|NIOSH In-house FACE Report 2001-13
On July 21, 2001, a 14-year-old youth (the victim) working at a rental
equipment company was fatally injured after becoming entangled in an electric
chain hoist. The youth was employed to assist customers with loading and
unloading rental equipment from customer vehicles and to prepare rental
equipment for use by the next customer. After using the electric hoist
to remove a vibratory plate tamper from a customer's truck, he was seen
operating the chain hoist without a load. Several minutes later, when
he had not returned to the office, his coworkers found him suspended by
the chain around his neck. He was removed from the chain by his coworkers,
cardiopulmonary resuscitation (CPR) was initiated, and emergency medical
services were called. He was transported by ambulance to the hospital
in critical condition and died 6 days later.
NIOSH investigators concluded that, to help prevent similar incidents,
- ensure that adequate adult supervision is provided for youth workers.
Training for all adult workers should emphasize their responsibility
to monitor, and intervene when necessary, if unsafe activities are being
performed by youth coworkers
- implement training programs targeted at youth workers which emphasize
the link between unsafe behavior and the potential for injury
- review the tasks to which youths are assigned and ensure that the
assigned tasks are as inherently safe as possible, given the relative
inexperience of youth workers
- place return chain containers on all chain hoists to decrease the
risk of becoming entangled in the return chain
Additionally, the Department of Labor should
- consider amending child labor regulations to remove the exemption
for less than one ton capacity when using an electric or air-operated
On July 21, 2001, a 14-year-old rental equipment worker (the victim)
died as a result of asphyxiation after becoming entangled in the chain
of an electrically powered chain hoist. On August 3, 2001, the National
Institute for Occupational Safety and Health (NIOSH), Division of Safety
Research (DSR), was notified of the incident by the US Department of Labor,
Wage and Hour Division. On September 12, 2001, a DSR occupational safety
and health team met with representatives of the U.S. Department of Labor,
Wage and Hour Division, and the Occupational Safety and Health Administration
(OSHA). During these visits, information collected during the Wage and
Hour Division and OSHA investigations were reviewed. On September 13,
2001, the DSR occupational safety and health team met with representatives
of the local Police Department, the County Coroner's Office, and the County
Office of Vital Statistics and spoke with the employer's legal counsel.
A formal visit to the site of the incident could not be arranged due to
the absence of the business owner. Photographs were obtained from the
Wage and Hour Division and OSHA investigations.
The equipment rental business had been in operation for 43 years. The
location where the incident occurred is one of two operated by the company.
The business employed approximately 27 workers, including 9 youths. At
the time of the incident, three workers were at the business location,
the victim and two adults. The business had no formal or written workplace
safety policies, although there were some basic written safety procedures.
The victim had been trained to operate the chain hoist by his father (also
an employee). All training was provided on the job. This was the first
fatality experienced by the business.
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At the equipment rental business, customers often use their pickup trucks
to transport equipment from the business to the use location. To facilitate
the loading and unloading of this equipment, the business installed a
small swing-arm crane with an electric hoist attached outside the building.
When a piece of heavy equipment was rented, the rental equipment employees
would locate the equipment under the hoist then use the hoist to raise
the equipment high enough for the customer's truck bed to pass beneath.
The equipment was then lowered onto the truck bed and disconnected from
the hoist. When the equipment was returned by the customer, the hoist
was used to raise the equipment off the bed of the truck. The truck would
be driven away and the equipment lowered to the ground.
