IMCA draws lessons learned from an incident where a crew member’s foot was fractured after becoming trapped between an elevator cage and trunk ladder due to unplanned movement.
What happened?
To conduct elevator inspections, it was necessary to access the top of the elevator cage and set the elevator to local service mode. To halt elevator movements and gain access to the top of the cage, the trunk doors at one level were opened, activating the elevator’s interlocking mechanism.
As one worker was descending to the next level down to operate the local service mode switch, his colleague released the trunk doors, disengaging the interlocking mechanism and allowing the elevator to move normally. While the first worker was attempting to reach the service mode switch, the elevator moved, trapping their foot between the elevator cage and the trunk ladder steps. The injured person was unable to reach the local emergency stop as the elevator cage continued upwards.
It should be noted that during scheduled elevator inspections, it was necessary that all relevant equipment was ‘live’ to allow for testing.
Elevator cage top, with safe area (red), car junction box with operation switched (blue) and location of IP during incident.
What went wrong?
- No Toolbox Talk was conducted prior to starting the work.
- There was a manufacturer manual / procedure for this work. It was not followed.
- There was insufficient communication: activation of service mode was not confirmed or communicated between the workers / work parties.
Lessons learned
- Follow applicable procedures and Control of Work processes.
- Ensure adequate risk assessment / job safety analysis.
