1All Rights ReservedCase Studies on Forklift AccidentsCase Studies on ForkliftCase Studies on Forklift Accidents AccidentsKhoo Heng TongInvestigation BranchOccupational Safety and Health InspectorateOccupational Safety and Health Division2ObjectivesBrief of forklift related accidentsAnalysis of accident causeLesson Learnt23Overview of casesCase 1: Forklift overturned during maneuveringCase 2: Forklift toppled due to instabilityCase 3: Unsafe loading by forkliftNote: The case studies are based on actual accident cases. However, to facilitatediscussion, some details had been modified or inserted.35In July 2003, a forklift operator was negotiating a forklift truck round an inclined road bend within a factory premises, the forklift overturned.He was pinned underneath the forklift and he died on the spot.Synopsis of Accident Synopsis of Accident6Works assigned: Thedeceasedworkerand3otherco-workers weredeliverycontractorsdeployedtoworkina company (Company A ) premises; Thecontractorworkersweretoassistthe company to deliver furniture to designated areas within Singapore; Onthedayoftheaccident,theworkerswere instructedtodeliver2palletsoffurnitureto anothercompany(Company B )locatedwithin the same building as Company A .Observation and Findings Observation and Findings47Lack of training: Totransportthefurniture,theworkersused aforkliftthatwasownedbyCompany A ; HOWEVER..thedeceasedworkerandhis supervisorhadnotattendedtheMandatory Forklift Drivers Training Course. Thefatalaccidenthappenedwhenthe deceasedwasdrivingtheforkliftbackfrom Company B to Company A to pick up the second pallet.Observation and Findings Observation and Findings8Company BWarehouse of Company AThe forklift was driving down this inclined bend when the accident happened59Mechanical failure ruled out: Forkliftwasabout13yearsoldandwas regularlyserviced,itslastservicingwas2 months before the accident. Aftertheaccident,forkliftwasinspectedand foundtobeinserviceablecondition.Thusit wasunlikelythattheaccidentwasduetoany mechanical fault of the forklift.Observation and Findings Observation and Findings10Lack of controls (1): Company As forklift was put under the charge of the warehouse storekeeper who is an authorisedforklift operator and had attended the Forklift Drivers Training Course; The storekeeper and his supervisor had allowed the supervisor of the deceased to operate the forklift even though they were aware that he had not attended the Training Course.Observation and Findings Observation and Findings611Observation and Findings Observation and FindingsLack of controls (2): On the day of the accident, the supervisor of the deceased had allowed the deceased to operate the forklift. There was no booking system within the factory to register/control the usage of forklift.The key of the forklift was left in its key ignition switch when the vehicle was not in use.12Root Cause Analysis Root Cause AnalysisDirect causes Operating at improper speed Improper steering Dangerous work area (curve road) UnauthoriseddriverIndirect causes Lack of training Lack of controlsSMS failure Safety training regime Controls of subcontractors Hazard Analysis713Lesson Learnt Lesson LearntImplementeffectivecontrolstoensureonly trainedpersonareallowedtooperate/drive machinery;Implementgoodsafetytrainingregimeto equippedemployeesinskillcompetenciesas well as OSH awareness;Conductriskassessmentand implement proactive control measures to eliminate/ reducehazards of operating forklifts in hazardous work areas, for protecting drivers & pedestrians;815Aforkliftoperatorwas transporting stacks of wire mesh using a forklift;After picking up a stack of wiremesh,theoperator raisedtheforksofthe forkliftasitmoved towardsthefactory entrance;Astheresult,theforklift tiltedandoverturned.The deceasedwaspinnedby theforkliftandhedied from his injuries.Synopsis of Accident Synopsis of Accident16Observation and Findings Observation and