On the day of the incident, the victim started work between 7:30 and
8 a.m. The victim and two coworkers loaded and unloaded rented equipment
from customer-owned vehicles and serviced returned equipment. At approximately
3 p.m., the victim and a coworker used the electric hoist to remove a
vibrating plate tamper, weighing between 150 and 200 pounds, from the
customer's pickup truck. After the tamper had been unloaded, one coworker
went to the restroom and the other went across the lot to the company
office. During OSHA interviews, coworkers stated that the victim had on
previous occasions been observed placing the hoist hook in a belt loop
of his pants and raising himself off the ground. Several minutes later,
the coworker in the office noticed that the tamper had not yet been taken
into the service area and went to investigate. The coworker discovered
the victim raised above the ground with the chain around his neck, and
he was not breathing. The coworkers removed him from the chain, initiated
cardiopulmonary resuscitation (CPR), and called Emergency Medical Services
(EMS) from the office phone. The victim was treated by the fire department
quick-response unit and EMS personnel at the scene and transported by
ambulance to the hospital in critical condition. The victim died 6 days
after the incident.
The hoist involved had a rated capacity of a half ton (500 kg) and a
chain speed of 16 feet per minute. The electric motor size was ½
horsepower. The hoist did not have a supply chain container, leaving a
loop of free chain hanging in addition to the hoist chain. The ASME/ANSI
B30.16 1 safety label was in place on the
control cable just above the control paddle and was clearly legible. This
label includes the warning (#5), "DO NOT Lift people or lift loads
over people." After the incident, OSHA had the hoist inspected, and
the only flaw noted was the absence of a spring-loaded latch on the hook.
The controls, motor, and chain were found to be in normal working order.
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Cause of Death
The county coroner determined the cause of death to be asphyxia by hanging.
Recommendation #1: Employers should ensure that adequate adult supervision
is provided for youth workers. Training for all adult workers should emphasize
their responsibility to monitor, and intervene when necessary, if unsafe
activities are being performed by youth coworkers.
Discussion: It was stated by coworkers that the victim had previously
been observed raising and lowering himself with the hoist. From the OSHA
interview it is clear that at least one of the adult coworkers was aware
of unsafe activity, yet there was no reported effort on the part of the
adults working at the time to stop this activity by the victim. There
is no evidence that any training specific to the supervision of youth
workers was provided to the adult employees.
Recommendation #2: Employers should implement training programs targeted
at youth workers which emphasize the link between unsafe behavior and
the potential for injury.
Discussion: The victim was reported to have engaged in a clearly unsafe
act, raising and lowering himself with the electric hoist. This clearly
is not the intended use of the hoist and is specifically warned against
by the label on the hoist control cable. Additional risks of a hoist include
being struck by the hook or the load, being caught between the load and
another object, and becoming caught on the load as it is raised or lowered.
There is no evidence that the victim had ever received training on the
risks of unsafe actions.
Recommendation #3: Employers should place return chain containers on all
chain hoists to decrease the risk of becoming entangled in the return
Discussion: Chain hoists are typically constructed using a single length
of chain. Exiting the hoist assembly is the single chain that supports
the load plus a loop of return chain that grows in length when the load
is lifted and shrinks when the load is lowered. Were a worker to become
entangled in the return chain, it would be very difficult for the worker
to free himself (he would need to push the up button to be let down).
Return chain containers are typically either metal or canvas boxes or
buckets which receive and pay out chain as is it needed for the lifting
operation, thus eliminating the return chain loop. Return chain containers
remove the hazard of becoming entangled in the return chain and should
be used on all powered hoists.
Recommendation #4: Employers should review the tasks to which youth are
assigned and ensure that the assigned tasks are as inherently safe as
possible, given the relative inexperience of youth workers.
Discussion: The employer should look at each task assigned to a youth
worker and remove as many of the identifiable hazards as possible. In
this case, the youth was working with an electric chain hoist. Replacing
the powered hoist with a manual chain hoist would decrease the chain speed
and increase the ability to control the load, providing additional safety
for the worker. A manual chain hoist, where the operator must pull on
a chain to raise and lower the load, will move the hauling chain with
a much slower velocity. This would make it much more difficult to inadvertently
become caught in the chain, and even if the youth were to become entangled
in the chain while operating the hoist, the motion of the hoist would
stop as soon as he/she stopped pulling on the chain. The use of a manual
(nonpowered) hoist by youth workers allows the worker to perform tasks
requiring the use of a hoist with less risk of injury. This type of additional
safety review and accommodation should be considered a cost of using youth
workers. The business temporarily replaced the electric hoist with a manual
one while the electric hoist was being inspected without any inhibition
of the business's ability to function.
