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NIOSH - National Institute for Occupational Safety and Health

Fatality Assessment and Control Evaluation (FACE) Program

 

Hispanic Forklift Operator Dies After Being Caught Between Mast and Cage of Forklift - North Carolina

In-house Case Report


On This Page...
 
  • Summary
 
  • Introduction
 
  • Investigation
 
  • Cause of Death
 
  • Recommendations and     Discussion
 
  • References
 
  • Investigator Information

NIOSH In-house FACE Report 2002-09
May 28, 2004

Summary

On July 13, 2002, a 54-year-old Hispanic forklift operator (the victim) died after being caught between the mast and the protective operator’s cage of a sit-down type forklift. The victim had been assigned the task of transporting pallets of yarn from the production floor of a textile plant to the plant’s warehouse. The victim had been performing the task since the beginning of the third shift which began at midnight. At approximately 5:40 a.m., the shift foreman and another plant worker were walking through the warehouse when they noticed the victim in a standing position caught between the mast and the protective operator’s cage of the forklift, with his left foot on the mast control and his right foot on the operator’s seat. They ran to assist the victim and found him non-responsive with no vital signs. The shift foreman summoned more coworkers to help, then called 911. When fire and police personnel responded, they cut the hydraulic lines on the forklift. As the hydraulic lines bled off, the mast lowered and they were able to extricate the victim from the machine. Emergency medical service personnel pronounced the victim dead at the scene. NIOSH investigators concluded that, to help prevent similar incidents, employers should

  • instruct forklift operators to ground the forks, turn the forklift off, set the parking brake, and neutralize the controls prior to dismounting the machine

  • instruct forklift operators to never stand inside the cage of the forklift while it is in operation


Introduction

On July 13, 2002, a 54-year-old Hispanic forklift operator (the victim) died after being caught between the mast and protective operator’s cage of a sit-down type forklift. On July 19, 2002, the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR) was notified of the incident by officials of the North Carolina Occupational Safety and Health Administration (NCOSHA). On August 1-2, 2002, a DSR occupational safety and health manager conducted an investigation of the incident. The incident was reviewed with the NCOSHA compliance officer assigned to the case, and the county police and coroner. Police photographs taken immediately after the incident were reviewed. The incident was discussed by phone with the company safety director.

The employer was a textile plant that specialized in the manufacture of yarn. The plant employed 440 workers and had been in operation since 1974. The employer had a comprehensive safety and training program and employed a full-time safety director. All forklift operators received OSHA required operator training and held current certification. Workers underwent classroom training prior to taking a written test and demonstrating their proficiency in operating the machine before receiving their certification. Hispanic workers received training in Spanish through an interpreter. Bilingual workers were present on all shifts to translate work and safety instructions to non-English speaking employees. The victim spoke no English and had been hired as a temporary employee on January 8, 2002. On January 14, 2002, he received his forklift operator certification. He was hired as a full-time employee on April 7, 2002. This was the first forklift fatality experienced by the company. The company experienced a non-forklift related fatality 10 years ago.

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Investigation

The company operated three daily 8-hour shifts manufacturing yarn. A new inventory tagging system had recently been initiated at the plant. The tags were placed on the pallets of yarn before warehousing to identify the yarn’s location in the warehouse, date of manufacture, the lot number, and grade and color of the yarn. Tag numbers were then entered into a master logbook by the shift supervisor.

The victim began his scheduled shift at midnight and received instructions to perform his regular duties of transporting pallets of finished yarn with his forklift to the appropriate areas of the warehouse as identified by the tags attached to the pallets. The 4-foot-square by 4-foot-high pallets of yarn were stacked two pallets high when transported. The victim performed these duties throughout the shift as assigned.

At approximately 5:40 a.m., the shift foreman and a worker were walking through the warehouse when they noticed the victim in a standing position with his torso and upper body positioned through the front of the protective operator’s cage and mast of the forklift. Upon closer examination, they saw that the victim was caught between the forklift mast and the protective operator’s cage, with his left foot on the mast control and his right foot on the operator’s seat. The victim was unresponsive and no vital signs could be detected. The shift foreman summoned more coworkers to help, then called 911. The other workers were not sure of the operation of the forklift controls and the victim remained pinned until fire and police personnel arrived a short time later. Upon responding, police and fire personnel cut the hydraulic lines on the forklift. As pressure bled off the hydraulic lines, the mast moved forward and the rescue personnel were able to extricate the victim from the forklift. Emergency medical service personnel could not revive the victim and pronounced him dead at the scene.

The forklift was inspected by company personnel, a private engineering firm, and the manufacturer after the hydraulic lines had been replaced. No modifications were made on the machine. All parties found the forklift to be operating properly, including the dead man switch under the operator’s seat. During testing, the dead man switch would shut down the machine immediately if the operator left the seat.

The victim was discovered in the area where the pallets were to be warehoused. The top pallet was not sitting squarely over the bottom pallet. Evidence suggests that the victim was able to stand on the seat to double check the location tag on the pallet or to attempt to straighten the pallets without activating the dead man switch. As he did so his foot inadvertently contacted the mast control and moved it in a downward direction causing the mast to rise toward the cage of the forklift, pinning him.

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Cause of Death

The coroner listed the cause of death as crushing injuries to the chest.

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Recommendations/Discussion

Recommendation #1: Employers should instruct forklift operators to ground the forks of the forklift, turn the forklift off, set the parking break, and neutralize the controls prior to dismounting the machine.1

Discussion: Employees should never attempt to adjust or otherwise access loads until the forklift is properly shut down. Loads should then be adjusted from outside the protective operator’s cage. This would eliminate reaching through the front of the protective cage and the inadvertent contact with machine controls resulting in the machine or machine components striking or pinning a worker. The company now plans to specifically address this topic during operator certification training.


Recommendation #2: Employers should instruct forklift operators never to stand inside the cage of the forklift while it is in operation.2

Discussion: Workers should not attempt to perform tasks inside the protective cage of a forklift unless the forklift is completely and properly shut down. This would eliminate the exposure of controls being inadvertently activated causing the operator to be contacted by the machine or machine components, or to lose balance and fall from the machine. This would also eliminate the hazard of a worker on foot being struck by the machine. This topic is now specifically addressed in this employer’s forklift operator certification training.

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References

  1. NIOSH [2001]. NIOSH Alert: Preventing injuries and deaths of workers who operate or work near forklifts. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2001-109.

  2. Government Institutes [1999]. Forklift Safety-A practical guide to preventing powered industrial truck incidents and injuries (Second edition), Rockville, Maryland: Government Institutes, a division of ABS Group Inc.
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Investigator Information

This investigation was conducted by Virgil J. Casini, Senior Investigator, Fatality Investigations Team, Surveillance and Field Investigations Branch, Division of Safety Research.

 

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