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Forklift Operator Crushed by Full Pallet of Soft Drink Cans - Oregon
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2020/12/07
[PDF-2.12 MB]
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Description:On February 28th, 2020, a 47-year-old forklift operator was crushed by a loaded pallet of soft drink cans that weighed approx. 2000 pounds. The pallet was on the top layer of a pallet row. Pallet rows were oriented back-to-back. The warehouse inventory management system directed the operator to pull pallets from a row that didn't contain any product. The operator pulled 4 pallets from the back of the adjoining row, destabilizing the top layer of pallets. While cleaning up some cases that fell off one of the pulled pallets, the top layer pallet fell onto operator (from a height of approximately 20 feet), causing massive internal injuries. The forklift operator worked swing shift full-time at the warehouse, as well as another job that started at 6am, working approx. 70 hours/week total. CONTRIBUTING FACTORS - Key contributing factors identified in this investigation include: 1) Back-to-back pallet row orientation without physical barriers or visual cues makes it difficult to distinguish where one pallet row ends and the other begins. 2) Pallet retrieval procedures not followed while working under and/or adjacent to a live load. 3) Fatigue due to lack of sleep may have adversely affected employee's judgment. RECOMMENDATIONS - To help prevent similar occurrences, employers should: 1) Ensure warehouse layout and pallet stacking procedures incorporate sufficient engineering controls to prevent distracted employees from inadvertently destabilizing multi-layer pallet rows. 2) Ensure pallet stacking procedures are written and accessible to employees, and include instructions on how to perform spot checks on pallet rows to assure they are safe. Ensure employees follow these procedures and provide retraining if an accident occurs. 3) Ensure employee training program includes training about the hazards of working around potentially unstable pallets, including awareness of potential pallet collapse areas while working on or below a live load. 4) Treat sleep deprivation as a workplace hazard, especially for swing and night shift employees.
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Pages in Document:1-15
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Contributor:Smart, Nikolas
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NIOSHTIC Number:20064097
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NTIS Accession Number:PB2022-100439
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Citation:Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 20OR010, 2020 Dec; :1-15
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Contact Point Address:Oregon Fatality Assessment and Control Evaluation (OR-FACE) Program, Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd. L606, Portland, OR 97239
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Federal Fiscal Year:2021
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Performing Organization:Oregon Health & Science University
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Peer Reviewed:False
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Start Date:2005/07/01
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Source Full Name:National Institute for Occupational Safety and Health
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End Date:2026/06/30
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Resource Number:FACE-20OR010
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