Date of incident: January 2020
Notice of incident number: 2020181890003
Employers: Millwright; lumber mill (prime contractor)

Incident summary
Two workers were dismantling a lumber-packing press at a lumber mill. The press was the last piece of equipment in a moulder line (equipment that moulds logs into wood products) that was being dismantled. One worker, a millwright, was using a cutting torch to cut the press’s four base plates, which were embedded into the concrete surface just outside the building. Another worker was operating a telehandler forklift, placing the forks under the top frame of the press to support the press as the base plates were cut one at a time. The millwright instructed the forklift operator when to also extend the boom, thereby applying pressure against the front of the press, to cause the press to rock back and forth so the millwright could see where the base plate was still attached and required further cutting.

The first three base plates were removed, and the millwright was cutting the fourth and final base plate. Just before the final cut, the millwright told the forklift operator to apply pressure to the press. The operator extended the boom to apply pressure to the press as instructed. When the millwright made the final cut to the base plate while standing between the press and a 15.2 cm (6 in.) high concrete footing, the press swung free and pinned him against the concrete footing, causing serious injuries.

Investigation conclusions

Cause

• Forklift applied pressure to lumber-packing press. The final base plate was cut while the forklift was applying pressure to the press. When the cut was complete, the pressure being applied to the press by the forklift caused the press to move, pinning the millwright against the concrete footing.

Contributing factors

• Lack of hazard assessment. A hazard assessment was not conducted before the dismantling of the moulder line with a forklift. The forklift operator followed the millwright’s instructions to apply pressure to the press with the forklift while the millwright went between the press and the concrete footing to make the final cut. If a hazard assessment had been conducted, the workers would have been in a better position to make an informed decision regarding the hazard created by pressure being applied to the press with the forklift while making the final cut.

Other safety issues

• Inadequate instruction, training, and supervision. The employer of the forklift operator failed to ensure that the forklift operator had demonstrated to a qualified supervisor or instructor competency in operating the forklift and that he had reviewed the instruction manual. The operator had not received adequate instruction or training in the safe use of the forklift.
• Lack of prime contractor oversight. As prime contractor, the lumber mill failed to establish and maintain a system or process to ensure that the work activities were in compliance with the Workers Compensation Act and the Occupational Health and Safety Regulation.
• Lack of new worker orientation. New worker orientation was not provided to workers who were hired to assist with the job. New worker orientation ought to have been specific to the new workplace and covered all health and safety issues.

Request the full report