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Falling 7 Feet From an Elevated Forklift Safety Platform Results in Death

Current / Previous Condition:

A 61-year-old male maintenance manager (victim) died after he fell seven feet from a safety platform that had been elevated by a forklift.  On the day of the incident, the victim and forklift operator arrived at work around 7:30 a.m. and performed various duties until noon.  At about 1:15 the victim informed the forklift operator that a number of fluorescent light bulbs in the entrance-way to the recycling center needed to be changed.  The fluorescent light bulb fixture was suspended from the ceiling by chains about 13 feet above the concrete floor.

The two men walked to an area where the Yale forklift and fabricated safety platform were located.  As the men approached the forklift/safety platform it appeared that the safety platform had previously been secured to the forklift (the forks of the forklift appeared to have been inserted through channels on the bottom of the safety platform, but in reality the forks had been positioned alongside the channels instead of into the channels). The operator drove the forklift from its location to the recycling center entrance-way just beneath the fluorescent light fixture.
The victim opened the door to the 36-inch-wide by 39-inch-long by 42-inch-deep steel-framed cage-type safety platform and entered and secured the door.  The operator elevated the safety platform about seven feet above the concrete floor. The victim reached up and removed one of the two fluorescent light bulbs from its fixture and stepped from the center of the safety platform to one side. At that time the safety platform became unstable because of the shifting weight from the center of the platform to its outer edge, and began to tip.  The safety platform, containing the victim, fell off the forks of the forklift to the concrete floor.
As the safety platform and victim fell, the victim was partially thrown from the platform and struck his head on the concrete floor. Also, as the platform fell to the floor it struck the victim in the face.  The operator rushed to the victim and found him unconscious but breathing, with a strong pulse.  The operator called 911 for the Emergency Medical Service (EMS).  The EMS arrived in seven minutes; by that time the victim had no pulse and was not breathing.  Although the operator had first aid and CPR training, he could not perform CPR because of the extensive facial damage to the victim.  The EMS transported the victim to a local hospital where he was pronounced dead on arrival.  The medical examiner listed the cause of death as blunt trauma head injury.

Analysis of Condition:

The employer in this incident participated in a rescue mission that provided shelter to the homeless.  The mission employed 22 workers, including five workers who operated the three forklifts on an as-needed basis.  The employer had a written safety program which was verbally communicated by the maintenance manager on a regular basis.  The safety program contained rules which included securing the safety platform to the forklift whenever the safety platform was to be elevated.  Training was provided on the job.  The victim had worked for the company for five years at the incident site as a maintenance manager.  This was the first fatality experienced by the employer.

Recommended / Implemented Actions:

Recommendation #1: Employers should implement 29 CFR 1910.178 (m)(12)(i), which requires the use of a safety platform firmly secured to the lifting carriage and/or forks when lifting personnel with a powered industrial truck (e.g., forklift).
Discussion: In this incident, a steel-framed cage-type safety platform used as a work surface was elevated, unsecured, on the forks of the forklift.  29 CFR 1910.178 (m)(12)(i) requires that whenever a truck is equipped with vertical only, or vertical and horizontal controls elevatable with the lifting carriage or forks for lifting personnel, the use of a safety platform firmly secured to the lifting carriage and/or forks shall be used as an additional precaution for the protection of the personnel being elevated.  If the safety platform had been firmly secured, the victim and safety platform would not have toppled from the forks of the forklift and the incident may have been prevented.  Note: the employer has secured the safety platform to a set of forks by welding the bottom of the steel-frame safety platform to the forks apparatus.  Also, to provide for additional safety while working from an elevated safety platform, workers should use a safety belt and lanyard secured to a point on the forklift or cage, in the event the worker should fall out of the platform.
 
Recommendation #2: Employers should ensure that personnel assigned to operate forklifts are thoroughly trained.
Discussion: The victim and forklift operator discussed changing light bulbs then proceeded to the area where the forklift was parked.  Without first checking that the safety platform was secured to the forks of the forklift, the operator and the victim moved the forklift to the recycling center entrance-way and commenced work.  Employers should ensure that forklift operators are not only thoroughly trained, but that they understand the hazards associated with all phases of using a forklift (e.g., the hazards of elevating personnel in a safety platform and the prevention or elimination of those hazards).
 
Recommendation #3: Employers should ensure that workers continually adhere to the safe work procedures that have been established by the employer.
Discussion: Employers should continually stress the importance of adherence to established safe work procedures.  In this instance, written safety rules regarding the securing of the steel-framed cage-type safety platform to the forklift were in effect when personnel were to be elevated.  During employee interviews with the NCOSHA compliance officer, it was learned that the forklift operators were aware of the rule and the rules had been communicated to them.  For rules to be effective, they should be reinforced on a regular basis and compliance with the rules should be enforced.
 
Recommendation #4: Employers should routinely conduct scheduled and unscheduled worksite safety inspections.
Discussion: Employers should be aware of any potential hazards or unsafe work conditions or practices in the workplace and should take an active role to eliminate them.  Scheduled and unscheduled safety inspections should be conducted by a competent person (One who is capable of identifying existing and predictable hazards in the surroundings or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has the authority to take prompt corrective measures to eliminate them.) to ensure that the workplace is free of hazardous conditions.  Even though these inspections do not guarantee the prevention of occupational injury, they may identify hazardous conditions and activities that should be rectified.  Further, they demonstrate the employer's commitment to the enforcement of the safety program and to the prevention of occupational injury.  

Benefits of the Lessons Learned:

Reminder to ensure proper forklift operation and training; and to evaulate fall protection for any elevated work.   

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