|Massachusetts Case Report: 03-MA-034-01
Release Date: July 6,
On July 1, 2003, a 16-year-old male stock clerk (the victim) was fatally
injured when the sit-down forklift he was operating overturned. The victim,
who was not wearing a seatbelt, was operating the forklift with the tines
raised on an outdoor ramp next to the building's loading dock. The forklift
started to tip and he attempted to either jump away from the forklift
or was thrown from the operator's seat when the forklift overturned. The
forklift's falling object protective structure (FOPS) landed on the victim's
chest and abdomen area. A coworker found the victim and yelled for help.
Other coworkers ran to assist the victim and they were able to lift the
forklift enough to free the victim. Coworkers then began cardiopulmonary
resuscitation (CPR) while Emergency Medical Services (EMS) were notified.
EMS responded to the incident site within minutes and transported the
victim to a local hospital where he was pronounced dead. The Massachusetts
FACE Program concluded that to prevent similar occurrences in the future,
- provide adequate supervision for young workers, new employees and
- establish work policies and procedures that comply with federal and
state child labor laws prohibiting youth less than 18 years of age from
performing hazardous work, including operating forklifts
- ensure that forklift keys are kept in a locked location and only accessible
by trained and authorized employees
- develop, implement and enforce a written comprehensive safety program
that includes training in safe operation of forklifts.
In addition, employers, distributors, and manufacturers should:
- place warning stickers on forklifts that state that forklifts are
not to be operated by workers under 18 years of age.
On July 2, 2003, the Massachusetts FACE Program was alerted by the local
media, that on July 1, 2003, a 16-year-old male was fatally injured when
the forklift he was operating overturned. An investigation was immediately
initiated. On July 29, 2003, the Massachusetts FACE Program Director traveled
to the incident location, a plumbing supply company, where the company
owner was interviewed. The death certificate, corporate information, police
report, and the OSHA fatality and catastrophe report were reviewed and
photographs of the incident location were taken during the course of the
The employer, a plumbing supply company, had been in business for approximately
75 years. The current owners bought the company approximately 27 years
prior to the incident. The company has eight locations in Massachusetts.
The incident location had been purchased approximately two years prior
to the incident. The company employed approximately 100 people, 12 of
these employees worked at the incident location. The victim and one other
employee were hired for the summer months, while they were on school vacation,
both held the title of stock clerk / general help. The victim had started
work approximately one week prior to the incident. The company owner reported
that the victim had a work permit. In addition, the victim's father worked
at the incident location as a salesperson.
The company did not have a designated person in charge of employee safety
and health nor did they have a safety and health program, but did have
a company handbook that contained job descriptions. The company owner
reported that their forklift operators, not including the victim, held
the Massachusetts Department of Public Safety issued 1C Hoisting license,
which are required in Massachusetts to operate forklifts. The company
employees were not part of a union collective bargaining unit.
The company was comprised of four divisions: plumbing, heating, industrial
supplies and kitchen supplies. The incident location consisted of a showroom,
sales counter and warehouse/stock area. The victim's main tasks were described
as labeling bins, moving around materials and putting away stock, such
as faucets and other small plumbing type products.
The incident company had purchased another plumbing supply company approximately
two years prior to the incident. The incident company acquired the forklift
with the incident location as part of this sale. This forklift was the
only one at the incident location. The company was not sure when the forklift
was manufactured and could not find the owner's manual at the time of
the investigation. The 3,000-pound-capacity sit-down forklift was propane
powered, had an operable seatbelt and a falling object protective structure
On the day of the incident, the victim had started work at 7:30 a.m.
and the incident occurred at approximately 4:30 p.m., at the end of the
workday. The victim, along with other coworkers, had been cleaning up
for the close of the business day. There were nine employees on site at
the time of the incident.
The incident location had an outdoor cement loading dock ramp that sloped
away from the building at an angle of approximately 33 degrees (Figure
1). Although not witnessed, the company owner reported that the victim
had boarded the forklift, which had the key in the ignition switch, and,
without putting on the seatbelt, raised the forklift tines with an empty
pallet to a height of approximately 10 feet. The victim then drove the
forklift in the forward direction, with the empty pallet on the raised
tines, down the left side of the loading dock ramp. It appears that the
victim was attempting to place the empty pallet on top of a stack of pallets
located at the bottom of the loading dock ramp.
When the forklift started to tip, the victim either attempted to jump
away from the forklift or was thrown from the operator's seat. As the
forklift overturned, it fell off of the bottom left edge of the loading
dock ramp, approximately one-foot to the ground level. The forklift's
FOPS crushed the victim's chest and abdomen area as it landed on top of
him. The combination of the forklift tines being raised 10 feet and the
33-degree slope of the loading dock ramp may have shifted the forklift's
center of gravity causing the forklift to overturn onto its left side.
A coworker found the victim and yelled for help. Other coworkers came
running to assist the victim and they were able to lift the forklift enough
to free the victim. Coworkers then began cardiopulmonary resuscitation
(CPR) while Emergency Medical Services (EMS) were notified. EMS responded
to the incident site within minutes and transported the victim to a local
hospital where he was pronounced dead.
