Abstract: At 11:25 a.m. on February 9, 2008, a full-time employee and three coworkers were working in Santa Barbara, CA. Using a shop-fabricated hoisting device, they were moving a compressor to a shipping area for shipment. The device had two uprights, an eight inch I-beam 20 feet long, two chain falls, two trolley rollers, and two nylon slings. The employees placed the slings underneath the compressor and attached the ends of the slings to the chain falls. They lifted the compressor approximately two inches from the concrete floor and then started pushing and pulling the compressor horizontally to place it on a pallet. There was a two-inch pipe protruding from the concrete floor that was in the way. To get the compressor past it, the employees moved the compressor off to the side. When they did, the hoisting device became unbalanced and tipped over on the employee and one of his coworkers. The I-beam struck the employee and fractured his leg.