Inspection Detail

Inspection: 125836197 - Sierra Pacific Industries

Inspection Information - Office: Sacramento District Office

Investigation Summary

At approximately 11:00 a.m. on October 11, 1998, Employee #1, a millwright with Sierra Pacific Industries, was repairing a hydraulic ram on the breakdown hoist on the outside feed to a planer. To disconnect the hydraulic ram, he raised the breakdown hoist into a vertical position, disconnected the power, and removed one of the two hydraulic rams that operated the hoist. He then opened the hydraulic fluid drain plug to relieve the pressure and thus be able to retract the extended rams. After replacing the leaking seals, Employee #1 tried to extend the hydraulic rams. The vacuum pressure was too great, and he loosened the end drain plug to allow the air to escape. Employee #1 was then able to extend the ram to a position only 1/4 in. short of being able to make the connection. The supervisor working with him called a forklift to the area to push on the breakdown hoist to close the gap. During reconnection of the ram, Employee #1 was standing on the underside framework of the hoist. When the forklift applied pressure to the vertical hoist table, it fell back to the sloped position, pinning Employee #1 against the table extension. He sustained a fractured pelvis and compression injuries to his torso. Paramedics administered first aid before Employee #1 was transported by ambulance to Sutter Roseville Hospital, where he was admitted for treatment. No attempt had been made to block or secure the breakdown hoist from inadvertent movement, or to limit such movement.

Keywords: CHOCK, FRACTURE, REPAIR, HOISTING MECHANISM, UNSECURED, PINNED, WORK RULES, MILLWRIGHT, PELVIS, UNSTABLE POSITION