Investigation: # 01MI068
Worker Falls From Wooden Pallet During Remodeling Work at a Fruit Processing Facility
|Figure 1. Police Department Photograph|
On August 22, 2001, a 55-year old male was injured when he
fell from a wooden pallet being used as a personnel platform. On September 4,
2001, MIFACE investigators were informed by the Michigan Occupational Safety
and Health Administration (MIOSHA) 24-hour fatality report system that a work-related
injury occurred on August 22, 2001, resulting in the death of the victim on
August 31, 2001. On November 26, 2001, a MIFACE researcher visited the facility.
The MIFACE researcher spoke with a company representative, but was not permitted
to visit the incident site or talk with the witnesses of this incident. The
death certificate, autopsy results, police report, and the MIOSHA narrative
were obtained during the course of the investigation.
The MIOSHA investigation resulted in 8 citations. One citation was issued for the lack of construction safe operating procedures, hazards, and safeguards in their written health and safety program. One citation addressed the personal protection of employees; they were not wearing hard hats. Five citations were directed at the scaffold issues: scaffold training, personal fall arrest system, platform access, the use of the wood pallet as a platform, and that the work platform did not comply with the requirements of the scaffold and scaffold platform safety standard. One additional citation was issued for unprotected roof edges when employees were working on the roof.
The incident occurred at a fruit processing and packaging plant. The company has been in business for approximately 40 years and employs 150+ employees. Approximately 45 employees were on site at the time of the incident. The company has been at the current site approximately 3 years, and was doing some remodeling of the facilities. The company was extending a roof from one building to another building. The company had no other building remodeling plans. The company has a written health and safety program, and, according to the company representative, there were specific procedures in place for lifting employees with a forklift. MIFACE was not permitted to look at the forklift operator-training program, nor the written health and safety program to ascertain if the program addressed issues related to this fatality. There is a joint health and safety committee that meets monthly, and semi-annual safety training is provided to employees. The safety training incorporated classroom, videos, and on-the-job training.
The victim had been employed as a maintenance person with the company for 7 years, and had a valid operator’s permit to operate a forklift. The victim had worked in another plant area that morning driving a forklift and delivering fruit. At lunch, the supervisor talked to him about removing the fascia boards. This was the first time that the victim had performed this type of task, according to the company representative. The supervisor did not cover health and safety issues applicable to the operation. The company required that safety glasses and gloves be worn during the remodeling; hard hats were not required. Harnesses were available for confined space, but no personal fall arrest systems were available.
MIOSHA Construction Safety Standard Part 12, Scaffolds and Scaffold Platforms defines a scaffold as a temporary elevated platform which is supported or suspended, including its supporting system and points of anchorage, and which is used for supporting an employee or materials or both. The wood pallet used is considered to be a scaffold under MIOSHA.
The firm had been doing the roofing work for three days. Employees
had been removing some roofing materials and 2”x10”x12’ long
fascia boards located approximately 12 feet above a concrete floor. The victim
and two coworkers arrived at the fascia removal site. Two fascia boards needed
removal. Coworker #1 had a valid forklift operator’s permit. It is unknown
what the content and extent of operator training the forklift driver received
before lifting the victim. The working surface for the forklift was level. A
wooden pallet (See Figure 1) was placed on the forks of
a Case Forklift, model G530 rough terrain forklift.
|Figure 2. Police Department Photograph|
There was an approved personnel-lifting platform that met General Industry safety standards, approximately 50 feet away; the platform was not used.
Co-worker #1 raised the victim standing on the pallet approximately 6 feet high, exited the forklift and stood on the forklift roll cage to assist the victim during board removal. Coworker #2 was standing on the ground to help lower the fascia board to the ground. The victim used a crowbar to loosen the fascia board. (See Figure 2) While pulling away one of the fascia boards, the long end of the board struck the wooden pallet, and caused the victim to lose his balance. He fell off of the pallet, landing on his back on the cement floor. The pallet remained on the forklift; the fascia landed next to the victim.
One of the coworkers called for emergency assistance. After providing emergency assistance at the scene, the victim was transported to a local hospital. He died 10 days later at the hospital.
