Summary
At a veneer and lumber manufacturing plant, a spareman was working in an area alone during the night shift. The spareman parked and exited a forklift loaded with four stacks of veneer. He entered the area in front of the machine. The mobile equipment rolled forward and pinned the spareman between the load carried on the forklift and two stacks of veneer he had previously positioned on the ground. A supervisor found the spareman, deceased, about one and a half hours after he had last seen him.

Conclusions

Findings as to causes

• Prior to exiting the cab, the spareman did not lower the load to ensure the forklift would not move. The machine moved forward and he was crushed between the load on the forks and the stack of veneer on the ground.

• An excessive load placed on the forks affected the machine's stability and centre of gravity.
• Sloping ground below the front wheels resulted in an uneven weight distribution.
• Even though the power from the transmission was disengaged and the emergency brake was on, the wheels were able to move because of the design of the four-wheel drive forklift and the type of driveshaft disc emergency brake.
• Working alone may have been a factor, although it cannot be determined whether the spareman would have been able to raise an alarm prior to becoming incapacitated.
• Informative manuals and materials to explain mobile equipment operations and the specific functions and features of the equipment in use were not available to operators.
• There were indications that workers were not sufficiently knowledgeable about the basic mechanical functions of the mobile equipment operated and about safe mobile equipment operating practices.
• The written work procedures in place for forklift use did not convey sufficient information to instruct and supervise workers adequately in the critical aspects of equipment operations and safe practices.
• The employer did not have a training program for forklift operators that met regulatory requirements.
• There were indications that supervision of forklift operators was not effectively ensuring safe and compliant forklift operations.