|NIOSH In-house FACE Report 2004-03
July 23, 2004
On December 26, 2003, a 17-year-old warehouse worker (the victim) was fatally
injured when the sit-down type forklift he was operating outside the warehouse
tipped over and crushed him. The youth was employed by an agricultural cooperative
through a work-based learning program in his high school. At approximately 2:00
p.m., the victim had apparently lost control of the forklift, which was not carrying
a load, as he was making a right turn toward the ramp leading to the warehouse
entrance. The forklift tipped over 90 degrees onto its left side. A customer heard
a loud noise and saw the victim trapped under the forklift. He ran to get help.
While the customer and the victim’s coworker ran back to assist the victim,
another coworker ran into the company’s store to call 911. The customer
and coworker were unable to lift the forklift manually. As coworkers lifted the
forklift off the victim using a front-end loader, the customer pulled the victim
clear. The victim was conscious but was having difficulty breathing. Police and
fire department personnel responded at 2:00 p.m. and provided emergency assistance.
The victim was transported by an emergency medical services (EMS) ambulance toward
a meeting point with a medical helicopter, but en-route the victim’s condition
deteriorated. EMS personnel transported the victim to a local hospital where he
was pronounced dead at 3:16 p.m. in the hospital’s emergency room.
NIOSH investigators concluded that, to help prevent similar occurrences, employers
- ensure, through periodic inspections and reminders, that equipment
operators use seat belts provided on equipment they are assigned to operate.
Operators should also be reminded that they should never try to jump from
an overturning sit-down type forklift.
- ensure that travel routes used by forklift operators are free
of obstacles and other unsafe conditions.
- establish work policies that comply with child labor laws prohibiting
youths less than 18 years of age from performing hazardous work, including
operating power-driven hoisting equipment such as forklifts. Employers should
communicate these work policies to all employees.
- develop, implement, and enforce a comprehensive written safety
program for all workers which includes training in hazard recognition and
the avoidance of unsafe conditions. A written training plan should require
training for all forklift operators that includes the equipment manufacturers’
recommendations for safe equipment operation.
- identify and label equipment that is not to be operated by young workers
less than 18 years and provide keys to only trained and authorized machine
- equipment manufacturers should consider placing a warning decal on
equipment indicating that the equipment is not to be operated by workers
less than 18 years, and note this restriction in the operator’s
- school officials and employers participating in work-based learning
programs for youth should ensure that work assigned to youth is allowed
by law, the work environment is safe and free of recognized hazards,
and that youth receive appropriate safety and health training.
Photo 1. This photo illustrates the
forklift used on the day of the incident.
On December 26, 2003, a 17-year-old warehouse worker (the victim) was
fatally injured when the sit-down type forklift he was operating outside
the warehouse tipped over on its side and crushed him. On January 7, 2004,
the U.S. Department of Labor, Wage and Hour Division, notified the National
Institute for Occupational Safety and Health (NIOSH), Division of Safety
Research (DSR) of the incident. On February 2, 2004, a DSR safety and
occupational health specialist met with the Occupational Safety Compliance
supervisor, Tennessee Department of Labor and Workforce Development (TDLWD),
Division of Occupational Safety and Health; a child labor investigator
(TDLWD), and a compliance officer and an Assistant Director of the U.S.
Department of Labor, Wage and Hour Division, Southeast Region. Findings
from their investigations were reviewed, in addition to the city police
report and the death certificate. On February 3, 2004, the DSR safety
and occupational health specialist discussed the incident with the employer’s
local manager, the general manager, and a coworker who assisted in lifting
the forklift from the victim. The incident site was examined and photographs
were taken. A telephone interview was conducted with the equipment dealer
who examined the forklift following the incident. A copy of the manufacturer’s
operator’s manual for the forklift was reviewed. A telephone interview
was conducted with the medical director for the responding emergency medical
Employer: The victim’s employer was an agricultural cooperative
(co-op) that had been in operation for 53 years and employed 22 full-time
employees in two locations. The company employed 7 full-time workers and
1 part-time worker (the victim) at the location where the incident occurred.
The victim had begun work on September 21, 2003, and was employed under
a work-based learning program. The program agreement was signed by the
victim, his mother, the high school principal, the work-based learning
program’s coordinator, and the employing company’s local manager.
