Blog Post #162 – Coroner’s Inquest Points to Deficiencies in the Elevator Refurbishing Business

Excerpt from the OH&S Canada Magazine

An inquest into the death of an elevator mechanic 6 years ago demonstrated that the lack of familiarity with an older building and deficient safety procedures may have proved contributing factors.

On March 29, 2005, James Sanford was refurbishing an elevator in the historic Dominion Building in London, Ontario when he hit his head on a metal beam and plummeted 20 feet to the ground. The 30-year-old employee of Schindler Elevator received fatal injuries at about 9am when he and his assistant tried to jump to safety from a runaway elevator, reports regional supervising coroner for southwestern Ontario, Dr. Jack Stanborough.

Sanford died the next day as a result of blunt force trauma to the head.

A coroner’s jury issued 10 recommendations aimed at enhancing elevator construction safety. Among the recommendations was the call for employers to adopt a written job hazard analysis that involves all workers and supervisor; and that employers overseeing modernizing or refurbishment projects, as well as new elevator installations, install a rope brake as soon as practical where required by regulation or as part of design.

As per the latter recommendation, the jury suggested that the employer complete a report explaining the decision to install or not to install the rope brake, the timing of the installation, and its rationale. The report should be readily available to employee representatives, Ontario’s Technical Standards and Safety Authority, (TSSA) and the Ministry of Labour. (MOL)

The elevator unit was very old, Stanborough says. “Most of these buildings are just being torn down, not refurbished.

The refurbishment process required the workers to take the elevator apart, remove the railings from the walls, and use the base of the elevator as a platform, he reports. This served to make the elevator lighter.

But the elevator counterweight “was not reduced as they took the elevator apart, so they had this huge imbalance.”

On that morning, Sanford and the assistant rode the elevator from the basement upward. The unit began to accelerate and the stop button failed to work.

At about the second floor, the men looked at one another and then jumped onto an 18 inch wide ledge. The assistant landed safely, Sanford fell backward.

Among the jury’s other recommendations are the following:

– Elevator mechanics undertake periodic refresher training to assess overall competency and knowledge, particularly as it relates to irregular tasks;
– Employers of elevators mechanics and apprentices distribute Field Employee Safety Handbooks (or a suitable substitute) to every worker in the field, and integrate these handbooks into training programs;
– Employers consult with the Labour Management Construction Safety Committee to establish both supervisory qualifications and standards for competence; and
– The committee assess the practicality of a lockout device or temporary controls to detect significant traction loss and render the motor and pendant station inoperable.

My opinion

As always, it takes a death in the workplace to drive change in any one sector of the workforce. Here we have the business of refurbishing an elevator. A well-trained mechanic did not review a job hazard analysis prior to the work. None was completed to determine possible hazards to review and avoid. Jim Sanford would be alive today if a practical ‘pre-meeting’ was initiated prior to beginning the work. In many other sectors of the workplace, there are pre-meetings that spell out the job, the expected time for completion, the employees to be involved, and most importantly, the hazards spelled out concerning the work being done.

Here we have a different type of work being done. I am very sure he was unaware of the type of hazard, especially dealing with such an antiquated piece of equipment. Jim would have been better served by being given a proper list of work instructions showing, in detail, the possible problems dealing with this type of work. I cannot believe Schindler Elevator did not know the issues and this type of accident, possibly with a previous near-miss instead of the workplace death, which should have driven proper instructions to protect their workforce. Some companies do not see the value of corrective action for near-misses. I wonder if the elevator industry, in general, may have had a similar experience that would have driven change. Ask the people in and out of ‘Confined Spaces’. The job is spelled out, a permit is in place, and all workers are trained in the hazards and review the controls in place to control the hazards. Nothing is left to chance as long as Ontario regulation 632/05 is followed.

If one goes into any workforce in Ontario, one will find a set of work instructions for most of the jobs out there. It is too bad the employees of Schindler Elevators were not afforded the same courtesies where health and safety were concerned. Mr. Sanford would be alive today.

Remember — In Ontario, “ALL Accidents are Preventable”

‘Work’ and ‘Play’ safe.

Daniel L. Beal
CHSEP – Foundation Level
VP & Senior Trainer
HRS Group Inc.