Inspection Detail

Inspection: 310100094 - Star Elevator, Inc.

Inspection Information - Office: Foster City District Office

Investigation Summary

At approximately 10:30 a.m. on June 14, 2011, Employee #1, a journeyman elevator mechanic, was working alone performing periodic maintenance activities for two overhead traction passenger elevators at a residential condominium building. Employee #1 performed a service sequence that involved inspection, service and cleaning for both units including equipment in the machine room which houses some the hoisting equipment for the elevators. Employee #1 inspected and serviced items on the second unit hoist assembly in the machine room and began servicing the first unit hoist assembly. Components for each hoist assembly include a drive motor, brake and gear assemblies, and a drive sheave which supports and drives four wire cable hoisting ropes which lift and lower the elevator car. Employee #1 used a paint roller to apply lubrication onto the wire ropes by reaching behind a metal guard that partially covered the ropes and allowing the elevator to run while applying the roller to the moving wire ropes. Employee #1 then held a cotton rag in his right hand, reached behind the guard, and applied the rag to the surface of the drive sheave as it turned in order to remove excess oil remaining from the lubrication procedure. The rag became entangled in the drive sheave as it turned and this pulled Employee #1's right hand into the nip point of the mechanism and severed most of three fingers and a portion of the index finger on his right hand. Although there was a disconnect point for each conveyance unit in a separate room where the control circuits for the elevators were located, the units were not deenergized or locked out during this service sequence. Additionally, there were emergency shut-off switches capable of turning off the power to the drive units inside the machine room where the accident occurred. The employer had training in place for lockout/tagout, but specific instructions regarding the procedures to be followed while lubing the ropes or cleaning excess oil from drive equipment for overhead traction elevators were not established or implemented by the employer. The employer holds current license by the State of California as Certified Qualified Conveyance Company, and Employee #1 holds a current State of California license as Certified Competent Conveyance Mechanic. One serious, accident-related citation was issued for violation of T8 CCR 3314(c) for failure of employer to deenergize equipment with moveable parts while performing cleaning and servicing operations on a drive sheave and hoist ropes for overhead traction elevator equipment. One general citation for T8 CCR 3314(g) was issued for the employer's failure to develop and implement a written lockout/tagout program and specific procedures for cleaning and servicing machine room equipment capable of movement

Keywords: AMPUTATED, FINGER, GUARD, LOCKOUT, ENTANGLED, NIP POINT, ELEVATOR