Inspection Detail

Inspection: 313147605 - Oracle Elevator Company

Inspection Information - Office: Columbus Area Office

Investigation Summary

At approximately 8:07 a.m. on April 13, 2009, Employee #1 and a coworker were tasked to remove the wooden raised panels from inside of the elevator cars in a bank of three elevators next to each other. While removing the wooden panels from elevator car Number 1, it was noted that something was holding the panel in place from outside of the elevator car. While one worker continued to work inside the car, Employee #1 was going to enter the elevator hoist way to see what was holding the panels in place. To gain entrance to the hoist way pit, Employee #1 had to enter the hoist way for car Number 2. Employee #1 sent elevator car Number 2 up to a holding position. Employee #1 than opened the hoist way doors and hit what he thought was the pit switch for elevator Number 2. Employee #1 then stepped onto a fixed ladder inside of the elevator pit. While Employee #1 was standing on the ladder, the hoist way doors closed and power was restored to elevator Number 2. When the power was restored, the elevator car descended and pinned Employee #1 between the ladder and elevator car. Investigation revealed that the pit switch that had been turned to the "off" position was for elevator car 1 and not for elevator car 2. The pit switch for car 2 was located on the right side of the hoist way. The employees did not lockout the elevators prior to entering the hoist way. The company also had not identified the elevator hoist ways pits as confined spaces. Employee #1 was killed.

Keywords: PINNED, LADDER, LOCKOUT, CRUSHED, ELEVATOR, ELEVATOR SHAFT