Leg Fractured (KV120)


What Happened?

At approximately 3:00 p.m. on July 12, 2017, an auto mechanic was moving a diesel engine part from one area of a shop to another. He was using an overhead crane to transport the part. The engine part was not properly secured or in an unstable position on the lifting strap. As the part was being transported, it fell out of the strap. The falling part struck the mechanic and fractured his leg. The mechanic was transported to a medical center, where he was hospitalized to received treatment on the fractured leg.

Contributing Factors

•None known. 

What Can We Learn?


Questioning Attitude: Had the employee used the 2 Minute Drill card to guide his Questioning Attitude he would have identified that he was in the line of fire. 

Second Check: The employee should have asked a coworker to validate that the engine part was secured before transportation.


Since the crane operator had completed this work many times before, he fell into the Overconfidence trap by underestimating the risks involved and overestimating his rigging skills.

As it was later in the workday the trap of Distractions may have influenced the worker to lose focus on proper rigging techniques. 

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?