According to the signed agreement, the victim was to work from 12:00 p.m.
to 5:00 p.m. six days per week as a warehouse laborer. Specific duties
were not written into the agreement.
Victim: The victim worked for the company as a warehouse laborer
for three months under a work-based learning agreement administered through
his high school. Successful completion of the work-based program, along
with successful completion of other school requirements, would allow the
victim to earn a graduate equivalency degree (GED) from his high school.
According to the local manager, the company had employed young workers
through work-based learning agreements in the past. The local manager
had contacted the school early in the school year, but the school did
not have anyone available. According to the general manager, the victim
approached him later personally, and was hired through the school’s
work-based learning agreement.
Training: The employer’s safety policies were unwritten.
According to the company’s local manager and general manager, training
was provided on selected topics using materials sent by the company’s
insurance company. Safe driving was one of the recent topics presented
to employees, but this training covered safe driving of automobiles and
trucks. It did not cover equipment operation. The training topic, date
of training, and training attendance was documented. The victim had not
attended any training sessions. The victim was given on-the-job training
in forklift operation by the warehouse supervisor but this training was
not documented. The company had no documentation indicating that the supervisor
had received forklift operator training. According to the local manager,
the warehouse supervisor worked with the victim in the warehouse. The
supervisor was terminated a month prior to the incident, and the position
had not been refilled.
Equipment: The sit-down type 2-ton propane powered forklift (Photo
1) had been purchased new by the company. It was approximately 2 years
old and was equipped with a seat belt and a rollover protective structure
(ROPS). The forklift had pneumatic tires and lifting capacity of approximately
3,000 pounds. The manufacturer’s operator’s manual was located
in a pocket behind the operator’s seat. The equipment dealer inspected
the forklift following the incident and determined that it was in good
The company had no previous history of employee fatalities.
The agricultural co-op was open for business 6 days per week. The co-op’s
retail store was connected to the co-op’s tire shop and a warehouse.
Also on the grounds were an equipment storage shed, a fertilizer shed,
and an outdoor storage area where 200 pound molasses animal licks were
stored. A large flat concrete parking lot extended in front of the store
entrance and around one side of the warehouse where a loading dock and
ramp were located. Normally, customers picked up orders at the loading
dock. However, when customers purchased heavy items stored outside that
required a mechanical lift, a forklift operator exited the warehouse using
the ramp, filled the order, and loaded the items. New supplies were also
unloaded at the side of the warehouse and large trucks were sometimes
temporarily parked there.
On December 26, 2003, at approximately 7:30 a.m., the victim reported
for work and began working alone in the warehouse. Two coworkers were
working in the tire shop, one coworker was working in the fertilizer shop,
and another coworker was working in the store. The local manager was on
vacation on the day of the incident.
According to the coworker who was working at the cash register and taking
orders, approximately 60 warehouse orders were received on the day of
the incident. Four of the day’s orders required the use of a forklift.
The victim filled many orders that morning. Coworkers could not recall
seeing the victim operating the forklift in the morning. At about 12:00
p.m., a coworker from the tire shop went to lunch with the victim. When
they returned, the coworker returned to the tire shop and the victim returned
to the warehouse. The coworker remembered seeing the victim operating
the forklift after lunch. A few minutes before 2:00 p.m., a customer helped
the victim as he loaded a molasses lick into another customer’s
trailer with the forklift. Approximately 5 minutes later, the customer
heard a loud crashing sound. He ran over to the area where the victim
had been operating the forklift and saw the forklift tipped over on its
side. The victim was laying face down with his back pinned under the cage
of the forklift and with one leg extended and the other leg doubled up
under him. The customer ran to the tire shop to get help. While he and
a coworker ran back to assist the victim, another coworker ran into the
company’s store to call 911. The customer and coworker were unable
to lift the forklift manually. They told another coworker to get a front-end
loader. As coworkers lifted the forklift off of the victim with a front-end
loader, the customer pulled the victim clear. The victim was conscious
but was having difficulty breathing. The police report indicates that
the city police and fire department responded to the scene at 2:00 p.m.
