Fatality Assessment and Control Evaluation (FACE) Program
A Youth Dies When a Forklift Rolls Over on Him
A 17-year-old Hispanic male died when he was crushed by a forklift that rolled over on him. The victim had been employed with the company for only one hour and had not yet received safety training. The victim was attempting to retrieve some bales of hay for a customer when the incident occurred. The company kept the forklift keys in the ignition of the forklift during normal business hours. The CA/FACE investigator determined that, in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP), should:
On Wednesday, June 9, 2004, at approximately 11:50 a.m., a 17- year-old Hispanic male died when the forklift he was operating rolled over on him. The CA/FACE investigator learned of this incident on June 24, 2004, from the Division of Occupational Safety and Health (Cal/OSHA). On July 7, 2004, the CA/FACE investigator traveled to the business where the incident occurred, and interviewed the company’s store manager and co-workers. The machine involved in the incident was photographed, and the area where the incident took place was also photographed and inspected.
The employer of the victim was a grain and hay store. The company had been in business for 11 years and had only three employees. The victim had been employed approximately one hour when the incident occurred. The victim was born in the United States, and spoke both English and Spanish. The victim had no employment history but he and his family were regular customers of the store for many years and the store manager was well acquainted with him. According to the store manager, he informally paid the victim out of his own pocket to do tasks around the store like sweeping floors, pulling weeds, and washing cars. The store manager stated he hired the victim the morning of the incident and planned to complete paper work for a new hire later that day.
The company did not have a written safety program, however there were
safety responsibilities assigned to all employees. The store was regularly
inspected for safety hazards by the store manager, and a representative
of their insurance carrier. The store also had a bulletin board with official
safety notices and posters attached. Safety meetings were held every three
months and were documented. The company had a training program that provided
specific training to its employees for the tasks being performed at the
store. The training program had a system to evaluate how well the employee
understood the training and this was documented. The victim had not received
any training prior to the incident.
The site of the incident was a commercial grain and hay feed store with an asphalt paved yard. The machine involved in the incident was a propane-powered forklift (Exhibit 2). The victim’s job title was a “bag hauler,” and his duties consisted of placing the items a customer purchased in a bag and then carrying the bag to the customer’s vehicle. The victim had graduated from high school, and was planning to work part-time, no more than three days per week, and no more than five hours per day.
On the day of the incident, the victim reported for his first day of work at the grain and hay feed store. The store manager had to go to the bank with the store receipts from the previous day. The store manager instructed another employee to work the cash register while he was gone and instructed the victim to “hang loose” until he returned. While the store manager was gone, customers were making purchases and the victim assumed the duties of a bag hauler. The employee assigned to the cash register was helping a customer who ordered three bales of hay, along with other items from the store, when he heard the forklift start up. A few minutes later another customer came running into the store stating the forklift had just turned over by the hay stacks. The employees and customers ran out of the store and found the forklift lying on its left side with the victim pinned underneath. The forklift was removed from the victim with the help of employees from a neighboring business. The paramedics were called and transported the victim to the hospital where he died.
According to witnesses, the victim overheard a customer order three bales of hay and then decided on his own to get the bales using the forklift. The forklift was always parked on the side of the store with the keys in the ignition. The victim started the forklift and then drove to the other end of the yard where the hay was stacked. The hay bales were stacked seven bales high, so the victim raised the forklift mast and attempted to get the top bale. With the forklift mast raised high in the air, the victim backed the forklift over a rain gutter built into the asphalt yard. The victim lost control of the forklift and it overturned on its left side, pinning the victim as he attempted to jump free.
Cause of Death
The cause of death, according to the death certificate, was mechanical compression of the torso.
Recommendation # 1: Ensure employees under the age of 18 do not operate power-driven machinery.
Discussion: In general, workers less than 18 years of age do not possess the experience, or the physical and emotional maturity, of older workers. They often attempt to balance conflicting time constraints from work and school by sleeping less. These are all factors that may place younger workers at increased risk for harm. Studies have shown that all factory workers and miners have higher rates of injuries the first five months on the job, and younger workers have higher rates than older workers. Laws and regulations try to shield the youngest workers from the most hazardous tasks. In a work setting like the one in which this incident occurred, there are several things employers can do to help ensure workers under age 18 do not use power-driven machinery. These include:
Exhibit 2. The forklift involved in the incident.
Exhibit 3. The forklift mast in the raised position.
Exhibit 4. The rain gutter built into the asphalt yard.
Exhibit 5. “NO OPERATORS UNDER 18 YEARS OF AGE. IT’S THE LAW,”
The California Department of Health Services, in cooperation with the Public Health Institute and the National Institute for Occupational Safety and Health (NIOSH), conducts investigations on work-related fatalities. The goal of this program, known as the California Fatality Assessment and Control Evaluation (CA/FACE), is to prevent fatal work injuries in the future. CA/FACE aims to achieve this goal by studying the work environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury, and the role of management in controlling how these factors interact. NIOSH-funded, state-based FACE programs include: Alaska, California, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, New York, Oklahoma, Oregon, Washington, West Virginia, and Wisconsin.
To contact California State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE website. Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.