|Oklahoma Case Report: 05-OK-117-01
A 21-year-old Hispanic laborer died on October 29, 2005 from head trauma after being struck
by a steel rectangular tube beam. At the time of the incident, the decedent and his coworker
were standing on a 32-inch by 48-inch platform that was elevated approximately six feet
above the ground by a forklift. They were preparing to secure a steel beam into place that
was being supported by a second forklift and wooden post. The steel beam consisted of two
20-foot long sections welded together. The middle of the beam rested on the forks of the
second forklift 11 feet, 6 inches above the ground. As the victim and his coworker were
preparing to bolt the beam into place, the forklift operator raised the beam to shift it to the
south. As he did that, the steel beam came off the south support post and tipped over. The
forklift’s hydraulic side shift was malfunctioning, but it is unknown whether that contributed to
the injury. The beam struck the decedent in the head and knocked his coworker off the
platform. A call was immediately placed for emergency response. The decedent was taken to
the nearest hospital by emergency medical services (EMS) and then airlifted to another
hospital where he was pronounced dead later that same day.
Oklahoma Fatality Assessment and Control Evaluation (OKFACE) investigators concluded
that to help prevent similar occurrences, employers should:
- Ensure that employees do not position themselves under elevated loads.
- Ensure that employees wear hard hats when working in areas where there is a potential
for head injury from falling or flying objects and fall protection when working at elevations
of six feet or more.
- Ensure that forklift operators elevate personnel only with approved lifting cages that are
properly attached to machinery.
- Develop, implement, and enforce a comprehensive written safety program and training in
the language(s) and literacy level(s) of all workers, which includes training in hazard
recognition and the avoidance of unsafe conditions.
- Ensure that forklifts and other machinery in need of repair are tagged and taken out of
service until maintenance personnel perform repairs.
On October 29, 2005, a 21-year-old Hispanic laborer died from head trauma after being
struck by a steel beam. OKFACE investigators were notified of the incident and conducted an
interview with the employer on January 11, 2006. OKFACE investigators reviewed the death
certificate and reports from the Medical Examiner, emergency medical services, local fire
department, and the Occupational Safety and Health Administration (OSHA).
Employer: The victim was employed by a roof truss manufacturing company. The company
had been in business for 20 years and employed approximately 10 full-time workers. Written
task-specific safe work procedures were available for all regularly performed tasks and the
employer conducted monthly safety meetings. The company had a written safety and health
program. Enforcement procedures for machinery operator training and evaluation were
utilized for some, but not all, machinery operators. The company did not have a
labor/management safety and health committee or written machine-specific safe operating
Victim: The victim was born in Mexico and had lived in the United States for an unknown
amount of time. He had been employed by the company for six months and his previous work
history and experience were unknown. His primary language was Spanish; he could not read
English and spoke very little English. English was the primary language of the employer and
direct supervisor; one of the victim’s coworkers was bilingual and could provide translations
as necessary, but he was not on-site during the incident.
Training: Task-specific on-the-job training was provided to employees. Classroom and on-the-
job machine-specific training was provided for some, but not all, forklift operators. At least
two persons who worked for the company had received forklift training and operator
certification from a local vocational school. The decedent received on-the-job training, but he
did not receive forklift operator certification training. The employer maintained records of
those employees who did receive forklift operator training. The company’s standard operating
procedures did not address the task being performed at the time of incident, as the task was
not part of regular employee duties or company operations.
Incident Scene: The incident occurred on company property at the lumber storage building
(Figure 1). The employer
and three employees were
present at the time of the
incident. The work shift
began at 8:00 a.m. and the
incident occurred at 4:00
p.m. The ground conditions
were dry level dirt.
Figure 1. Incident scene: A indicates the position of the forklift holding the
steel beam, and B indicates the position of the forklift holding the platform.
conditions at the time of
incident were cool and dry.
The decedent’s coworker
had been assigned the task
of fabricating the beam and
the decedent was assigned
as his assistant. This
assignment was not a usual
work task for either
employee. After fabricating the beam, the decedent and a coworker were using two forklifts to replace a wood beam with
the new rectangular tube steel beam on a lean-to roof of a storage building (Figures 1 and 2).
The steel beam was composed of two 20-foot long rectangular shaped steel tubes measuring
four inches by six inches with one-quarter-inch thick walls (Figure 3). The two tubes were
welded together with a one-and-one-half-inch by three-inch steel channel welded to the top to
form a single steel beam 40 feet long, weighing approximately 1,000 pounds. Three brackets,
composed of 3-inch by 3-inch by 12-inch angle iron (L-shaped) (Figure 4), were welded to the
six-inch face of the steel beam. Six inches remained to attach the beam to three new 5-inch
by 5-inch by 11-foot, 6-inch treated wood posts. The decedent and coworker assembled the
steel beam, steel channel, and angle iron brackets at the worksite. They worked together to
shore up the roof, remove the old wooden beam, and place the new steel beam on top of the
three support posts. Although hard hats were available, neither employee was wearing one.