During the investigation, the company owner reported that the victim
had operated the forklift in the past and that the victim had been warned
against using the forklift. The employer also mentioned that the local
fire department requires forklift keys to be kept in forklifts at night
in case of a fire so the forklifts can be removed from the building. The
FACE program contacted the local fire department and asked about leaving
keys in forklifts at night. The fire department's response was that there
is no requirement and they don't ask employers to do this.
Cause of Death
The medical examiner listed the cause of death as blunt force abdominal
Recommendation #1: Employers should provide adequate supervision for
young workers, new employees and inexperienced workers.
Discussion: Research indicates that 80 percent of occupational
injuries to young workers occur when no supervisor was present in the
immediate work area. There is also evidence that inexperienced workers
are at a higher risk of occupational injury than experienced workers.
Employers of young workers, new employees and inexperienced workers should
provide adequate and frequent supervision for these employees. An adequate
supervisor would be a person who has the knowledge, training, and experience
to routinely evaluate the worker's performance and competency and has
the authority to enforce workplace policies and procedures.
In this case, the victim was operating a forklift during the un-witnessed
incident. The company owner reported that the victim was told prior to
the incident not to operate the forklift. Adequate supervision would have
involved routine checks to ensure that the victim was performing only
tasks to which he was assigned with consequences for violating the rules.
Recommendation #2: Employers should establish work policies and procedures
that comply with federal and state child labor laws prohibiting youth
less than 18 years of age from performing hazardous work, including operating
Discussion: State and federal child labor laws are intended
to protect working youth by prohibiting their employment under conditions
that would be detrimental to their health or well being. These laws establish
minimum ages for employment, limit the hours and times of day youth can
work and prohibit employment of youth in certain jobs/tasks deemed as
particularly hazardous for young workers. The federal Fair Labor Standards
Act prohibits youth less than 18 years old in nonagricultural occupations
from performing certain jobs that are particularly hazardous (Hazardous
Orders). Hazardous Order (HO) No. 7 prohibits persons below the age of
18 from operating power-driven hoisting apparatus, which includes forklifts.
The Massachusetts State child labor law also prohibits workers under the
age of 18 from operating any motor vehicles, including forklifts (Massachusetts
General Laws Part II Title XXI Chapter 149 Section 62).
In this case, the victim who was 16 years old had been seen operating
the forklift in the past to transport wooden pallets. Once this was observed,
the company owner reported that the victim was told not to operate the
forklift. Employers should establish policies and procedures to make certain
that workers under 18 years of age are not performing tasks prohibited
by child labor laws and ensure that all staff including supervisors are
trained in these polices. In addition, employers should explain to supervisors
that young workers are at increased risk for injury at work and reinforce
the importance of assigning youth to appropriate work tasks.
Reference and educational materials on child labor laws can be obtained
by contacting either the Massachusetts Attorney General Office, Fair Labor
and Business Practices Division, the U.S. Department of Labor's Wage and
Hour Division, or the Massachusetts Department of Public Health, Teens
at Work: Injury Surveillance and Prevention Project.
Recommendation #3: Employers should ensure that forklift keys are kept
in a locked location and only accessible by trained and authorized employees.
Discussion: Although not required by the local fire
department, the company owner reported that keys were left in the forklift
ignition switch to ensure that the forklift could be moved out of the
building in case of a fire. This practice could create a welcoming situation
for any employee to operate the forklift. Keeping the forklift keys in
a locked storage location and giving access only to employees that are
licensed (1C Hoisting license) through the Massachusetts Department of
Public Safety, would eliminate the possibility of non-licensed employees
including any employee under 18 years of age from operating forklifts.
Recommendation #4: Employers should develop, implement and enforce a written
comprehensive safety program that includes training in safe operation
Discussion: A written comprehensive safety program should
be developed with employee input, implemented and strictly enforced by
the employer. In this case, a written comprehensive safety program should
include, but not be limited to, sections on young workers, hazard recognition,
and the avoidance of unsafe conditions. A summary of OSHA's draft proposed
safety and health program rule, which discusses employee training, has
been included at the end of this report.
The young worker section of a safety program should include child labor
laws and the role of supervisors (discussed in above recommendations).
The safety program should also include standard operating procedures (SOP)
that have sections on hazard recognition and avoidance of unsafe conditions.
In this case, a SOP should include forklift stability, safe operating
speeds and forklift maneuverability. Also, prohibiting the driving of
forklifts with the tines raised, use of operator seat restraints at all
times, and knowledge of how to respond when a forklift starts to tip should
be addressed in the safety program.
When a forklift is overturning the operator should make every attempt
to stay within the operator's compartment. This can be accomplished by
the operator wearing the seat restraint, holding on firmly, leaning in
the opposite direction that the forklift is tipping, and keeping all body
parts within the operator's compartment. It is very important that the
operator does not attempt to jump from the operator's compartment when
a forklift is overturning. By staying inside the operator's compartment
during a overturn, the operator can greatly reduce the risk of being crushed
by the overhead guard or another rigid part of the forklift.
