Inspection Detail

Inspection: 307399873 - Kwan Wo Ironworks, Inc.

Inspection Information - Office: San Francisco District Office

Investigation Summary

On June 9, 2008, Employee #1 was working as an iron worker for Kwan Wo Ironworks, Inc., in San Francisco, California. The employer was a licensed contractor fabricating and erecting structural iron. The flatbed truck involved in the incident was parked next to the entrance to the storage yard. The flatbed had two piles of triangular structural iron trusses. The stack involved in the incident was at the tail end of the flatbed. The triangular trusses were approximately 10 feet by 13 feet by 16 feet. Each weighed approximately 1,100 pounds. The trusses were constructed of square tubing that was 6 inches by 8 inches. On the shortest side of the 3-sided triangular truss, six rectangular brackets were welded in place for attachment and installation of the truss. On the day of the incident, there were three employees standing on top of the flatbed. The foreman was standing on the tail end of the flatbed. A coworker, who was the rigger, was standing near the center of the flatbed. Employee #1 was standing inside of the openings of the three stacked triangular trusses. The truss in the middle of the stack was five feet longer and heavier than the top and bottom ones. The crew wanted to remove the middle, longer truss, and put it in another stack, so that this stack would have pieces of the same size. In order to remove the middle piece, the top truss had to be removed first. Another employee was operating a "Lull" Model 10K-54 rough terrain forklift on the ground at an angle towards the cab end and on the same side of the flatbed where the pieces were stacked. (Note: The truck or cab at the time of the incident was not hitched onto the flatbed.) The angle of the boom was approximately 30 degrees to the side of the flatbed. Since the trusses were stacked, there was no space for the blades of the rough terrain forklift to slip between the top and middle trusses. In order for the top truss to be removed, cribbing had to be placed under it (between the top and the middle trusses). When that was done, the forks could then be placed beneath the top truss and it could be lifted away. In order to place the cribbing, consisting of 4 inch by 4 inch timbers, beneath the top truss, the top truss had to be lifted just enough so that they could be put in place. A chain was attached and suspended from the boom of the rough terrain forklift. The bottom end of the chain was looped around a bracket of the top truss. When that was completed, Employee #1 was standing inside the triangular openings of the three stacked trusses as he signaled to the operator to raise the looped end of the top truss. The looped end was raised approximately 6 inches above the middle, longer truss. At approximately 3:30 p.m., the top truss began sliding off the stack and fell off the 5-foot high flatbed. As the truss was sliding, the chain also slid off the bracket. The coworker, who was standing in the middle of the flatbed, realizing it was sliding, jumped off and away from the falling truss. Employee #1 was caught inside of the sliding truss and may have attempted to jump away. He was struck and/or pinched as the truss fell, and he landed beneath the flatbed motionless. The employer called emergency services when Employee #1 fell and did not move. Employee #1 was taken to the San Francisco General Hospital by ambulance, and was pronounced dead when he was at the hospital.

Keywords: CHAIN, TRUSS, BOOM, HOIST, INDUSTRIAL TRUCK, OFF LOADING, STRUCK BY, FLATBED TRUCK