Maintenance Worker Struck by Forklift Carriage - Tennessee
NIOSH FACE Report 2014-01
July 22, 2016
On February 28, 2014, a 51-year-old maintenance worker was crushed by the forks of a forklift he was repairing. At the time of the incident, the maintenance worker was working below the elevated forks, replacing a hydraulic seal on the forklift carriage lift mechanism while the carriage and forks were supported by resting the fork tips on the edge of a shipping container. The forklift operator was standing next to the forklift. As the maintenance worker tightened a hydraulic fitting, the fork tips slipped off the container edge. The carriage and forks fell, striking his head and pinning him underneath. The forklift operator radioed to call 911. Emergency medical services dispatched to the incident, and the maintenance worker was transferred to the hospital where he succumbed to his injuries.
Key contributing factors identified in this investigation include:
- Lack of specific written maintenance procedures for hydraulic seal replacement
- Working under an elevated, unsecured forklift carriage
- Lack of job and task analysis to identify the hazard
- End of work shift
NIOSH investigators concluded that, to help prevent similar occurrences, employers should:
- Establish an equipment maintenance and inspection program and ensure workers follow manufacturer and company safety guidelines for repair and maintenance of equipment.
- Develop, implement, and train workers on proper hazardous energy control procedures, specifically unsecured elevated loads.
- Ensure only trained, authorized personnel maintain, repair, adjust, and inspect powered industrial trucks (e.g., forklifts) and provide periodic refresher training.
- Complete job and task hazard analyses and train workers on the results of these analyses.
The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. In 1982, NIOSH initiated the Fatality Assessment and Control Evaluation (FACE) Program. FACE examines the circumstances of targeted causes of traumatic occupational fatalities so that safety professionals, researchers, employers, trainers, and workers can learn from these incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar occurrences. These NIOSH investigations are intended to reduce or prevent occupational deaths and are completely separate from the rulemaking, enforcement and inspection activities of any other federal or state agency. Under the FACE program, NIOSH investigators interview persons with knowledge of the incident and review available records to develop a description of the conditions and circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH summary of these conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim. For further information, visit the program website at www.cdc.gov/niosh/face/ or call toll free at 1-800-CDC-INFO (1-800-232-4636).