Recommendation #5: Employers, distributors, and manufactures should place
warning stickers on forklifts that state that forklifts are not to be
operated by workers under 18 years of age.
Discussion: A few years prior to this incident, a similar
incident occurred in Massachusetts involving a 16-year-old male worker
who was also killed when a forklift he was operating overturned. This
incident led the Massachusetts Department of Public Health, FACE Project
and the Teens at Work: Injury Surveillance and Prevention Project to develop
a young worker forklift safety sticker (Figure 2).
This sticker is available from the Massachusetts Department of Public
Health, from the local Wage and Hour office of the U.S. Department of
Labor and from the DOL web site http://youthrules.dol.gov/news/posters-stickers-bookmarks/index.htm.
(Link updated 3/21/2013)
Employers and distributors should affix these stickers in a conspicuous
place on forklifts. In addition, during the manufacturing process, manufacturers
should consider adding a similar sticker to all forklifts and other equipment
that are prohibited for use by workers under 18 years of age.
- 29 CFR 1910.178 . Powered industrial truck operator training,
Washington, DC: U.S. Government Printing Office, Office of Federal Register.
- 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, Center for Disease
Control, National Institute for Occupational Safety and Health, DHHS
(NIOSH) Publications No. 2000-112.
FACE Report Number 00MA058-01, Massachusetts Youth Killed While
Operating Forklift at Seafood Processing Facility.
FACE Report Number 2002-02, Seventeen-Year-Old Warehouse Laborer
Dies After the Forklift He Was Operating Tipped Over and Crushed Him
- National Academy Press, Protecting Youth at Work, Washington, D.C.,
Figure 1 –
2 – Young worker forklift safety sticker
Summary of OSHA'S Draft Proposed Safety and
Health Program Rule for Employers
(29 CFR 1900.1 Docket No. S&H-0027)
- Management leadership and employee participation
- Hazard identification, assessment, prevention
- Access to information and training
- Evaluation of program effectiveness
- Set up a safety and health program, with employee
input, to manage workplace safety and health to reduce injuries, illnesses
- Ensure that the safety and health program is appropriate
to workplace conditions taking into account factors such as hazards
employees are exposed to and number of employees.
- Establish and assign safety and health responsibilities
to an employee. The assigned person must have access to relevant information
and training to carryout their safety and health responsibilities and
receive safety and health concerns, questions and ideas from other employees.
- Regularly communicate with employees about workplace
safety and health matters and involve employees in hazard identification,
assessment, prioritization, training, and program evaluation.
- Establish a way and encourage employees to report
job-related fatalities, injuries, illnesses, incidents, and hazards
promptly and to make recommendations about appropriate ways to control
Identify and assess hazards to which employees are exposed
- Conduct inspections of the workplace at least
every two years and when safety and health information change or when
a change in workplace conditions indicates that a new or increased hazard
may be present.
- Evaluate new equipment, materials, and processes
for hazards before introducing them into the workplace and assess the
severity of identified hazards and rank those hazards that cannot be
corrected immediately according to their severity.
Investigate safety and health events in the workplace
- Thoroughly investigate each work-related death,
serious injury, illness, or incident (near miss).
Safety and health program record keeping
- Keep records of identified hazards, their assessment
and actions taken or the plan to control these hazards.
Hazard prevention and control
- Comply with the hazard prevention and control
requirements of the OSHA standards by developing a plan for coming into
compliance as promptly as possible, which includes setting priorities
and deadlines for controlling hazards and tracking the progress.
Information and training
- Ensure each employee is provided with safety and
health information and training.
- If an employee is exposed to hazards, training
must be provided on the nature of the hazards to which they are exposed
to and how to recognize these hazards. Training must include what is
being done to control these hazards and protective measures employees
must follow to prevent or minimize their exposures.
- Safety and health training must be provided to
current and new employees and before assigning a job involving exposure
to a hazard. The training should be provided routinely, when safety
and health information is modified or a change in workplace conditions
indicates a new or increased hazard exists.
Program evaluation and maintenance
- Evaluate the safety and health program at least
once every two years or as often as necessary to ensure program effectiveness.
- Revise the safety and health program in a timely
manner once deficiencies have been identified.
- The host employer's responsibility is to provide
information about hazards and their controls, safety and health rules,
and emergency procedures to all employers at the workplace. In addition,
the host employer must ensure that assigned safety and health responsibilities
are appropriate to other employers at the workplace.
- The contract employer responsibility is to ensure
that the host employer is aware of hazards associated with the contract
employer's work and how the contract employer is addressing them. In
addition, the contract employer must advise the host employer of any
previously unidentified hazards at the workplace.
To contact Massachusetts
State FACE program personnel regarding State-based FACE reports, please
use information listed on the Contact Sheet on the NIOSH FACE web site
Please contact In-house
FACE program personnel regarding In-house FACE reports and to gain
assistance when State-FACE program personnel cannot be reached.