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Cal OSHA report cites ‘human misjudgment’ as factor in elevator death

The elevators in the Foundation Building are undergoing “modernization,” according to Associate Vice President of University Relations Toni Beron. Elevator 1 has been closed since October 2011 due to hydraulic fluid leakage, and elevator 2 has been closed since the accident in December 2011.

After a six-month investigation, a newly released report has cited human “misjudgment of a hazardous situation” as a factor in an accident when a 48-year-old Cal State Long Beach employee was crushed in an elevator.

California Occupational Safety and Health Administration conducted trials of the accident that occurred in elevator 2 of the Foundation Building. The investigation summary concluded there were no elevator malfunctions.

Annette Lujan of Huntington Beach, who worked in the Foundation Building, tried to crawl out of the elevator when it was stuck between the second and third floor. She was crushed on the neck and shoulders when it dropped.

The Daily 49er reported in March that there were other maintenance problems with elevator 2 within the last year and a half, according to service records by Schindler Elevator Corp.

On Oct. 1, 2011 the elevator was reported bouncing on the third floor and needed oil. On Oct. 19, 2010, the elevator was jumping before reaching the third floor and would jerk, according to service records.

Cal OSHA investigated the conditions of the elevator for six months and attempted to recreate the exact circumstances under which Lujan died.

“We did an exhaustive investigation – our elevator experts, the company’s experts and an independent testing lab could not find a mechanical failure that caused the elevator car to drift down,” Cal OSHA Chief Ellen Widess said. “That is why we did not issue a citation.”

Investigators opened the manual lowering valve to conduct the test and found no evidence to show that the valve was open prior to Lujan’s death.

According to Cal OSHA, the elevator car that Lujan died in passed inspection and had no signs of problems. Cal OSHA and the elevator maintenance company also investigated the elevator’s components to see if they were defective and found it inconclusive.

According to the investigation, Lujan died of traumatic asphyxia after being crushed between the hoistway wall at the top threshold and the top of the elevator car.

A student worker at the Foundation Building had attempted to help Lujan out of the stuck elevator but was unable to after the elevator plummeted down the shaft.

CSULB attorney Andrew Jones said that CSULB has “not been served with a lawsuit, and to my knowledge the [Lujan] family has not filed one against the school either.”

However, Jones said that the family had filled out a claim form under the California Tort Claims Act. The act states that any person seeking to sue a public entity must fill out a form first, regardless of whether they will eventually sue or not.

Lujan’s family could not be reached for a comment.

Cal OSHA will not issue a citation as a result of the investigation.
 

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