Inspection Detail

Inspection: 313129454 - Universal Silencer, Llc

Inspection Information - Office: Madison Area Office

Investigation Summary

At approximately 4:40 p.m. on July 9, 2009, Employee #1, a welder, was working with a coworker (the second shift lead person) to correct a problem with an exhaust silencer (Part Number 15983XJ). The lead person had noticed that drain holes were misaligned on the head unit, which had been tack welded into place by first shift personnel. To correct the misalignment, the lead person attached an overhead crane hook to the head unit to support the weight (approximately 775 pounds). Six lever-operated chain hoists were used inside the silencer to hold the head unit in place, laterally, against the silencer body. The lead person broke the tack welds and used the chain hoists to rotate the head unit, thus aligning the drain holes properly. A fabricator then asked to use the crane that was supporting the head unit. The lead person granted the request. The fabricator disengaged the load block and hook from the head unit and took the crane to an adjacent work bay. After the crane was taken away, the lead person removed five of the six chain hoists used to hold the head unit in place., Employee #1 was preparing to hand welding equipment, through an access hole in the head unit, to the lead person. With a single chain hoist remaining in place, the head unit shifted, causing the hoist hook to slip off the unit. It fell over onto Employee #1. He was hospitalized with a fractured pelvis, broken ribs, crushed vertebrae, and a ruptured bladder.

Keywords: FRACTURE, REPAIR, WELDER, HOIST, PELVIS, RIB, STRUCK BY, FALLING OBJECT, VERTEBRA, UNSTABLE POSITION