Cause Map™ C

Possible Solution:
Wind loads and specific
site parameters to be
calculated for all lifts

Collapse of Big Blue Post Collapse

calculated 11mph
maximum winds
acceptable
Evidence:
The absence of procedures to adequately
account for wind speed appears to have
played a predominate role.

AND

Prime Contract stated

that Lift Company
should have calculated
Possible Solution: winds
A Crane installed with
anemometers at the tip of the AND
boom

Possible Solution: Local weather stations

B Anemometers mounted on reported 20mph
stadium roof for continuous sustained winds with
recording 25-30mph gusts
Evidence:
Wind Conditions Weather service data and verbal reported
exceeded rating conditions from Big Blue Operator. Actual
for Crane wind data lost (see branch below)
Step
1 Define the Problem
AND

Load Chart Crane Operator

What Problem(s) 3 Fatalities from Collapse of Big Blue Crane required winds reported wind gusts
AND 28-30mph an hour
<20mph
When Date July 14, 1999 before lift
Time apprx 5.15pm AND

AND
Different, unusual, unique High Wind Conditions, Behind on Project Winds were
15-20mph
Facility, site Actual Wind data Actual Wind data
Where Milwaukee Brewers Baseball Stadium sustained
lost prior to lost prior to ?
Significant investigation investigation
Unit, area, equipment "Big Blue" Lampson Transi-Lift 1500 series crane Wind Gusts
AND

Evidence:
Task being performed lifting roof sections into place Computer that captured wind
Wind gusts were
recordings for day were lost
25-30mph
Impact to each GOAL after computer disconnected by
Prime Contractor
Safety 3 Fatalties & 5 Injuries AND

Environment ?
Customer Negative Reputation/National Publicity
(7 week trial, $94 Million was punitive damages) Truss behaved
$99,254,000 Additional Loads like a sail in
Prime Contractor found to be 97% liable for damages winds
Legal Costs 20 OSHA Citations $539,000 Evidence:
Unclear if Load Chart wind ratings
Cost for all Attorneys & Support Personnel Big ? were for only crane. Limited
investigation findings to reference
Production, Schedule 1 year delay to construction project Possible Solution: Evidence:
AND
Property, Equipment D Utilize crane with installed with
Repairs to areas impacted by truss & crane $100,000,000 computerized load monitoring
Critical Lift plan did not take into
account any additional wind
Labor, Time loading variables

Excessive
This incident $199,793,000 Loads

Limited Safety Lift at 97% of Lifting Truss

Margin rated capacity Piece 4R3

Evidence:
110ft wide
200-220ft long
Man Basket Personnel were AND 13ft high
being used during monitoring & 913,000lbs
Step Cause MapTM lift guiding lift 32,400lbs from cable, headache ball, etc
2
Analysis Stress
Exceeded
AND Possible Solution:
AND Strength of rig F Install Mats to ensure
safe/stable foundations Multiple
Impacted additional loads
3 Fatalities Possible Solution: Loss of Footing of gravel used
Safety Goal E Minimize number of under rig
personnel in fall radius of
crane
crawler ? AND/OR

Crawler sinking Broken Water

Three Personnel
and tipping crane main discovered
in Man Basket
? after collapse
Evidence:
Crane Structure Evidence:
OSHA Finding; Exceeded the
number required for the work appeared to fall After the collapse, a broken water main
being performed. Reduce number from was discovered within 20 feet of the
of people at risk bottom up crane. Mitsubishi argued that the water
main ruptured prior to the accident and
Insufficient AND/OR rendered the sur- rounding soil unstable.
AND Strength of Rig ball, etc
Inappropriate
parts installed
on kingpin
Man Basket assembly ?
Big Blue Rig
Man Basket Fell Crane collapsed AND
Collapsed Evidence:
from Big Blue Mitsubishi also argued that a "spacer" or
washer of unknown origin was installed as
Evidence:
part of the crane's kingpin assembly
Decedents fell over Lift #2 was
, etc
200ft to ground delayed for 17
Evidence: days due to wind
Consequently, an unfavorable bending moment was imposed Lifting Company conditions
on the king pin which was designed to serve uniquely as an behind on
unloaded locating means between the crane upperworks, or AND
Project
tub, and the crawler base, or carbody. Ultimately, the side
loads which provoked incipient failure in the king pin, bottom Lift #10 resulted
end cap fixation assembly were almost 2–1/2 times greater Contractors
facing penalties AND in collapse of 30
than the requisite 2% design condition
postulated in SAE J1093. for delays planned lifts

Project
Completion
required for
baseball season
AND

AND/OR

Other project
delays ?
Lift Company
Supervisor fired for
previously stopping
work
Evidence:
Insufficient Prime Contractor requested Lift
Safety Focus Contractor to fire individual. The Site
Supervisor has stopped the job 10+ times
ordering gravel to help stabilize the ground
Evidence: under the crane. (Lawyers report)
The day of the crane collapse, OSHA
investigators were inspecting the site
because of concerns about visible fall AND
hazards. An OSHA videoed the collapse
event (see YouTube public record)
Crane Operator had
verbally voiced
concerns about wind
conditions

AND

Possible Solution:
G AND
Establish key roles &
responsibilities for load
calculations
Step
3 Solutions Unclear Authority
for Calculating
Possible Solutions for Consideration Select Implementation ‐ Action Plan Wind Loads & Evidence:
Measuring Prime Contractor Site Supervisor admitted on
Measurable the stand that he had "dropped the ball" in failing
Work Process Implement? Specific Actions Owners Due Date to make sure that wind speed calculations were
Ref. Possible Solution Cause Controlled No. (how will we verify completion Status
(process to be improved) (yes or no) (specific actions to be taken) (names) . AND performed more recently than two hours prior to
and effectiveness)
the lift. , etc
AND

Previous events
Human Factors with Safety
Issues Concerns for Prime
Contractor
Evidence:
Prime Contractor Site Supervisor
characterized as authoritarian
management style that appears to have
High H F stifled dissenting views and prevented
E G C
D AND worker concerns from being fully
expressed

A B
Evidence:
Pervious incidents at site prior to crane collapse
• An employee fell about 80 feet and survived by hitting an
Possible Solution: occupied scaffold. The employee that fell was back at work
H Execute Stop Work in a few weeks while the person on the scaffold was put on
Authority. Several Iron disability.
workers expressed concern
prior to the lift • A grinding wheel bounced off the surface being smoothed
and hit the user in the leg.
Payback Possible Solution:
Medium I I • There was no major damage. A 25-ton roof section shifted
Benefit Utilize Behavior Base Safety
in a sling and broke a man's leg.
philosophies for senior
management and ensure buy-in • An explosion occurred while a heater was being lit which
burned two employees.

Management
System
Breakdowns

Evidence:
Prime Contractor Site Supervisor was
portrayed by witnesses as both "sloppy" in
his approach to safety and "authoritarian"
in his re-sponse to subordinates who
expressed concerns about the safety
Low Medium High procedures.
Effort
Cost