The medical director for EMS reported that the ambulance was dispatched
at 2:08 pm. and responded at 2:09 p.m. EMS personnel examined the victim
and inserted an endo-tracheal tube at 2:18 p.m. followed by a needle chest
decompression immediately after, to help alleviate the victim’s
breathing difficulty. A medical helicopter was dispatched to transport
the victim to a trauma center, but while the EMS ambulance was on its
way to meet the medical helicopter, the victim’s condition deteriorated
and the victim was transported instead to a local hospital. The victim
arrived at the hospital at 2:32 p.m. and was pronounced dead at 3:16 p.m.
in the hospital’s emergency room.
The DSR investigator examined the site on February 3, 2004. Based on
information obtained from the local manager, photographs taken the day
of the incident, and measurements taken at the site, it appeared that
the victim was traveling toward the warehouse ramp on a level surface
of the parking lot and made a sharp right turn to enter a narrow ramp
leading up to the warehouse. It is surmised that this is when the forklift
tipped over onto its left side. The forklift was not loaded but its forks
were raised approximately 20 inches so the forks would not dig into the
ramp. There was a single 12-foot skid mark located on the parking lot
where it is surmised that the victim started into a right turn toward
The ramp had an 18.6% grade. It measured 7-foot ¼ inches wide,
39 ½ inches high at its point of entry into the warehouse, and
18 feet long (Photos 2 and 3).
The entrance/exit of the warehouse was narrow, measuring 70 inches in
width. However, a post and an abandoned grain feed dispersal bin located
inside left just enough room for the forklift to pass through. Old scrape
marks on the forklift and on the post and grain bin inside the warehouse
in the only area where the forklift could pass through may be indicative
of the tight fit. The local manager said that forklift operators had to
speed up to make it up the ramp and then had to slow down at the entrance
to fit through the narrow passage after passing through the warehouse
door. The ramp’s surface was patched and rough where the ramp joined
the flat, level parking lot. The local manager informed the DSR investigator
that the co-op was being relocated and therefore the rough pavement in
the transitional area where the level parking lot met the ramp, and the
confined areas in the warehouse, although identified as problematic, had
not been changed because of the planned move.
Cause of Death
The coroner’s report indicated that the cause of death was severe
Recommendation 1: Employers should ensure, through periodic inspections
and reminders, that equipment operators use seat belts provided on equipment
they are assigned to operate. Operators should also be reminded that they
should never try to jump from an overturning sit-down type forklift.
Discussion: Use of seat belts is important in protecting workers from
serious harm, and periodic inspections should be conducted to ensure compliance
with seat belt use. Workers should be reminded that a properly secured
seat belt keeps the operator inside the protective envelope of the rollover
protective structures (ROPS).
In addition, operators should always be reminded what to do if an emergency
situation, such as an overturn, occurs. Workers should be reminded that
they should not jump from an overturning, sit-down type forklift. They
should stay with the truck, holding on firmly and leaning in the opposite
direction of the overturn.1
Recommendation 2: Employers should ensure that travel routes used by forklift
operators are free of obstacles and other unsafe conditions.
Discussion: Employers should perform an assessment of the travel routes
used by forklift operators, including warehouse access/exits, ramp design,
the condition of the concrete at the end of the ramp, and the parking
lot over which forklifts must travel. According to Swartz2
“Operating environments that include railroad tracks, rough pavement,
holes in the roadway, uneven surfaces, ramps, grades, or other less than
desirable features can be dangerous.”
Improving travel surfaces to make them less rough, making access ways
wider, and requiring truck drivers to move trucks after off-loading would
improve travel pathways for forklift operators. Employers should also
consider marking a route with yellow paint that provides forklift operators
with guidance regarding specified pathways and appropriate turn radiuses.
Employers should also consider posting signs warning forklift operators
to drive at slow speed and to use their seat belts. A sign should also
be posted warning truck drivers to park their vehicles away from forklift
Recommendations 3: Employers should establish work policies that comply
with child labor laws prohibiting youths less than 18 years of age from
performing hazardous work, including operating power-driven hoisting equipment
such as forklifts. Employers should communicate these work policies to
Discussion: Employers should ensure that workers less than 18 years old
are not assigned to perform prohibited work. If employers do not fully
understand the types of work prohibited for workers under the age of 18,
they should contact the U.S. Department of Labor, Employment Standards
Administration (ESA), Wage and Hour Division. This Division enforces child
labor laws under the Fair Labor Standards Act (FLSA).
