Inspection Detail

Inspection: 1457595.015 - Alfred Conhagen Inc. Of California

Inspection Information - Office: American Canyon District Office

Investigation Summary

At 1:00 p.m. on January 23, 2020, an employee and a coworker were moving a 3,700-pound, 7 feet by 4 feet by 3.5-inch steel heat exchanger head plate about 20 feet from the machine shop welding area to an aisleway to be staged for painting. The team rigged the plate to the hook of a 5-ton capacity Kone Model UN1441F Bridge Crane using a Tuflex EN150 by 20-foot polyester sling. The sling was placed in a continuous loop around the 4-foot end of the plate, through notches in the edges and around a rectangular 6-inch by 6-inch tab that was centered on the 4-foot end. The plate was supported by two 41-inch by 36-inch work stands prior to attempting the lift. The employee and coworker attempted to lift the plate using a shorter sling and when they lifted the plate a few inches it began to tilt. They lowered it back onto the stands, obtained the Tuflex sling and arranged it on the plate as described. The team lifted the plate a few inches to check the load balance and adjusted it 2 to 3 times until it appeared to be in balance. The employee removed the work stands from underneath the load and moved them approximately 20 feet away to the new location where the plate would be set down. The coworker was operating the crane using a suspended pendant control, standing on the trailing end of the plate. The employee had moved the stands and began moving the plate by moving the bridge a few feet South before moving it West with the trolley control. The employee started to rotate the leading edge of the plate clockwise on the hook by grasping the corner of the plate to guide it through the gate opening in the welding area fence. As the plate started to turn it became unbalanced when the sling slipped in the crane hook causing the plate to tilt, the sling became slack on the leading end of the plate and the sling slipped off the tab and fell onto the lower right leg of the employee pinning him beneath it. The employee's leg was crushed, requiring hospitalization and amputation.

Keywords: Amputated, Amputation, Crane, Crane Hook, Crane Load, Crushed, Falling Object, Heat Exchanger, Hoist, Hoisting Mechanism, Hoistline, Lack of Work Procedures, Leg, Machine Shop, Marking, Material Handling, Misjudgment, Misjudgment of Hazardous Situation, Pinned, Rigging, Sling, Slip, Steel Plate, Struck By, Welder, Welding