Date of incident: October 2022
Notice of incident number: 2022167090022
Employer: Kitchen cabinet manufacturer

Incident summary
At a kitchen cabinet manufacturer’s shop, a worker was tasked with loading a work van with kitchen cabinets for delivery to a customer. The worker had to rearrange parked work vans in the parking lot to gain access to the work van that was to be used for the delivery. While rearranging the parked vans, the worker temporarily parked a work van on a slight incline with the engine running. The worker exited the van through the driver-side door, and the van moved backward down the incline and struck the worker. The worker sustained serious injuries.

Investigation conclusions

Cause

• Worker struck by work van inadvertently placed in reverse. The worker attempted to park a work van on a slight incline and exited the van through the driver-side door with the engine running, the parking brake disengaged, and the gear selector inadvertently placed in the reverse position rather than the park position. As a result, the van rolled backward down the incline.

Contributing factors

• Failure to identify hazards and create safe work procedures. The employer had not conducted a documented hazard identification of the work processes of rearranging and loading work vans. Had the employer collaborated with workers to identify workplace hazards, safe work procedures could have been developed to mitigate the associated risks.
• Inadequate supervision. The employer did not adequately supervise its workers. The employer’s reliance on undocumented verbal discussions that generally referenced the safe handling of work vans was inadequate and did not take into consideration the loading of vans on inclines. The employer also failed to ensure the work van was operated in accordance with the manufacturer’s instructions for safe operations.
• Inadequate training. The employer’s use of on-the-job training and reliance on the worker’s driver’s licence qualifications proved inadequate, as evidenced by the fact that the cargo van’s engine was running, the gear selector was in reverse, and the parking brake was disengaged when the worker exited the van.
• Lack of health and safety program. The employer did not initiate and maintain a less formal occupational health and safety program and was unaware of the requirement to do so. A health and safety program that complied with the Workers Compensation Act and the Occupational Health and Safety Regulation could have guided management and workers to develop and follow safe work procedures relevant to the workplace.

Request the full report