Abstract: At approximately 1:00 p.m. on July 21, 1999, Employee #1, of the Otis Elevator Company, and a coworker were in a false car at the top of an elevator shaft, stringing six hoist cables between the counterweights, elevator car, and over the hoist motor pulley. When they had finished, they released the slings holding the counterweight at the top of the shaft, tensioning the hoist cables. The counterweights did not stop when the cables were tensioned but continued down the elevator shaft, gaining speed. As the counterweights moved down, the elevator car, which was only a framework, was going up the shaft. The top of the elevator car went through the bottom of the false car from which the employees were working. The coworker jumped off the platform onto the adjacent floor, but Employee #1 became caught on the platform and was pinned against the ceiling of the shaft. It took the local fire department over an hour to extract him. Employee #1 was then taken to the UC Davis Medical Center, where he was hospitalized with a fractured leg. The counterweight was found to be heavier then the elevator car frame, and it did not have a safety choker to prevent a runaway. The braking system on the hoist motor was not properly adjusted upon installation of the brake shoes, which were not in contact with the brake drum.