Abstract: On March 19, 2009, Employee #1 was working at a power plant operating and maintaining chillers, boilers, medical air systems, for a hospital. He was assigned to work on a York chiller, Model Number 29168C, to close it off by placing back the cover plate of the chiller. Employee #1 and two coworkers were trying to close off the chiller by placing the condenser head back on. Employee #1 was having an issue with the studs that are on the chiller, because some of the studs were bent. He decided to use a Westward portable hydraulic engine crane-hoist to carry the approximately 700 pound cover plate. He was not trained on how to use this equipment. They were unable to use the chain hoist due to not having enough room to place it properly above the chiller. They had a difficult time extending the outriggers of the engine hoist due to the base of the chiller. Employee #1 extended the arm further than the outriggers and placed his weight on the left side of the crane-hoist by placing his feet on top. He lost his concentration and removed his weight. The engine crane-hoist tilted up, and the cover plate that was being held by the boom went forward and fell on top of his left ankle, pinning it to the floor. Employee #1 was hospitalized with a fractured foot.