Accident Report

Interoffice Memorandum
Buchanan Dies, Inc.
Facility: EAST PEORIA
Date June 22, 1994
Department: Plant Engineering - KK- 1

Attention: Dick Berger
From: Ted Jackson
cc: T. K. Essington, KK-l
Ken Towles, HH Facilities Services
Dave Monroe, Purchasing, A1
Robert Hennelly, Meg., Tl

Subject: ACCIDENT INVESTIGATION - Building HH:20E

A. Accident description:
A Buchanan employee, West Michaels, was injured on May 23rd, 1994 while performing his duties as a FMS operator on the HH Track Shoe line. He was using a Lakewood "Hi-stak" self-contained storage/retrieval system to store fixtures and dies. The system consists of a top running crane supported by storage racks on each side. The trolley/stacker unit fell to the floor throwing Mr. Michaels about 20 feet. The crane was loaded with a pallet and die weighing a total of 1460 pounds which is well below the system rating of 2000 pounds.

B. Summary & Conclusions:
The employee was doing his job using the tools and procedures provided to him by Buchanan. Buchanan had purchased the unit as a self-contained system from Lakewood, Inc. through their representative Fogerty Brothers Company. The 2 bridge crane girders were obviously too weak to keep the trolley unit in its proper position during normal loading. Our structural calculations, based on the known live and dead loads without adding impact, show that the one girder was overloaded. The girder was not stable under load and deflected laterally enough to allow the trolley wheels to slip off the girder flange. The crane girders must be reinforced for vertical load. The lateral loading caused by the trolley wheel position on the crane girder bottom flange should be reduced or the girder must also be reinforced for lateral stability. Safety lugs mounted on the trolley unit and over the crane girders should also be installed. Lakewood will design the changes and obtain our agreement on the design. Buchanan HH Facilities Services personnel will make the changes at the direction of Lakewood's serviceman.

We will also work with Stans-Vixen to verify the safety of their similar type storage units.

C. Detailed investigation & findings:

The following is a complete history of all my contacts with Lakewood and others that I have received or made since this accident occurred. I have also listed other activities completed during this time period.

1. Wednesday, MAY 23rd
   On Wednesday, May 23, 1994 at 8:47 a.m. a Buchanan employee, West Michaels, was injured while using an Lakewood "Hi-stak" storage/retrieval system. A copy of the accident report is enclosed.
   
   
2. 10 am - I went to HH20E to investigate the accident. The crane trolley had slipped out from between the two crane girders and fell to the shop floor. The load was high above the floor and behind the south girder at time of failure. The evidence at the accident scene indicated that two trolley wheels had slipped off the south girder first. The weight of the load caused the trolley mast unit to pivot about the front girder. The mast swung up striking Mr. Michaels and throwing him about 20 feet north. Fortunately, he was thrown clear of the falling equipment. See also my notes on physical dimensions taken of crane unit, and photographs taken at the scene of the accident.
   
   
3. 11:40 am - Dennis Pond reported that the die that fell actually weighed 1285 pounds.
   
   
4. 12:32 pm - Ron Fox left a message that the die pallet weighed 175 pounds. Therefore, actual total weight of die and pallet of 1460 pounds is much less than the rated system load of 2000 pounds.
   
   
5. A drawing file search found 3 drawings on this "purchased finished" Lakewood system as follows:
   
   PE15000-L8 Die Storage Loads Layout
   PE15000-L12 Area Layout including Die Storage Area
   PE15000-S26 Lakewood proposal drawing. FMA-22393
   
   These drawings were used to install the storage system and do not include any details on the components of the system.
   
   
6. 12:47 pm - Dennis Pond expressed a concern about the rack structure also moving when the stacker crane travels.
   
   
7. 1:53 pm - At his request, I updated Larry Lindsey of Y3 Safety on the accident. He was interested in the proper technical terminology for the crane storage system.
   
   
8. Purchasing notified Tom Damman at Fogerty Brothers Company of the accident. Fogerty sold Buchanan the Lakewood system in 1986. It has been used successfully and without incident until now. Tom made arrangements to get Lakewood people in as soon as possible. Dave Monroe, Tom Damman and I visited the accident site in the afternoon.
   
   
9. 7 pm - I inspected 3 similar Stans-Vixen units in building KK. See enclosed data sheet for summary units at buildings KK31B, KK37A and KK48A.
   
   
10. Thursday, MAY 24th
    7:57 am - Dave Monroe called to say Lakewood will be here today.
    
    
11. 9 am - Lakewood representatives Nick Magotta (District Sales Mar.) and C. R. (Dick) Johnston (Customer Service Rep.) and Mark Witt from Fogerty Brothers visited the accident site with Dave Monroe and myself. We met in a conference room and agreed to the following plan of action: |
    
    1) Lakewood will proceed to repair the trolley unit.
    
    2) Lakewood will investigate installing safety lugs or beams on the trolley unit to prevent a similar accident in the future.
    
    3) Lakewood will check the need to reinforce or rework the bridge crane girders.
    
    4) Lakewood to verify if this system was a standard unit or a specially designed unit for Buchanan's needs. (Sue later found that this 8 foot 3 inch wide aisle unit was one of Lakewood's standard units.)
    
    5) Lakewood to inform us of the timing (schedule) and who will do the actual repair work. Buchanan to write a B94 account work order to accumulate our costs for possible back charging to Lakewood at a future date. Lakewood said they were no longer in this storage unit business and had sold the division to MBT Systems. They said it would take a few days to locate the original drawings for this system. We also agreed that all contacts must be coordinated through Dave Monroe in Buchanan purchasing or his designated person.
    