The Fair Labor Standards Act (FLSA) prohibits employment of workers younger
than age 18 in nonagricultural occupations which the Secretary of Labor
has declared to be particularly hazardous. Hazardous Order (HO) No. 7
prohibits persons below the age of 18 from operating power-driven hoisting
apparatus including high-lift trucks (i.e., forklifts). Information regarding
the FLSA can be obtained by visiting the DOL ESA web site at http://www.dol.gov/whd/. (Link Updated 1/7/2010) FLSA employment standards for nonagricultural occupations are listed and
explained in Child Labor Bulletin 1013
and summarized in DOL Fact Sheet No. 43.4
Child labor information can also be obtained by calling or visiting offices
of Federal and State child labor departments, located by using the telephone
directory government pages.
Employers should meet with their workforce to communicate the company’s
policies regarding appropriate work assignments for young workers. They
should explain that young workers are at increased risk for injury at
work and reinforce the importance of assigning youths to appropriate work
tasks. They should provide all staff with a description of the youth worker
assignments. They should identify the person(s) responsible for supervision
of young workers, inform all staff about assigned supervisors, and direct
staff to notify supervisors immediately if they see young workers performing
hazardous work or working outside their assigned tasks.
Recommendations 4: Employers should develop, implement, and enforce a
comprehensive written safety program for all workers which includes training
in hazard recognition and the avoidance of unsafe conditions. A written
training plan should require training for all forklift operators that
includes the equipment manufacturers’ recommendations for safe equipment
Discussion: A comprehensive written safety program should be developed
for all workers that includes training in hazard recognition and the avoidance
of unsafe conditions. It should then be noted in a company’s safety
program that certain types of training, i.e., training in forklift operation,
is limited to workers who are at least 18 years of age. All employees
should be instructed that they are not to provide forklift operator training
unless they are trained forklift operators and are assigned to this task
by their employer.
OSHA requires the employer to certify in writing and identify by name
each operator that has been trained, the date of the training, the date
of the evaluation, and the identity of the person(s) performing the training
or evaluation. This training in forklift operation should be given by
a person who has the knowledge, training, and experience necessary to
train operators and should consist of a combination of formal instruction
(i.e., lecture, discussion, interactive computer learning, videotape,
written material), practical training (demonstrations performed by the
trainer and practical exercises performed by the trainee), and evaluation
of operator performance in the workplace. The requirements for training
forklift operators are available at https://www.osha.gov/
and stipulated in Part 29 Code of Federal Regulations, 1910.178 (l)(1)
Additional information useful for training workers about forklift safety
can be found in the NIOSH Alert: Preventing Injuries and Deaths of
Workers Who Operate or Work Near Forklifts1
available through the NIOSH web site at http://www.cdc.gov/niosh
or by calling 1-800-356-4674. The Alert contains a tear-out sheet (Appendix)
that summarizes safety precautions for forklift operators. Posting this
tear-out sheet at the worksite may serve as an additional means of communicating
safe work procedures to workers. Another source of information on forklift
safety is Forklift Safety: A Practical Guide to Preventing Powered
Industrial Truck Incidents and Injuries.2
With regard to turning forklifts, the author explains that “Operators,
especially those that are new, are to be reminded that the turning radius
of a forklift is much smaller that that of an automobile. Operators have
to be reminded that a car carries its load on the inside center of the
vehicle. A forklift carries its load outside of its supporting base. Cars
have four point suspensions, forklifts have three. With this in mind the
forklift can become unstable rather easily. When a forklift is empty there
is a significant weight imbalance. An empty forklift does not imply the
forklift is safe. A forklift can turn over much easier than a car and
at much lower speeds.” The book offers a wide range of guidance
for operating forklifts safely that can be incorporated into training
After the incident, the local manager, whose forklift operator training
certification had lapsed at the time of the incident, was recertified.
He then provided forklift operator training to company employees currently
assigned to operate forklifts. The company has hired a consultant to assist
in developing their comprehensive written safety plan and training program.