Recommendation #5: The US Department of Labor (DOL) should consider amending
child labor regulations to remove the exemption for less than one ton
capacity when using an electric or air-operated hoist.3
Discussion: Youth workers come to an employer with minimal experience
in the workplace. They do not have the experience to evaluate the safety
of the tasks they are being asked to complete. To protect youth workers,
the child labor laws give the DOL the authority to issue special regulations
for workplaces where youths are employed. The Hazardous Orders are promulgated
by DOL to identify and list recognized dangerous tasks so that youths
under the age of 18 can be protected from engaging in these occupations.
The current Hazardous Order #7 (29 CFR 570.58) states that "the following
occupations involving operation of power-driven hoisting apparatus are
prohibited: 1. Work of operating an elevator, crane, hoist, or highlift
truck (including a forklift) except operating an unattended automatic
elevator or an electric or air-operated hoist not exceeding one ton capacity."
The hazards of a powered hoist are twofold: first is the risk of the load
either falling or being mishandled, and the second is the risk of being
caught in/by the moving chain. Both of these hazards are present regardless
of the capacity of the hoist, and a one ton load could certainly cause
considerable injury to the worker were it to be dropped or handled improperly.
These risks are not changed by the weight of the load, and precluding
youths from operating all powered hoists would provide more protection.
- ASME/ANSI. Overhead hoists (underhung). New York:American Society
of Mechanical Engineers/American National Standards Institute, B30.16.
- DOL [March, 2001]. Child labor requirements in nonagricultural occupations
under the Fair Labor Standards Act. Washington, D.C.: U.S. Department
of Labor, Employment Standards Administration, Wage and Hour Division,
- NIOSH . National Institute for Occupational Safety and Health
(NIOSH) Recommendations to the U.S. Department of Labor for Changes
to the Hazardous Orders - Morgantown, WV: Division of Safety Research.
This investigation was conducted by Carl Werntz, DO, Occupational Medicine
Resident at West Virginia University assigned to NIOSH, Division of Safety
Research, Surveillance and Field Investigations Branch, Special Studies
Section; Virgil Casini, Safety and Occupational Health Specialist, NIOSH,
Division of Safety Research, Surveillance and Field Investigations Branch,
Fatality Assessment and Control Evaluation Team; and Anne Mardis, MD,
MPH, Epidemiologist, NIOSH, Division of Safety Research, Surveillance
and Field Investigations Branch, Special Studies Section.
FATALITY ASSESSMENT AND CONTROL EVALUATION (FACE) PROJECT
The National Institute for Occupational Safety and Health (NIOSH), Division
of Safety Research (DSR), performs Fatality Assessment and Control Evaluation
(FACE) investigations when notified by participating states (North Carolina,
Pennsylvania, South Carolina, Tennessee, and Virginia); by the Wage and
Hour Division, Department of Labor; or when a request for technical assistance
is received from NIOSH-funded state-level FACE programs in Alaska, California,
Iowa, Kentucky, Massachusetts, Minnesota, Missouri, Nebraska, New Jersey,
Ohio, Oklahoma, Texas, Washington, West Virginia, and Wisconsin. The goal
of these evaluations is to prevent fatal work injuries in the future by
studying the work environment, the worker, the task the worker was performing,
the tools the worker was using, the energy exchange resulting in fatal
injury, and the role of management in controlling how these factors interact.
The FACE program does not seek to determine fault or place blame on companies
or individual workers. For further information visit the FACE Web site
or call toll free 1-800-35-NIOSH.