Date of incident: October 2023
Notice of incident number: 2023181310007
Employer: Ski hill

Incident summary
A worker was operating a rough terrain telehandler forklift carrying a load of aluminum pipes on a ski hill service road. The worker stopped the telehandler and exited it, and the telehandler unexpectedly began rolling down the slope. The worker ran along the left side of the telehandler and attempted to climb back into the cab. The telehandler gained speed and travelled onto softer terrain, where it tipped onto its side and onto the worker. The worker sustained fatal injuries.

Investigation conclusions

Cause

• Leaving operator’s position without engaging parking brake. The worker exited the cab of the telehandler to check the load while stopped on a plateau with a gradual slope of 13–17% without engaging the parking brake. As the worker exited the cab, the telehandler unexpectedly began rolling toward the edge of the plateau onto the steeper section of the slope.

Contributing factors

• Inadequate training. The employer failed to ensure that the worker was a qualified operator and that the worker received proper training and instruction on the safe operation of the telehandler before being tasked with operating it.
• Inadequate supervision.
  • The employer did not ensure that its supervisors were knowledgeable about the occupational health and safety (OHS) provisions of the Workers Compensation Act and the sections of the Occupational Health and Safety Regulation applicable to the work, or that its workers complied with those OHS provisions and sections of the Regulation.
  • The employer did not ensure that its workers were qualified to operate the telehandler prior to tasking them with that duty. It also did not ensure that workers followed the manufacturer’s recommendations for the telehandler, including fully reading and understanding the operator’s manual prior to being allowed to operate the machine; travelling correctly on slopes while carrying a load; complying with the maximum slope capacity of the telehandler for safe operation; and inspecting and maintaining the telehandler in accordance with the manufacturer’s instructions.
• Inadequate hazard identification and risk assessment. The employer did not assess the maximum slope percentages encountered on the road or the manufacturer’s identified maximum slope capacity for the telehandler during its hazard identification and risk assessment. As a result, the employer did not communicate this information to the workers operating the telehandler. The employer did not ensure that the telehandler was capable of safely performing the functions for which it was used or that it was operated in accordance with the manufacturer’s instructions, safe work practices, and the requirements of the Regulation. The employer also did not ensure that a risk assessment was conducted to confirm that the loads of pipes were secured for safe transport.

Other health and safety issues

• No safe work procedures for working downslope from mobile equipment. Workers on the ski hill service road were working downslope from mobile equipment, which exposed them to the risk of being struck or crushed by mobile equipment. The employer should consider updating its safe work procedures for working around mobile equipment to include procedures for working downslope from mobile equipment.

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