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Elevator maintenance worker dies from fall in an elevator shaft in California.

Public Health Institute
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 94CA014, 1995 Jan; :1-4
A 34-year-old white, non-Hispanic, male elevator maintenance worker (the victim) died after falling approximately 30 feet into an elevator shaft. At the time of the incident, the decedent and two coworkers were pulling a hydraulic piston out from the bottom of the elevator shaft so that a new liner could be installed. Prior to performing this operation, the workers had installed an electrically powered, base mounted capstan (a revolving barrel on a vertical axis for winding cable) or cathead in the bottom of the elevator shaft which was to be used as a hoist to lift the piston up to the top of the shaft. Co-worker #2 had been sent to the fourth floor so that he could inform the other workers when the piston reached the top of the shaft. The victim was working from the first floor and co-worker #1 was at the bottom of the shaft. Co-worker #2 yelled when the piston hit the top of the elevator shaft but his co-workers apparently did not hear him. Co-worker #1 continued in his efforts to raise the piston which resulted in the capstan being pulled out from the floor of the shaft where it had been anchored. It flew up into the shaft and the piston fell back down to the bottom of shaft. Co-worker #1 became entangled in the hoisting ropes and was pulled up into the air. The victim, stationed on the first floor, apparently looked into the shaft to help and was hit in the head by the capstan. The victim then fell to the bottom of the shaft. Both co-workers pulled the victim out from the elevator shaft and began First Aid. The security guard called 911 and fire department paramedics were summoned to the scene. An on-site examination revealed multiple fractures of the skull and jaw. The decedent was pronounced dead at the scene by fire department paramedics. The CA/FACE investigator concluded that in order to prevent similar future occurrences employers should: 1. mount capstans (catheads) into the sidewall of elevator shafts, and not the floor, in order to create a shearing effect to insure that the capstan does not pull out during hoisting operations. 2. allow elevator doors to be opened only enough to permit workers to observe work being performed in the shaft or, if kept in a fully open position, should have all hatchways or openings in the elevator shaft protected by guardrails or their equivalent. 3. only have properly licensed employees working at the site performing complicated operations that require licensed personnel. 4. only allow qualified employees whose duties are required to be present during elevator repair work. 5. have a standard operating procedure (SOP) which gives specific safety instructions on accomplishing hazardous tasks such as hoisting pistons. 6. instruct employees and have a standard operating procedure (SOP) in standardized communication signals to use when voice contact is not adequate or provide employees with control devices that allow employees to ascertain the position of hoisted equipment.
Region-9; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Training; Maintenance-workers; Occupational-hazards
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
NTIS Accession No.
NTIS Price
Identifying No.
FACE-94CA014; Cooperative-Agreement-Number-U60-CCU-907284
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Public Health Institute
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division