Recommendation 5: Employers should identify and label equipment that is
not to be operated by young workers less than 18 years and provide keys
to only trained and authorized machine users.
Discussion: Employers can obtain a sticker that alerts employees that
young workers are not to operate forklifts. Employers can obtain stickers
in English and Spanish that indicate “NO OPERATORS UNDER 18 YEARS
OF AGE. IT’S THE LAW,” from the local Wage and Hour Office
of the U.S. Department of Labor (Photo 4). These
stickers can be downloaded from the internet and should be affixed in
a conspicuous place on forklifts. As an additional safety precaution,
employers should ensure that keys used to operate forklifts are in the
possession of only selected workers whom they have authorized and trained
to operate forklifts. A supervisor should be assigned to ensure, through
periodic inspections, that only authorized and trained operators are operating
Recommendation 6: Equipment manufacturers should consider placing a warning
decal on equipment indicating that the equipment is not to be operated
by workers less than 18 years old, and note this restriction in the operator’s
Discussion: Manufacturers can obtain assistance in identifying forklifts
and other types of equipment that are prohibited for use by workers less
than 18 years old by calling their local DOL Wage and Hour Division office.
These offices can be located by using the telephone directory government
pages. The manufacturer should ensure that the operator’s manual
includes a statement indicating age restrictions for operating and/or
Recommendation 7: School officials and employers participating in work-based
learning programs for youth should ensure that work assigned to youth
is allowed by law, the work environment is safe and free of recognized
hazards, and that youth receive appropriate safety and health training.
Discussion: When special employment arrangements exist, such as employment
of a student-learner through a work-based learning program, school officials
and employers entering into an agreement for employment of a student-learner
should evaluate the tasks to which student learners will be assigned,
identify safety training required, determine who will provide safety training
and supervision, and ensure that workers are trained before work is assigned.
Resources for training young workers can be found in the NIOSH Alert:
Preventing Deaths, Injuries and Illnesses of Young Workers,6
available through the NIOSH web site at http://www.cdc.gov/niosh
or by calling 1-800-356-4674.
All parties signing a work-based learning agreement (school officials,
employer, parent, student-learner) should review the work to which youth
less than 18 years old are assigned to ensure that the assigned work does
not include hazardous occupations, such as operating a forklift. Exemptions
from some hazardous occupations are allowed (but never operation of a
forklift) for student learners in approved programs under a written agreement3
which provides “(i) That the work of the student learner in the
occupations declared particularly hazardous is incidental to the training;
(ii) That such work shall be intermittent and for short periods of time,
and under the direct and close supervision of a qualified and experienced
person; (iii) That safety instruction shall be given by the school and
correlated by the employer with on-the-job training; and (iv) That a schedule
of organized and progressive work processes to be performed on the job
shall have been prepared.”
It would be helpful to list on the agreement, occupations which can never
be exempted and have all parties initial this part of the form
showing that they understand that student-learners are never to perform
occupations which include: manufacturing or storage involving explosives;
motor vehicle occupations; coal mining; logging and sawmilling; occupations
involving exposure to radioactive substances and to ionizing radiation;
power-driven hoisting apparatus (a forklift is a power-driven hoisting
apparatus); occupations in connection with mining other than coal; power-driven
bakery machine occupations; occupations involved in the manufacture of
brick, tile and kindred products; and occupations involved in wrecking,
demolition, and ship breaking operations. The work-based learning agreement
signed in this incident did not include a list of prohibited activities.
The signed agreement included a list of the hazardous occupations that
can be exempted. These exemptions are to be checked when they apply to
the student-learner (none were checked for the victim).
All tasks to which a student-learner will be assigned should be listed
and attached to agreements before agreements are signed by any of the
parties. If there is any change in these tasks, the parties should meet
to ensure that new assignments are not in violation of child labor laws
before the student begins performing the added tasks, and that appropriate
training and supervision is provided to ensure youth safety.
The employer should ensure that the person(s) assigned to supervise the
student-learner at work understand the tasks to which the student learner
can be assigned and those to which they cannot be assigned. A list of
accepted tasks and a list of prohibited tasks should be provided to each
- NIOSH . 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 and Prevention, National Institute for Occupational Safety and
Health, DHHS (NIOSH) Publication No. 2001-109.
