Date of incident: May 2020
Notice of incident number: 2020181890006
Employer: Auto services store

Incident summary
A worker was operating a forklift carrying two empty wooden pallets through an alleyway between storage containers at a tire storage facility. One of the pallets hit the corner post of a container, causing the forklift to tip over in the opposite direction. The worker fell out of the operator’s cab and the forklift’s overhead guard landed on him. He sustained fatal injuries.

Investigation conclusions

Cause

• Impact caused forklift’s centre of gravity to shift. The worker was operating a forklift with its forks elevated to 191 cm (75 in.), carrying two empty wooden pallets through the alleyway of the tire storage area. The front right corner of the bottom pallet struck the corner post of a container that protruded 5 cm (2 in.) into the alleyway. The force of the impact caused the forklift’s centre of gravity to shift. The energy from the collision was pushed back to the forklift and was sufficient to tip the forklift in the opposite direction.

Contributing factors

• Operating forklift with forks in elevated position. The forklift was travelling down the alleyway with the load (two empty wooden pallets) elevated to just below the height of the unit’s overhead guard when a corner of the bottom pallet struck the post. This sent the top pallet, which was unsecured, clockwise off the forks as the unit simultaneously tipped to the left. Carrying a forklift’s load in the lowest possible position and as close to the front wheels as possible is essential to preserve the forklift’s stability. Because the forklift was travelling with the load raised, the impact of the bottom pallet hitting the protruding container post caused the forklift’s centre of gravity to shift, destabilizing the unit.
• Alleyway congestion. The practice of staging product along the sides of the alleyway made it difficult for the forklift to manoeuvre through the alley with the forks in the lowered position. The tight work area contributed to the forklift encroaching on the container and striking the protruding corner post. If the alleyway had been clear of staged product, the worker would not have needed to elevate the forks while driving through the alley.
• Failure to carry out hazard identification and develop safe work procedures. At the time of the incident the employer had not conducted a hazard identification and risk assessment for work activities in the tire storage area and did not have safe work procedures for such work. If the employer had identified the hazards of work in the tire storage area and assessed the related risks, it would have been able to develop relevant safe work procedures. A procedure for staging product to relieve alleyway congestion might have helped prevent the incident.
• Seat belt not used. The investigation determined that the forklift’s seat belt was in good condition prior to the incident, but the worker was not using it. When a seat belt is properly used, a forklift operator is more likely to remain positioned on the forklift seat inside the protective structure of the cab should the forklift tip over. Wearing a seat belt would have reduced the risk of serious injury and would likely have prevented the worker from sustaining fatal injuries during the tipover.
• Inadequate visibility. The ground surface in the tire storage area was dirt that was prone to potholes in wet weather. Further, mud from the potholes could spray up onto the equipment such as the forklift. The forklift was found with mud splatter up both sides of its windshield. This would have obstructed the worker’s view, directly affecting his ability to navigate around obstacles in the alleyway like the container’s protruding corner post.
• Failure to conduct and monitor inspections. A pre‑use inspection of the forklift had not been completed on the day of the incident. Investigators determined that there was a recent pattern of incomplete pre‑use inspections. Investigators also found the forklift with mud splatter up both sides of its windshield. The splatter constituted a safety issue that had not been corrected prior to the operation of the forklift. The investigation determined that the mud splatter on the forklift’s windshield directly affected the worker’s ability to navigate the alleyway. If the employer had monitored inspections conducted by its workers, it might have been aware of the mud splatter on the windshield and the lack of seat belt use, and could have had the opportunity to address and correct these safety issues.
• Inadequate supervision. The employer’s safety policies and procedures do not list a requirement for management to conduct job area inspections in the tire storage area or to review equipment pre‑use inspections. Work activities in the tire storage area were not being supervised and monitored to verify that working conditions were safe and that workers were using safe work procedures.

Other safety issues

• Workload. An additional pick list of tire sets was given to the worker at about noon on the day of the incident. This increased the amount of product that needed to be picked before the end of his shift. It was the worker’s last shift before several days off. It is likely that a backlog of tires to put away from the day before, the unexpected additional pick list, and the upcoming time off created pressure on the worker to complete these tasks before the end of his shift. Although this pressure alone did not directly cause the incident, combined with the contributing factors it may have increased the likelihood of an incident taking place.

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