A wood forklift platform was used during the work to elevate the decedent and his coworker.
The forklift platform was built with a 32-inch by 48-inch wood pallet and a ¾-inch by 33-inch
by 48-inch piece of plywood banded to the pallet (Figure 5). Forklift A was positioned on the
north side of the center wood post facing east and was used to elevate the steel beam to a
height of 11 feet, 6 inches. Investigation records indicated that the hydraulic side shift on the
carriage of forklift A, which controlled the side-to-side motion of the forks, was in need of
repair. It is unknown if this malfunction contributed to the incident. Forklift B was located on
the south side of the center wood post facing northeast. Forklift B was used during the
incident to elevate the wood platform holding the decedent and coworker. Forklift A was
approximately 20 years old and forklift B was 10 years old. The forklift platform was not an
approved lifting device and it was not secured to the forklift; the forks of the forklift just went
through the open slots on the bottom of the pallet.
Figure 2. Overhead view diagram of the scene at the time of the incident (not to scale)
Figure 3. Two 20-foot sections of steel rectangular tube beam involved in
Figure 4. L-shaped angle iron brackets attached to the steel beam
Figure 5. Wood platform used during the incident
The decedent had been
operating forklift B to
elevate his coworker on
the platform during most
of the work. However,
about the time they were
ready to bolt the steel
beam to the posts, the
employer, who was
forklift certified, arrived at
the site. The forklift
platform was lowered,
the employer instructed
the decedent to join his
coworker on the platform,
and the employer raised
the forklift platform to an
approximately 6 feet.
The employer moved to the controls of forklift A
after he raised the
platform with forklift B.
The employer stated that
the steel beam needed to
be shifted towards the
south, but the decedent’s
coworker disagreed with
him and said it did not
need to be shifted. The
decedent and the
coworker were standing
on the platform with the
roof at approximately
chest level before they
both squatted under it to
bolt the beam to the
center post. During this
time, the new steel beam
was resting on the tips of
the forks of forklift A and only the south end of the
steel beam was in
contact with a support
post. When the employer used forklift A to raise the beam to shift it to the south, the end of
the beam came off the support post and fell. As the steel beam fell, the north end of the steel
beam tipped upward and struck the northwest edge of the roof. As the beam fell, it struck the
decedent’s coworker and knocked him off the platform to the ground. It also struck the decedent in the head and landed
on him. After falling to the ground,
the coworker climbed the mast of
forklift B to push the steel beam off
the decedent. When the decedent’s
coworker moved the 40-foot beam,
it fell to the ground, breaking the
weld. The forklift platform was
lowered and a call was immediately
placed for emergency medical
response. The assistant manager
of the company had just arrived at
the site as the incident occurred
and was standing on the north side
of forklift A. EMS arrived in less
than 10 minutes and transported
the decedent to the nearest
hospital from which the decedent was airlifted to a trauma facility. He
was pronounced dead later that same day.
Cause of Death
The Medical Examiner listed the cause of death as blunt force head trauma.
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Recommendation # 1: Employers should ensure that employees do not position
themselves under elevated loads.
Discussion: Employers should ensure that employees are trained not to position themselves
under elevated loads and that forklift operators are trained to recognize the hazard of
allowing employees under loads elevated by forklifts. Areas below and adjacent to
suspended loads should be controlled access zones, which employees should not occupy.
According to OSHA standards, “no person shall be allowed to stand or pass under the
elevated portion of any powered industrial truck, whether loaded or empty.” Furthermore,
employers should ensure that elevated loads, particularly ones that are heavy and subject to
tipping, are supported properly. Loads should be braced or tied off so as to protect from
potential movement, and they should be leveled prior to initiating the lift.
Recommendation #2: Employers should ensure that employees wear hard hats when
working in areas where there is a potential for head injuries from falling or flying
objects and fall protection when working at elevations of six feet or more.
Discussion: Employers should maintain and enforce written policies that require employees to
wear appropriate personal protective equipment when exposed to hazards. Although
personal protective equipment may not have prevented the fatality in this incident, its use is
always a prudent safety practice. In this incident, the employees should have been required
to wear hard hats to protect themselves from head injury, regardless of the methods used to elevate and secure the steel beam. OSHA standards require protective hard hats to be worn
when working in areas where there is a potential for injury to the head from falling or flying
objects. Personal fall protection should be utilized when working at elevations of six feet or
Recommendation #3: Employers should ensure that forklift operators elevate
personnel only with approved lifting cages that are properly attached to machinery.
