Abstract: At approximately 5:30 a.m. on November 19, 2007, Employee #1, a machinist, was in a machine shop using a 0.5-ton underslung electric hoist to move a utility access cover from a drilling station to the floor. The access cover consisted of an iron ring and two, inner and outer, iron covers with total weight of approximately 770 lbs. The hoist consisted of a steel I-beam jib with a hoist motor and jib that slid along the beam. The jib was attached to a structural member of the building at a swivel bearing, the lower-bearing mount. It was also supported by a steel pendant bar that was attached to the building's structure at another swivel bearing, the upper-bearing mount. After drilling the holes in the covers at the drilling station near the hoist, Employee #1 secured the access cover to the hook of the hoist using a shop-made attachment and began to move it off of the drilling station. He moved the access cover to where he was to place it on the floor when the upper-bearing mount failed. It allowed the hoist jib to fall, and the access cover dropped on Employee #1's feet. Employee #1's toes on his feet were amputated, and he was hospitalized. California Department of Industrial Relations determined that the hoist was not properly maintained and the upper-bearing mount was significantly worn out.