Date of incident: December 2022
Notice of incident number: 2022189840018
Employer: Cardboard manufacturer

Incident summary
A warehouse worker was unstacking pallets loaded with litho-laminated corrugated boxes using a forklift. The worker exited the forklift to speak with some co-workers in another area of the warehouse. He returned to the work area, and before he re-entered the forklift, a stack of pallets fell over and struck him. The worker sustained serious injuries and later died.

Investigation conclusions

Cause

• Worker crushed by falling stack of unstable loaded pallets. The unique characteristics of the bundles of loaded pallets of litho-laminated boxes — such as the slippery laminated surface of the boxes, inconsistent palletization, and a lack of straps around the bundles — caused them to be particularly unstable. Over the 10 days before the incident, the front row of a large stack of loaded pallets of litho-laminated boxes was completely removed, leaving the back row stacked alone against the wall to a height of 6.3 m. Although it is not known what caused the stack of loaded pallets to fall at the moment it did, the removal of the entire front row of loaded pallets made the remaining back row unstable and vulnerable to disturbance and subsequent collapse.

Contributing factors

• Workers on foot exposed to hazardous conditions. Workers at the warehouse who were on foot in proximity to unstable stacked loaded pallets were exposed to hazardous conditions. This included the forklift operators, who were outside the protection of the overhead guard of the forklift when they were on foot.
• Inadequate hazard identification and risk assessment. The employer did not identify the hazardous conditions that were present at the warehouse, or the unique hazards and handling requirements of the loaded pallets of litho-laminated boxes that caused them to be particularly unstable. The employer did not assess the risks or implement corrective measures to eliminate or mitigate those risks.
• Stacking procedures not distributed to workers. A warehouse stacking policy drafted at another location was not distributed to the employer’s other worksites. There was no company-wide stacking policy with guidance on stacking and unstacking methods, stacking height limitations, or the characteristics of the product being stacked. Litho-laminated boxes were stacked and unstacked in a similar manner as other products that were more stable and more common at the warehouse.
• Inadequate supervision and training. The employer did not ensure that the supervisor and manager were provided the training and instruction required for them to adequately supervise the warehouse. Forklift operators at the warehouse had not been provided with adequate training and instruction regarding how to stack and unstack pallets loaded with litho-laminated boxes in a way that may have prevented instability. In addition, there had been other incidents where objects fell from above, but the employer’s instructions to workers were not clear on when to report such incidents.

Request the full report