Discussion: Employers should provide an approved lifting cage when employees need to
work at elevated heights. An approved lifting platform was not used during this incident.
Company-built personnel platforms should comply with OSHA regulations and standards
from the American National Standards Institute (ANSI) and the American Society of
Mechanical Engineers (ASME). Employers should also consider consulting with their forklift
manufacturer to identify appropriate personnel platforms designed for their particular
machines. OSHA standards require lifting platforms and other types of scaffolding to be
examined by a competent person before each work shift to ensure structural integrity.
Approved lifting platforms should be equipped with a means of protecting workers from falling
from the platform and also should be attached to the forklift to prevent the platform from
falling. When lifting employees in an approved lifting cage, basic safety measures should be
utilized. Basic safety measures include the use of restraining means, such as rails, chains, or
body harnesses with lanyards or deceleration devices; elevating a worker on a platform only
when the vehicle is directly below the work area; securing and leveling the platform to the
forklift; and lowering the platform before driving to another location. Sway controls should not
be used to make lateral movements while workers are on a raised platform; even small
adjustments in the hydraulics can produce exaggerated, jerky movements of the forks and
Recommendation #4: Employers should develop, implement, and enforce a
comprehensive written safety program and training in the language(s) and literacy
level(s) of all workers, which includes training in hazard recognition and the avoidance
of unsafe conditions.
Discussion: Employers should develop comprehensive, written safety programs that include
safety and hazard recognition training. The effects of training should be measured through
testing and demonstration. In the case of noncompliance with training, corrective action
through additional training and retesting should be performed to address safety concerns.
Untrained employees should be prohibited from operating machinery or performing tasks for
which they have not been instructed. Employees should be trained to recognize hazards
posed to themselves and other persons working near them. Periodic testing and evaluation
can provide opportunities for the evaluator to identify unsafe operating procedures and
provide corrective action through retraining on safe operating procedures. All written and oral
training should be appropriate for the language and literacy level of the employees who are
being trained. Overcoming language and literacy barriers is crucial to providing a safe work
environment. Organizations that employ workers who have a limited understanding of English
should design, implement, and enforce a safety program in the language(s) of the employees
and should provide a competent interpreter who can clearly convey instructions and explain
workers’ rights. Employers should consult resources, such as OSHA’s website, Compliance
Assistance: Hispanic Employers and Workers, (https://www.osha.gov/dcsp/compliance_assistance/index_hispanic.html), for assistance in developing and improving multilingual
safety and training programs.
Recommendation #5: Employers should ensure that forklifts and other machinery in
need of repair are tagged and taken out of service until maintenance personnel
Discussion: All equipment and machinery, including forklifts, should be maintained with
regular, thorough safety checks. Pre-start safety inspections should be conducted by trained
and authorized operators at the beginning of each shift. A supervisor should be designated to
ensure that inspections are performed daily, necessary repairs are made, and records are
kept on file. OSHA standards require that powered industrial trucks be taken out of service
when found to be in need of repair, defective, or in any way unsafe. Maintenance issues
should be immediately reported to the designated authority and the truck should be taken out
of service until it has been restored to a safe operating condition.
- Occupational Safety and Health Administration, 29 CFR 1910.178, Powered Industrial
- Occupational Safety and Health Administration, 29 CFR 1926 Subpart E, Personal
Protective and Life Saving Equipment.
- Occupational Safety and Health Administration, 29 CFR 1926 Subpart M, Fall Protection.
- Occupational Safety and Health Administration, 29 CFR 1926.602, Material Handling
- American National Standards Institute, B56.1-1969, Section 606, Safety Standard for
Powered Industrial Trucks.
- NIOSH ALERT: Preventing Injuries and Deaths of Workers Who Operate or Work Near
Forklifts. Department of Health and Human Services, Center for Disease Control and
Prevention, National Institute for Occupational Safety and Health, 1998. Publication No.
- Occupational Safety and Health Administration, Standard Interpretations: Fall Protection
Requirements for Elevated Platforms of Powered Industrial Trucks; Body Belts Versus
- Operating manual and specifications for the type of vehicle in use.
Oklahoma FACE Program
The Oklahoma Fatality Assessment and Control Evaluation (OKFACE) is an occupational fatality surveillance project to determine the epidemiology of all fatal work-related injuries and identify and recommend prevention strategies. FACE is a research program of the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research. These fatality investigations serve to prevent fatal work-related injuries in the future by studying the work environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in injury, and the role of management in controlling how these factors interact.
To contact Oklahoma
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.