- Swartz G . Forklift safety: A practical guide to preventing
powered industrial truck incidents and injuries. Rockville, MD: Government
Institutes, ISBN: 0-86587-663-0.
- DOL (U.S. Department of Labor)[ 2001]. Child labor requirements in
nonagricultural occupations under the Fair Labor Standards Act. Washington,
DC: U.S. Department of Labor, Employment Standards Administration, Wage
and Hour Division, WH-1330. Child labor Bulletin No. 101.
- DOL[2002a]. Fact Sheet no. #43: Child labor provisions of the Fair
labor Standards Act (FLSA) for non-agricultural occupations. [http://www.dol.gov/whd/regs/compliance/whdfs43.htm (Link updated 1/7/2010)].
Accessed May, 2004.
- Code of Federal Regulations . 29 CFR 1910.178 (1)(1). Powered
industrial truck operator training. Washington, DC: U.S. Government
Printing Office, Office of Federal Register.
- NIOSH . Alert: Preventing deaths, injuries, and illnesses of
young workers. Cincinnati, OH: U.S. Department of Health and Human Services,
Public Health Service, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health, DHHS (NIOSH) Publication
This investigation was conducted by Doloris N. Higgins, Occupational
Safety and Health Specialist, Fatality Investigations Team, Surveillance
and Field Investigations Branch, Division of Safety Research.
|Photo 2. This photo illustrates
a close-up of the ramp to the warehouse.
|Photo 3. This photograph
illustrates the parking lot, warehouse and ramp, and other co-op buildings.
Lines on the photo approximate the travel path of the forklift on
the day of the incident. An “X” marks the approximate
location of the forklift that had tipped over. Photograph courtesy
of the Tennessee Department of Labor and Workforce Development, Division
of Occupational Safety and Health.
|Photo 4. This photo illustrates
the sticker “ NO OPERATORS UNDER 18 YEARS OF AGE. IT’S
THE LAW,” which is available from the local Wage and Hour office
of the U.S. Department of Labor or from the DOL web site
http://www.youthrules.dol.gov/news/posters-stickers-bookmarks/index.htm (Link Updated 3/14/2013)
Source: NIOSH . NIOSH Alert: Preventing Injuries and
Deaths of Workers Who Operate or Work Near Forklifts. U.S.
Department of Health and Human Services, Centers for Disease Control and
Prevention, National Institute for Occupational Safety and Health, DHHS
(NIOSH) Publication No. 2001–109. Fax: 513–533–8573
or visit the NIOSH Web site at http://www.cdc.gov/niosh
for a copy.
Preventing Injuries and Deaths of Workers
Who Operate or Work Near Forklifts
Workers who operate or work near forklifts may be struck or crushed
by the machine or the load being handled.
Workers: If you operate or work near forklifts, take
these steps to protect yourself.
- Do not operate a forklift unless you have been trained and licensed
- Use seatbelts if they are available
- Report to your supervisor any damage or problems that occur to a forklift
during your shift
- Do not jump from an overturning, sit-down type forklift. Stay with
the truck, holding on firmly and leaning in the opposite direction of
- Exit from a stand-up type forklift with rear-entry access by stepping
backward if a lateral tip over occurs
- Use extreme caution on grades or ramps
- On grades, tilt the load back and raise it only as far as needed to
clear the road surface
- Do not raise or lower the forks while the forklift is moving
- Do not handle loads that are heavier than the weight capacity of the
- Operate the forklift at a speed that will permit it to be stopped
- Slow down and sound the horn at cross aisles and other locations where
vision is obstructed
- Look toward the travel path and keep a clear view of it
- Do not allow passengers to ride on forklift trucks unless a seat is
- When dismounting from a forklift, set the parking brake, lower the
forks or lifting carriage, and neutralize the controls
- Do not drive up to anyone standing in front of a bench or other fixed
- Do not use a forklift to elevate workers who are standing on the forks
- Elevate a worker on a platform only when the vehicle is directly below
the work area
- Whenever a truck is used to elevate personnel, secure the elevating
platform to the lifting carriage or forks of the forklift
- Use a restraining means such as rails, chains, or a body belt with
a lanyard or deceleration device for the worker(s) on the platform
- Do not drive to another location with the work platform elevated