Inspection Detail

Inspection: 310100284 - Schindler Elevator Corporation

Inspection Information - Office: Foster City District Office

Investigation Summary

Approximately 2 pm on April 29, 2011 a reportable injury occurred at 1501 Page Mill Rd. in Palo Alto the injury was timely reported by the employer. The injured Employee #1, an apprentice elevator mechanic was working with a foreman and mechanic for the installation of a new hydraulic elevator into a 3 level office building. There were two personnel assigned to the crew for this installation. At the time of the accident the foreman was at the bottom of the hoist way about 19 feet below the landing where Employee #1 was working near the hoist way opening on level 2. Prior to and at the time of the accident, the workers were in the process of lowering equipment, tools and materials into the hoist way by use of a pulley which the foreman had installed at the top of the hoist way and a capstan motor installed at the base of the shaft with a hoist line and shackle. The materials to be lowered included six, sixteen-foot metal elevator rails. Employee #1 would attach the end of the hoist line to the leading end of the rail through a hole in the rail end and then manually lift the trailing end and walk it forward while straddling it as the foreman ran the capstan motor until the trailing end cleared the landing at the 2nd floor level, at which point the rail was then lowered down to the bottom. Employee #1 experienced difficulty untying the first rail they lowered because the shackle in the end of the 16 ft. rail was 3 ft. below the edge of the hoist way 2nd level landing when it reached bottom, requiring him to reach down into the hoist way to disconnect it. He next utilized some 1/2 inch nylon rope to extend the hoist line length and lifted four more rails in this manner which allowed him to disconnect without leaning into the hoist way, however he was not wearing or using the available fall protection equipment during these lifts. The nylon rope apparently loosened while lifting the final rail, but this occurred before the trailing end had cleared the edge of the 2nd level landing. Employee #1 was about 3 feet from the edge of the hoist way when the leading end of the rail began to drop downward and the trailing end began to shift back into the 2nd level landing. Eventually the trailing end being carried by Employee #1 levered upward as the leading end fell into the hoist way, catapulting him forward and into the hoist way. Employee #1 landed on the concrete floor below, suffering multiple injuries including: broken vertebrae, broken left ankle, broken left tibia and fibula, and a broken pelvis. The foreman for this crew failed to ensure that Employee #1 or himself were using fall protection where exposed to potential falls into the elevator hoist way. The Division concluded that this accident was preventable had the provisions of T8 CCR 1670(a) been followed to ensure the use of fall protection and a serious accident-related violation was issued.

Keywords: HOISTING MECHANISM, ROPE, HEALTH CARE FACILITY, SHACKLE, EXCAVATOR, FALL