But did you read the suggestions on how to prevent this?
Some are relevant, some don't strike me as being all that helpful.
1. Notify supervisor before changing generator.
----> Uh... yeah. Because the supervisor would have foreseen this.
---> Uh... yeah. Because a JHA would have prevented this.
3. Car in center of hoist way.
---> Because after 20 floors the car would have been going slower than after 40 floors?
4. Put car on inspection.
---> Always. This is aways good advice. Going to AUTO should be the LAST step.
5. Maintain visual.
---> True dat. This is why I'm not a fan of MRL's.
6. Check direction on INS.
---> Again, testing in INS is always good practice.
7. Second person to pull the disconnect.
---> A buddy is fine. But always know where the disconnect is. When things get too weird and you don't know what's going on, kill it. It might not have helped in this case, but the option should always be in our minds.
One take-away is that brakes are kind of important. That's why they need to be tested. If the car needs to be shut down until the office can send out weights, then the car will just have to be down. It's an inconvenience, but not as inconvenient as an injury or death. These guys were lucky.