CAUSE OF DEATH
The medical examiner recorded the cause of death as cerebral edema due to a closed head injury. No alcohol or drugs of abuse were found in the victim’s blood or urine.
MIOSHA Construction Safety Standard Part 12, Scaffolds and
Scaffold Platforms Rule 1243 (4) lists the specific requirements a work platform
must meet to be used for elevating employees with a rough terrain forklift.
The wood pallet used to elevate the victim did not meet the specific requirements
listed in Rule 1243(5). The pallet did not have other platform requirements,
such as scaffold sleeves, a securing mechanism, and employee protection from
moving parts of the mast. Employers must enforce the use of approved personnel
The police report stated that one of the witnesses indicated that the reason the wood pallet was used because it was more convenient and less restrictive than the platform with the side rails. The importance of side rails is evident in this incident. The pallet was not secured to the mast, did not have fork sleeves, side rails, safety chain or toe board.
Although the unsecured pallet did not fall off of the forks
when the fascia board hit it, the employee did fall as a result from a loss
of balance. A properly secured, approved work platform with side rails may have
prevented the employee from falling off the platform.
The employer stated that employees who were authorized to drive a forklift received training on elevating co-workers. This training does not appear to have been adequate. The employees did not choose the approved lifting platform because of the restriction it placed on the work being done; safety concerns were secondary to job completion.
The MIOSHA Scaffold Standard Rule 1243(1) requires that when
a rough terrain forklift is used to elevate personnel, a pre-lift meeting must
be held. The pre-lift meeting must occur before the employee(s) are elevated
and include all persons involved in the lift (i.e., the lift operator, signal
person, employee(s) to be lifted and the person responsible for the task to
be performed). The meeting must address the requirements and procedures to be
followed so a safe work operation may occur. An initial assessment of the job-at-hand
should include identification of the hazards involved.
The supervisor talked to the victim prior to the lift to instruct
him to remove the fascia boards, but to the knowledge of the company representative,
did not address safe work procedures. It is unknown if the supervisor talked
to the other coworker who performed the lift about safe work procedures. A pre-lift
meeting should have covered the importance of selecting the proper platform,
i.e. the work platform located 50 feet from the operation would provide the
safety features necessary to minimize the risk of employee injury from a fall.
The pre-lift meeting should also address the need for fall protection and appropriate personal protective equipment such as hard hats, gloves, safety glasses, etc.
Part 12, Rule 1243(9) states that if an employee is elevated
in a platform on a variable reach lift truck, a personal fall arrest system,
including anchorage required in Part 45, Fall Protection and Part 6, Personal
Protective Equipment is required and shall be worn when an employee is elevated.
The employee was elevated approximately 6 feet above a concrete floor. If the worker had a correctly attached personal fall arrest system, when he lost his balance, he would not have fallen to the concrete floor. He would have been suspended from the elevated fork/mast. The fatal injury may have been prevented if he had been wearing a correctly attached, approved fall protection system.
The company representative stated that the company did have a comprehensive health and safety program. According to the representative, the powered industrial truck operator training covers how to safely elevate an employee to perform work. The policy mandates that the lifting cage be used when an employee is elevated. The policy was not enforced in this incident.
The company did not have a written procedure in place for the
removal of the fascia boards. A job hazard analysis is a procedure used to review
each job, identify potential hazards, and design actions and procedures to eliminate
or control the hazards. The fascia removal was considered a one-time event,
the workers involved were unfamiliar with how to safely perform fascia removal,
and specific employee training for this activity was not provided. Of primary
importance is the recognition that hazards exist; it is unknown if the employees
were aware of the hazards of working on the wooden pallet; the statement that
it was easier to work on the pallet and not in the protective cage does not
indicate that they were unaware, only that a decision was made to not use the
lift cage due to the restrictions it provided. Company policies and training
should be implemented based upon the findings of the job hazard analysis.
It is unknown if the company health and safety program has
a section about conducting a job hazard analysis for existing and new work procedures,
and for providing employee job hazard analysis training. Especially in the performance
of a one-time activity, a job hazard analysis should be conducted so employees
can recognize unsafe work practices and potentially hazardous work conditions
when setting up and performing the activity. The employer (or outside consultant)
can provide hazard analysis training as part of the development and implementation
of the company health and safety program.
