Abstract: On March 13, 2006, Employee #1 was working as a foundry worker. He was hoisting a sand-filled mold box weighing 1,167 pounds and measuring 73 inches by 61.5 inches by 15 inches to an adjacent pallet. The hoisting accessory he was using was built at the shop and was so old that no one knew how old it was or how it came into service at the foundry. It consisted of two hooks attached along a spreader bar. The width of the hooks could be adjusted using a track and a series of notches cut out above the track. The spreader bar lifting apparatus, which measured 109.5 inches in length, had no markings on it to indicate manufacturer, rated capacity, or any other information. Employee #1 had attached one of the hoist's hooks to a trunnion on the mold box on the opposite side from where he was standing. He had some difficulty attaching the hoist's hook on the side closer to him and in securing the hook to that trunnion. Employee #1 had hoisted the cast mold box only a few feet, when it slipped from the hoist and fell on him, amputating three toes on his right foot. He was hospitalized. He believes that, when he struggled with the hook on the side of the box closer to him, he loosened the seat of the hook on the opposite side of the box. There were no direct witnesses to the event.