Summary
A worker was using a forklift fitted with a fork extension to install a pump into an amphibious craft. He lifted the pump with a sling, and with a co-worker's help, the pump was lowered to an inch above the base.

The worker left the forklift controls and entered the hull of the craft to help the co-worker. When they were ready to lower the pump the final inch into position, the worker attempted to activate the forklift controls from inside the hull. He stood under the elevated fork extension, bent over the hull wall, and reached through the forklift carriage. When he moved the control, the forklift carriage and fork extension suddenly dropped onto him, causing fatal injuries.

Conclusions

Findings as to causes

• The roller of the forklift carriage was not properly aligned, and it got hung up during re-entry into the channel. When the controls were activated for the final lowering, the roller suddenly released into the channel, dropping the fork extension onto the worker.
• The worker was standing under a fork extension that had not been securely blocked. While leaning over the hull of the craft, he reached through the mast and under the carriage.

• The forklift sat idle for approximately four years and was not inspected and maintained by a qualified mechanic before being returned to service.
• The worker was not trained and qualified as a forklift operator. An adequately trained and qualified forklift operator would have received information during training that no person should pass under an elevated part that had not been securely blocked.
• The worker was not adequately supervised. No safety audits or observations had been conducted on his work activities.