Date of incident: August 2023
Notice of incident number: 2023192870015
Employer: Poultry processing company

Incident summary
At a poultry farm, a worker was helping the operator of a forklift to load a truck with poultry transportation modules (interlocking crates). As the worker walked behind the forklift, it moved backward and struck the worker. The worker sustained serious injuries.

Investigation conclusions

Cause

• Worker struck by reversing forklift. The forklift operator was operating the forklift while the other worker acted as a spotter to help load the modules on the truck. The forklift operator reversed the forklift while the spotter was walking closely behind the forklift to reach a better vantage point from which to see the placement of the module. The spotter was in the forklift’s blind spot, and the forklift operator was unaware that the spotter was walking behind the forklift.

Contributing factors

• Adaptation of work procedure exposed workers to risk.
  • To achieve their tasks while overcoming pressure to work quickly, the forklift operators adapted their work procedures by acting as spotters for one another. Workers acting in the spotter role were exposed to the risk of being struck by the forklift.
  • Neither the employer nor its parent company were aware of the adaptive work practice. The written work procedures did not include the tasks associated with confirming that the modules were securely interlocked. This gap resulted in the forklift operators creating the spotter role, which required the spotter to check both ends of the modules. Because the task was not identified, no instruction or training had been provided that would eliminate the spotter being exposed to the hazard of the moving forklift.
• Modules blocked sightline. The blocked sightline created by the modules meant that it was difficult to tell from the driver’s seat of the forklift whether the module was fully interlocked without the assistance of a spotter.
• Lack of remote communication equipment. While loading modules onto the truck, the forklift operators and the spotters communicated through hand signals and by shouting to each other. Without remote communication equipment, the spotter was required to be in the immediate vicinity of the forklift to communicate with the forklift operator about module placement.

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