Abstract: At 8:15 a.m. on July 21, 2014, an employee was working for a manufacturer of concrete products. The employee was cleaning dried slurry from a newly manufactured manhole riser. Just prior to the incident, the employee used a Coffing 1,800-kilogram (2-ton) chain hoist to remove the 1,630-kilogram (3,600 pound) riser from its form. The employee used the hoist to raise the riser approximately 1.5 meters (5 feet) from the ground and away from the form. The load was attached to the hoist hook by a lifting device that had been manufactured by the employer. The attachment device utilized two pins that were positioned into lewis holes that were formed by the concrete mold. When fully extended, the pins would seat 75 millimeters (3 inches) within the riser. The bar did not have any type of feature that would indicate to the operator that the pins were fully seated within the riser. Further, the pins did not have any type of locking mechanism. While the load was suspended, the employee left the hoist controls unattended. He moved beneath the riser to clean dried concrete slurry from the bottom. As the employee was working underneath the suspended manhole riser, the load detached. The employee was crushed beneath it. The concrete riser came to rest along the center line of the employee's torso and head. The employee sustained multiple skeletal fractures, internal injuries, head injury, and he was killed. The lifting device had obvious signs of deformity. The main structural member of the device was bent and the hoist hooking point was worn.