusetts since the accident, and none are scheduled through the end of the year.

All Sizzlers operating in the state were shut down after the accident, and Gatzunis announced that every mobile carnival ride in the state will be inspected by years’ end, and a task force will look into stricter safety rules. There are 39 mobile carnival companies licensed to operate amusement rides in the state.

The Sizzler fatality was the second amusement ride death in Massachusetts this year. A 55-year-old man with cerebral palsy was thrown from a roller coaster at Six Flags New England in Agawam in May.

AP-ES-10-29-04 1916EDT