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Occupational Safety and Health Administration OSHA

Inspection Detail

Violation Summary
Serious Willful Repeat Other Unclass Total
Initial Violations 1 1
Current Violations 1 1
Initial Penalty $4,000 $0 $0 $0 $0 $4,000
Current Penalty $3,000 $0 $0 $0 $0 $3,000
FTA Amount $0 $0 $0 $0 $0 $0

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ Fta$ Contest LastEvent
  1. 01001 Serious 5A0001 04/08/2003 04/16/2003 $3,000 $4,000 $0 05/01/2003 F - Formal Settlement

Accident Investigation Summary
Summary Nr: 202013785 Event: 12/12/2002Employee Killed After Being Struck By Elevator Car
On December 12, 2002, Employee #1 was chipping out a hole in a block wall in an elevator shaft to install an access switch in the hall frame of an elevator, while standing on a ladder set up on the pit floor. The elevator car came down and struck and killed Employee #1, when it pinned him in between the elevator car and the shaft wall. At the time of the accident, the elevator car was not locked out, not in inspection mode and the car doors were closed. The access switch was being installed as part of a modernization project. The pit was 10.4 feet below the lowest floor level, and there were two pit switches in the shaft. The lower pit switch was in the run position and was approximately 48 inches above the pit floor. The upper pit switch was approximately 48 inches above the floor level and wasn't fully in either the run or stop position but a New York City building inspector determined that the switch contacts were made which meant it was in the run position. Employee #1 was working in close proximity to the upper pit switch. The inspector surmised that the employee may have accidentally hit the switch causing it to go into the run mode, which would have placed the elevator car "in service", assuming that it had been placed in the stop position prior to that. The pit switches were installed in series, which meant if both or either of the pit switches were in the stop mode the elevator would not operate as long as they were functioning properly. A foreman had installed all the other access switches up to that point of the project. The foreman performed that work from atop of the respective elevator cars with the cars in inspection mode and the main line turned off for the respective car. The main lines were not locked or tagged out. The foreman explained that although he didn't lockout or tagout the car he had full control of the car and in order to move the car, even if someone turned on the main line two buttons located on a control box on top of the car would have to be pressed at the same time. The foreman explained that he and Employee #1 had discussed how the foreman had done the work. The foreman explained that Employee #1 borrowed his saw sall and said he would first use the saw sall in the hallway and then use a hammer drill to chop from inside the shaft. The foreman explained that he expected to see Employee #1 during the morning break to see how things were going and didn't expect him to have finished the portion of the work done in the hallway with the saw sall by that time. The foreman explained that he didn't know why Employee #1 didn't perform the chopping portion of the work from atop the car like he did. The foreman also explained that the access switch installation normally took approximately 3-4 hours per elevator to complete. Employee #1's coworker explained the Employee #1 set the ladders up in the shaft and had the car up 1 floor above. He explained that he suggested to Employee #1 that he would ride the car up further on inspection and then lockout the main line but Employee #1 said not to and that he had shut off the pit switch. The coworker further explained that Employee #1 chipped the hole a good 15 minutes with the doors open and then told the coworker he needed to close the doors to reach the rest of the work. The coworker explained that approximately 15 seconds went by after the doors were closed and he heard what he believed to be the ladder falling. He called out to Employee #1 but heard no response. He said he opened the doors and noticed that the elevator was level with the floor and knew something was seriously wrong. Both Employee #1 and the coworker had completed a safety class provided by the company prior to the accident. The class did cover Lockout and tagout procedures, and the employees were provided with lock out and tagout kits, which included locks, tags and multi-lockout device hardware.
Keywords: struck by, elevator shaft
Inspection Degree Nature Occupation
1 305768061 Fatality Fracture Elevator installers and repairers

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