Hoist Failure: Snapped Chain

Incident Summary
While moving a large piece of a Mill body (approximately 2500 lbs.) using a tandem lift (2 portable hoists @ 2-tons
ea.) one of the hoist’s upper limit switches failed causing the chain to impinge and snap in half. This caused one side
of the load to drop between 6-12 inches to the floor. Fortunately there were no injuries and no property damage
beyond the hoist. This activity was conducted using one Veolia employee and three contractor employees. During
the formal RCA and interview process, it was determined that although all the participants were aware of a limited
overhead space, and while both operators were watching their load, nobody had been assigned to watch the upper
limit on either hoist. At least two of the contract employees indicated that they did not know that portable hoists
had an upper limit switch.

The Veolia operator identified that a pre-use test had been completed and was successful. The unit has historical
monthly inspections as well as a proper load test. However, the annual 3rd party inspection had not been completed
in 2013.

Root Cause Analysis

• Equipment failure
• Lack of employee knowledge and lack of verified contractor qualifications
• Poor communication
• Inadequate maintenance

Potential Serious Injuries

• Appendage and/or core body crushing; Death

Corrective Action / Preventive Actions:

1. Removed damaged hoist. An additional hoist was identified to not have an upper limit switch. That was
removed as well. (Site action)
2. When hiring contractors/vendors to conduct tasks on-site involving cranes/hoists, verify what specific training
is provided to ensure that workers are qualified to operate this equipment
3. If vendors/contractors will be using Veolia-owned equipment or on-site equipment maintained by Veolia
(e.g., hoists, cranes, lifts, etc.), train contractor employees as needed on any specific policies or procedures
associated with that equipment
4. Create a work order in the site’s system for the annual 3rd party inspection of cranes hoists

Veolia North America May 14, 2014