FindingsItwasunknownwhy deceasedhadraisedtheload when he was approaching the entrance,therewassufficient overheadandsideclearance attheentranceofthefactory buildingforforklifttruckwith the load to pass; 917Investigationrevealedthatthe forkswereabout4mabove ground when it overturned;Freshabrasionmarksand matchingpaintflakesleftonthe backrestfortheforksofthe forkliftsuggestsithadhitthe girderoftheoverheadtraveling cranelocatedjustbeforethe entrance;Observation and Findings Observation and Findings18Observation and Findings Observation and FindingsOverloadingisunlikely,totalweightofthewire mesh was about 720kg;Floorattheentrancewasdryandtherewasno tyre brake marks on the floor;Theforkliftwasserviced3monthsagopriorto the accident;Theforkliftoperatorcompletedtheforklift operation course 1 year ago.1019Root Cause Analysis Root Cause AnalysisDirect causes Failed to keep proper lookout Unsafe forklift practiceIndirect causes Fatigue? Rush work? Inadequate knowledge safe work practices Poor safety cultureSMS failure Hazard analysis Safety training Safety Policy20Lesson Learnt Lesson LearntRisk assessment: The stability of the forklift will be affected as the loadwasraisedtoohighandwhileonthe move;Needtoreducespeedatanyentrance/exitor whenpassinganyobstacles.Loadsshouldbe kept low when traveling;Forkliftoperatorsshouldcheckforoverhead and side clearance at all entrance, exit points;Training:ConductregulartrainingstocreateOSH awarenessanddevelopgoodsafetyculture within1122In Jun 2005, an accident occurredwhenaforklift wasusedtoliftand placedasteelstructure onto a metal rack. Thesteelstructure becameunstableand toppledwhileitwasin themidstofplacing onto the rack.Synopsis of Accident Synopsis of Accident1223Synopsis of Accident Synopsis of AccidentThestructurestruck thedeceasedwhowas guidingtheforklift nearbyandwaskilled on the spot.Deceased was pinned here24Thedeceasedinstructedaforkliftoperatorto liftandplacedasteelstructureontoametal rackusingtheforklift.Theoperatorwas assisted by 3 other co-workers; The steel structure weighed about 0.8 ton and waspartofapaintblendingmachine.The structurewassupposedtobespray-painted by the company.Oneendofthestructurewasheavierthatthe other end.Observation and Findings Observation and Findings1325Thestructuretoppledshortly afteritwasplacedontothe metal rack. Thedeceasedwasstanding nearbythesteelstructurewhen the falling structure struck him. Theplacingofthesteel structurewasunsafe,thewider sidecouldbeplacedonthe structure instead;Themannerandmethodusing thismetalrackwasalsowrong, therackwasnotsufficiently stable.Observation and Findings Observation and Findings26Investigationrevealedthatthismethodwas instructed,guidedandcommunicatedbythe deceasedandtheoperatorwasjustfollowing his instruction. Observation and Findings Observation and Findings1427Root Cause Analysis Root Cause AnalysisDirect causes Improper loading of material Improper coordination of work Failed to keep a safe distanceIndirect causes Lack of safety awareness Lack of risk assessment and risk controlSMS failure Safety training regime Hazard Analysis & Risk Assessment Safety policy28Lesson Learnt Lesson LearntConductriskassessmenttoeliminate foreseeablehazardsi.e.providestable supporting structure for safe loading;Mitigatehazardsbykeepingsafety distance from hazardous work;Communicateriskbythroughgood training regime of safe work practices;Developgoodsafetyculturethrough management commitment and education.1529Summary of Lesson Learnt Summary of Lesson LearntDevelopsafetyculturethroughgoodmanagement commitment and communication.Implementeffectiveriskmanagementtoeliminate/ reduce all foreseeable hazards;Conduct regular trainings to develop skill competencies as well as create OSH awareness;Developeffectivemaintenanceregimetokeepforklifts safe and in good working condition.30All accidents are preventableBeproactive:itisuptoUSto prevent it.Conclusions Conclusions16