|Oregon Case Report: 04OR004
On February 10, 2004, a 42-year-old forklift operator was crushed between
the forklift he had been operating and a semi-trailer he was helping to
load. Assisting the truck driver to tie down the load, the operator backed
the forklift to the opposite side of the trailer, put the automatic transmission
into neutral, engaged the parking brake, and jumped out to take the strap
thrown across the load by the truck driver. The forklift’s engine
was left running. While the operator was facing the trailer and busy with
the strap, the forklift engaged in reverse and backed into him, crushing
him against the trailer with enough force to make the trailer shudder.
The truck driver looked under the trailer and saw the victim’s legs
dangling in the air. He ran to engage the gearshift on the forklift into
forward to release the victim. Efforts to revive the victim were unsuccessful,
and he was pronounced dead at the scene.
Twin of forklift that backed into and
crushed the operator after he jumped out to help load a truck.
- Before exiting any powered industrial truck, even briefly, completely
shut down power, place controls in neutral and apply parking brake.
- Employers should provide ongoing evaluation and feedback for operators
of mobile machinery to ensure that operator proficiency and safe work
practices are maintained.
- Maintain the machine in safe operating condition.
- Employees should be encouraged to report concerns related to the safe
operation and maintenance of mobile machinery.
On February 10, 2004, a 42-year-old Hispanic forklift operator was crushed
between the forklift he had been operating and a semi-trailer he was helping
to load. The incident occurred at about 2 p.m. OR FACE received notification
of the incident on February 11. An onsite visit and interview with the
employer was conducted on February 12. Copies of the sheriff and deputy
medical examiner reports were obtained from the county sheriff, and the
investigating deputy was interviewed. A representative of the forklift
manufacturer was also interviewed, and the Operator’s and Owner’s
Manual was obtained. Reports were also obtained from the state police
The employer manufactures fuel for wood pellet stoves, fireplace logs,
and products for enhancing the flavor of smoked meats. The company employs
36 employees at this location, mostly of Hispanic ethnicity.
The company’s two identical forklifts are maintained by a mechanic
onsite, with on-call support from a manufacturer’s representative.
Operation and maintenance training on the equipment was sponsored by the
employer in 1999, and again in 2001. All employees at the facility were
issued certificates on forklift operations. The training sessions were
in Spanish. The employer has a written safety program and safety committee,
with a suggestion box in the lunch room.
The victim worked for the employer for 8 years, and was experienced in
operating the forklift. He was viewed as a leader who communicated well
with management and the largely Spanish-speaking workforce. He was fluent
On the day of the incident, the forklift operator completed loading a
curtain semi-trailer with pallets of product, and noticed the truck driver
needed help with the straps to secure the load. He backed the forklift
around to the opposite side of the trailer from the driver, pushed the
automatic transmission into neutral, engaged the parking brake, and jumped
out to fix the strap on the load.
While the operator was facing the trailer, the forklift unexpectedly
engaged in reverse and backed into him, crushing him against the trailer
with enough force to make the trailer shudder. The truck driver looked
under the trailer and saw the operator’s legs dangling in the air.
He ran to the other side, heard the operator having difficulty breathing,
and hurriedly engaged the gearshift on the forklift into forward to release
him. The victim fell to the ground, with extensive chest and airway injuries.
Efforts to revive him were unsuccessful, and he died shortly thereafter
at the scene. The truck driver was the only other worker present at the
time of the incident.
The forklift was parked approximately parallel with the trailer, an estimated
4-6 feet away. The forks were on the ground, in accordance with safe practice,
but the engine was left running, and the wheels were turned in the direction
where the worker was standing. The mechanism by which the forklift drive
engaged and moved from its parked position remains uncertain. The following
points bear on the issue.
- The surface of the yard where the forklift was
parked next to the semi-truck is hard-packed gravel with a 2.5% slope.
Testing determined the slope was not sufficient to cause the forklift
to roll without power.
- The forklift was equipped with an operational
backup alarm system, but the backup alarm did not sound before the forklift
struck the victim. After repeated testing and some difficulty, it was
found the gearshift could be adjusted to move the machine in reverse
without the alarm sounding.
