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Case No.15


Caught between the cage of a cargo elevator and the underside of the second floor at a fish processing plant
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[Circumstances of Incident]

The accident involved a cargo elevator at a fish processing company.

This company cleans, salts and lays out fish pieces in steaming baskets on the first floor, takes them to the second floor for the drying process, and packages and ships the products.

Work at the plant was being carried out as usual on the day of the accident. Although the husband of the victim had been complaining about lower back pain, he continued to work in spite of the pain until around 14:00, when he decided to leave early as a precaution when the pain grew worse.

After he left, the victim took over her husband's work under the direction of the firm's president, and carried out the delivery work and drying work by following the same procedure as usual through three steps of the work process.

At around 17:20, the victim undertook the last work for the day by loading a carrying cart into the cage of the elevator, pushing the button for the second floor and the elevator ascended to the second floor.

When the elevator cage had not returned to the first floor after some 20 minutes, the eldest daughter of the firm's president felt that something was wrong as the process usually takes some four to five minutes. The daughter went to the second floor to see what had happened, and found the head of the victim was caught between the upper frame of the elevator cage and the underside of the second floor. The victim was lying on her stomach at the entrance of the elevator shaft.
[Causes]
The following can be cited as the causes of this accident.

1 A door was not installed at the entrance of the elevator shaft on the first floor.

2 A door was not installed at the entrance of the cage.

3 The elevator structure was such that even when all of the openings to the elevator shaft were not closed, the elevator cage could still move up and down between floors.

4 The victim was operating the elevator with insufficient knowledge and experience as she was doing work that she does not usually do. As a result, she did not close the door to the elevator shaft while she operated the elevator.
[Type of business] Seafood processing
[Type of accident] Caught
[Number of victims] One fatality
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