    
12. Phil Burroughs of HH provided a sketch of the trolley wheel dimensions. The critical distance from the small guide roller to the edge of the trolley wheel tread on the crane girder is only 1 and 5/16 inches. The tread radius reduces the wheel tread contact width to 1 and 5/32 inches. See the sketch enclosed.
    
    
13. Dave Monroe telephoned Gene Kent of Crank Midwest Co. to express our concern about the safety of similar Stans-Vixen units he has sold to Buchanan. Dave and I wanted Gene to make arrangements with Stans-Vixen people to visit our plant and discuss the safety of their product.
    
    
14. 1:20 pm - I expressed our concern about the safety of Stans-Vixen units to Vim Joliat, Technical Sales Mgr. at Allentown, PA based our accident yesterday.
    
    
15. Friday, MAY 25th
    12:20 pm - Ken German called and I updated him on Lakewood's visit.
    
    
16. 2:10 pm - Ed Smith from General Business Services, Inc. in Springfield called to make an appointment to see the accident site in HH. He said he represented Lakewood as a "claims adjustment" service. He also said he was trying to reach Ken German to set up the visit. I told Ed I would forward his request to Ken German.
    
    
17. 2:32 pm - Left message for Ken German about Ed Smith's request to visit accident site on Tuesday May 29th.
    
    Monday, MAY 28th
    Memorial Day Holiday
    
    
18. Tuesday, MAY 29th
    10:30 am - Ed Smith here and visited accident site with Ken German after Ken received advice from Tom Skowronski in Legal, G.O. to allow the visit. A set of 18 photographs were taken at the site and forwarded to Ed Smith via Legal.
    
    
19. 10:40 am - Vim Joliat from Stans-Vixen called and set up a conference call with me and his people. He had Jack Remington and Bill Deveny in the room with him. We discussed Buchanan's concern with their crane system design based on the accident we had on May 23rd. They said there were many of these units in use worldwide. They had experienced no similar failures with their cranes. We discussed their structural design of the trolley and crane units and they could see no problem. They mentioned a maximum trolley wheel load of 3133 pounds on their 2000# rated load system. I expressed a concern about the torsion load on their MC 6x12 ship channel girders due to the eccentric wheel loading condition. They tried to convince me that their system design was good and I said we would probably be calling them again for more information.
    
    
20. 11:29 am - Called Stan Hufford and arranged meeting to get information on the Lakewood system from his file on purchase of the system in 1986-87.
    
    
21. 2:04 pm - Stan Hufford called and we set meeting for today. Met with Stan at his office and copied several documents about the system purchase and obtained his copy of the 1985 Lakewood system catalog. This system was ordered from Fogerty Brothers on 12-08-86 on P.O. PYXD93375 U.
    
    
22. 22. 3:20 pm and 3:52 pm - Discussed the accident and progress with Lakewood, first with Ken German and then with Dave Monroe.
    
    
23. Wednesday, MAY 30th
    9:53 am - Gene Kent of Crank Midwest Co. (Stans-Vixen rep.) called and left message he wanted to see me today.
    
    
24. Gene Kent met with me and gave me a list of 38 Stans-Vixen storage units sold to Buchanan. These units were sold to our East Peoria plant, York plant, Aurora plant, and Juliet plant. His list shows 29 units sold to East Peoria plant. He also included two catalogs on the units.
    
    
25. Thursday, MAY 31st
    I went to HH:20E and recorded additional dimensions needed to do structural calculations on the Lakewood system. The rack system and aisle width were verified with catalog data as originally ordered. 3:22 pm - Dave Monroe called to inform me that Dick Johnson at Lakewood was having problems locating the storage unit drawings. He may have to travel to Michigan on Monday to find the drawings at MBT Systems.
    
    
26. Friday, JUNE 1st
    12:35 pm - Dave Monroe called to say Jim McLeod would be my Purchasing contact next week since Dave would be in Europe on business.
    
    
27. Saturday, JUNE 2nd
    I dropped off to Ken German at Y3 a list of items discussed with Lakewood at the 5-24-94 meeting and other storage system information I had recently gathered from Stan Hufford.
    
    
28. Monday, JUNE 4th ( I was sick & off work)
    12:59 pm - Angela Kemp from Public Affairs called and left message to set up a safety video taping of the HH accident story for Friday, June 8th at 8 am.
    
    
29. Tuesday, JUNE 5th
    7:09 am - Jim McLeod called for update on Lakewood communications.
    
    
30. I received by U.S. mail additional data from Gene Kent of Crank Midwest Co. on the Stans-Vixen Stak-System. The three pieces of literature covered
    1) warranty information,
    2) Stak-System installation & operation, and
    3) Duff-Norton hoist operating & maintenance instructions.
    
    2:50 pm - Dick Johnson of Lakewood called to say he has found the trolley drawings and they would be sent out today. He also verified that the crane girder section is a W6x12 as we had suspected.
    
    
31. Wednesday, JUNE 6th
    8:52 am - Jim McLeod called to say Dick Johnson of Lakewood would be here at 10:30 am to visit the accident site again.
    
    
32. Friday, JUNE 8th
    8:00 am - JMS did engineering calculations showing the original design of the Lakewood Hi-stack system to be inadequate under the design loads. The major problem is the equivalent 813 pound lateral load on the W6x12 wide flange, which bends the section about its weak axis. The wide flange is overstressed by 3.29 to 1.