- The second forklift at the company was under repair
on the day of the incident, so the single forklift performed all activity,
and the brakes may have overheated and failed. The truck driver was
apparently able to put the machine in gear and move it forward without
releasing the brake. Later inspection showed the brake system on the
forklift, though poorly maintained, met safety specifications.
Victim’s position when the forklift
Cause of Death
Crush injuries to chest and head.
Recommendation #1: Before exiting any powered industrial truck, even
briefly, completely shut down power, place controls in neutral and apply
The forklift should be secured so that it will not move when the operator
is not in the driver’s seat. Operators should always: (a)
place the front forks in firm contact with the ground, (b) turn the steering
wheels away from the direction where work will be performed, (c) put the
shift in neutral and set the parking brake, (d) shut off the engine, and
(e) block wheels if parked on an incline.
Recommendation #2. Employers should provide ongoing evaluation and feedback
for operators of powered industrial trucks to ensure that operator proficiency
and safe work practices are maintained.
The employer supplied forklift training to workers. The manufacturer’s
operation manual recommends employers follow training requirements outlined
in the manual, as well as guidelines from ANSI Std. B56.1-1993 and OSHA
Standard 29CFR1910.178. Employers should ensure that operator proficiency
is maintained through evaluations and random checks. Training should be
repeated whenever there is a noted deficiency. In addition, retraining
should be performed at least every 2 years.
Recommendation #3. Maintain the machine in safe operating condition.
Although the mechanical basis of this incident is difficult to reproduce,
there is some indication that the forklifts at the work site were heavily
used and may have been in need of preventive maintenance or repairs. Equipment
should not be used unless needed repairs are completed and the machine
is in safe operating condition. Written documentation is an important
component of a safety program. A standard checklist helps to identify
hazards, and encourages accountability for regular inspections and a timely
response to safety concerns.
Recommendation #4. Employees should be encouraged to report concerns related
to the safe operation and maintenance of mobile machinery.
A work site safety committee provides an opportunity for employees to
report unsafe working conditions or equipment in a cooperative, nonadversarial
environment. To be effective, a safety committee needs to actively encourage
employee feedback, and also evaluate its own procedures to be sure employees
are contributing and feel their contributions are valuable. Accountability
for both employer and employees may be improved by the safety committee
promoting its activities and accomplishments, and explicitly recognizing
the contribution of employee suggestions. Employee feedback should be
documented and included in the minutes of the safety committee.
- Center for Research on Occupational and Environmental Toxicology (n.d.).
Powered industrial trucks (forklifts). Online information resource:
- Nash, J. (2004). Construction safety: Best practices in training
Hispanic workers. Available online: http://ehstoday.com/construction/news/ehs_imp_36851/
(Link updated 4/1/2013)
- National Institute for Occupational Safety & Health (2001). Preventing
injuries and deaths of workers who operate or work near forklifts
[Pub 2001-109]. Available online: http://www.cdc.gov/niosh/2001-109.html
- Oregon Occupational Safety & Health Administration (2005). Safety
committees for the real world: OR-OSHA’s guide to starting an
effective workplace safety committee. Available online: http://www.cbs.state.or.us/external/osha/pdf/pubs/2341.pdf (Link no longer available 3/31/2009)
- Oregon Occupational Safety & Health Administration (2005). Innovative
safety committees. Available online: http://www.cbs.state.or.us/external/osha/pdf/pubs/3124a.pdf (Link no longer available 3/31/2009)
- Occupational Safety and Health Administration. (n.d.). Powered
industrial trucks. Online information resource: https://www.osha.gov/SLTC/poweredindustrialtrucks/index.html
Oregon FACE Program
The Center for Research on Occupational and Environmental Toxicology
at Oregon Health & Science University performs Fatality Assessment
and Control Evaluation (FACE) investigations through a cooperative agreement
with the National Institute for Occupational Safety and Health (NIOSH),
Division of Safety Research (DSR). The goal of these evaluations is to
prevent fatal work injuries in the future by studying the working 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.
To contact Oregon
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.
Oregon FACE reports are for information, research, or occupational injury
control only. Safety and health practices may have changed since the investigation
was conducted and the report was completed. Persons needing regulatory
compliance information should consult the appropriate regulatory agency.