A copy of the OSHA Job Hazard Analysis publication is included with this report. This document may also be found and downloaded from the OSHA website: http://www.osha.gov/pls/publications/publication.html. A job hazard analysis may have potential safety issues, such as employee balance issues during the removal of the long fascia boards, the necessity of using a platform with side rails to prevent a fall, the proper location of other employees (one employee was standing on the forklift cab and also could have fallen), and the identification of appropriate personal protective equipment. Employees were using gloves and safety glasses, but should have also worn a hard hat due to the hazard of falling objects during the fascia removal operation.
The company considered the renovation as a maintenance activity;
MIOSHA considered the activity a construction activity. The company’s
health and safety program did not include specific references to construction
safety requirements, such as a pre-lift meeting. Generally, forklift trucks
are used in settings other than construction in a material handling capacity;
they are not used primarily to lift employees. If the available basket was used,
the accident may have been prevented, but the company would still have been
in non-compliance with the construction standard, since they did not have apre-lift
meeting. The company health and safety policy must address anticipated construction
activities if the company is to be in compliance with the construction standard.
The company representative stated that they were unaware that facia removal was considered a construction activity. Companies that primarily comply with general industry standards may not be familiar with the health and safety requirements of the construction standards. MIFACE recommends that MIOSHA consider developing additional information to assist these companies to recognize potential construction operations/activities. With the knowledge the MIOSHA information would provide, companies could evaluate their health and safety program in light of a potential construction activity, identify construction standards applicable to the activity, incorporate into their program the appropriate measures/equipment required by the standard(s), and provide appropriate employee training.
General Industry Safety Standard Part 21, Powered Industrial
Trucks, Rule 2166 (Order picker trucks, high lift platforms) and Rule 2167 (fork
lift truck platforms) contain the requirements for an employee lift platform.
Part 21 also contains both an employee training and a performance-testing component
to ensure that the operator can operate the truck through the functions necessary
to perform the required job. If the forklift is used to lift employees, this
activity should be covered in the training and tested. If the forklift is used
infrequently to lift employees, the forklift operator and co-workers may underemphasize
and/or not recognize the safety implications of not using the proper lifting
platform and personal safety equipment.
Before an employee is elevated, a pre-lift meeting would highlight
the importance of properly and safely performing the lift. A pre-lift meeting
could review the appropriate requirements and procedures to be followed by all
involved in the lift, such as: the platform meets safety requirements and attached
so it cannot tip off of the forks, the truck is on firm footing, the platform
is returned to the ground before the truck is repositioned, the lifting mechanism
is operating smoothly, identifying overhead electrical hazards, specifying required
personal protective equipment, etc.
To encourage employers and employees to safely perform a personnel lift in settings other than construction, MIOSHA may wish to consider exploring whether there are circumstances in general industry settings where a pre-lift meeting would be beneficial in increasing the worker safety when elevating personnel, the applicability, and possible incorporation of a pre-lift meeting requirement in the General Industry Safety Standard Part 21, Powered Industrial Trucks.
MIOSHA Standards cited in this report can be directly accessed from the Consumer and Industry Services, MIOSHA website http://www.michigan.gov/lara/0,4601,7-154-61256_11407_15368---,00.html.
The Standards can also be obtained for a fee by writing to the following address: Department of Consumer and Industry Services, MIOSHA Standards Division, P.O. Box 30643, Lansing, MI 48909-8143. MIOSHA phone number is (517) 322-1845.
MIFACE (Michigan Fatality and Control Evaluation), Michigan State University
(MSU) Occupational & Environmental Medicine, 117 West Fee Hall, East Lansing,
Michigan 48824-1315. This information is for educational purposes only. This
MIFACE report becomes public property upon publication and may be printed verbatim
with credit to MSU. Reprinting cannot be used to endorse or advertise a commercial
product or company. All rights reserved. MSU is an affirmative-action, equal
To contact Michigan 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.
OSHA JOB SAFETY ANALYSIS
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