Investigation: # 01MI094
Bridge Painter Dies When He Falls Out of an Unsecured Rough Terrain Forklift Scaffold Platform
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| Figure 1. Rough Terrain Forklift |
RECOMMENDATIONS
INTRODUCTION
On October 19, 2001, a 31-year old male died from injuries
sustained when he fell out of an unsecured rough terrain forklift scaffold platform.
MIFACE investigators were notified of the work-related construction fatality
by the Michigan Occupational Safety and Health Administration (MIOSHA) 24-hour
fatality report system that a work-related fatal injury occurred on October
19, 2001. The company did not return MIFACE phone calls to discuss the fatality.
On October 30, 2001 MIFACE accompanied a MIOSHA inspector to view the incident
site because the incident occurred on public property. The death certificate,
autopsy results, police report (including photographs of the scaffold platform
and lift), and the MIOSHA narrative were obtained during the course of the investigation.
All Figures are police photographs taken during the police investigation.
This investigation report is based upon the police and MIOSHA
compliance officer reports of the incident.
MIOSHA issued 8 citations to the company. Five citations were violations of MIOSHA Part 12, Scaffolds and Scaffold Platforms, one citation was failure to report the fatality to MIOSHA, one was the lack of a company accident prevention program, and one citation was the lack of first aid supplies and employees trained in first aid at the site. The Part 12 citations included no pre-lift meeting was conducted, the platform was not attached and secured to the forks, a personal fall arrest system was not worn, lack of employee training before elevating employees, and the driver of the Sky Trak did not have a valid operator permit for the forklift.
INVESTIGATION
The company employed approximately 25 people; two company employees
were working at the job site on the day of the fatality. The company is a special
trade contractor that does varied work, such as painting, masonry and is also
a general contractor for road and building construction. The company had been
in business for at least 13 years at the time of the incident. The decedent
had been working for the company for 2 days. There was a corporate safety program,
but the company did not implement their program at the job site.
The telescopic rough terrain forklift elevating the victim
was a model 8042 Sky Trak. The maximum lift capacity was 8,000 pounds. The forks
attached to the boom were 48 inches long. This type of forklift is considered
a rough terrain powered industrial truck for purposes of forklift operator training.
MIOSHA Construction Safety Standard Part 12, Scaffolds and
Scaffold Platforms defines a scaffold as a temporary elevated platform which
is supported or suspended, including its supporting system and points of anchorage,
and which is used for supporting an employee or materials or both. The basket
used to elevate the employee is regarded by MIOSHA as a scaffold platform. The
scaffold platform used to elevate the victim was 8 feet long, 4 feet wide and
44 inches high. The basket was equipped with a tie-off chain with shackle pins
and forklift sleeves at its base.
Another company owned the Sky Trak and had used the Sky Track
earlier in the day to move pallets from one area at the site to a staging area
at another location at the site.This company had previously allowed other employees
of the victim’s company to borrow the Sky Trak to perform work. The Sky
Trak forks were set to accommodate the pallet fork sleeves. The Sky Trak driver
borrowed the forklift from another location on the work site so he could elevate
the victim. The victim was assigned to paint the underside of the bridge.
Prior to elevating the victim, the forks were not reset to
accommodate the width required by the platform’s fork sleeves. The driver
placed the forks under the basket so the basket rested on the forks; the forks
were located between the fork sleeves on the basket. Figure
2 illustrates the location of the forks. The forklift was moved to another
location on the site during the rescue operation. It is unknown if, at the time
of the lift, the wire mesh screen faced outward or was adjacent to the back
of the forklift.
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| Figure 2. Location of Forklift Forks |
It is unknown the content and extent of operator training the Sky Trak driver
received before lifting the victim. The Sky Trak driver elevated the victim
approximately 16 feet so he could begin to paint the bridge underside. The victim
began painting at one end of the bridge, moving a section at a time. It is unknown
if the boom was lowered each time the Sky Trak moved to each new painting position.
During the painting of the third area of the bridge’s underside, the worker
shifted his weight to the side of the platform (See Figure 3).
The basket began to tilt to the side and the worker fell out. The victim landed
on the packed dirt. The platform fell from the forklift, landed on the ground,
and rolled on top of the victim. Emergency personnel were called and the victim
was transported to a local hospital where he later died.
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| Figure 3. Painting Location |
The Sky Track was designed by the manufacturer to elevate personnel
scaffold platforms. On the boom was a warning label for
carrying personnel. MIOSHA allows for the use of platforms on rough terrain
forklifts if the manufacturer designates that the forklift may be used for that
purpose.
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| Figure 4. Sky Track Warning Sign |
The American Society of Mechanical Engineers (ASME) takes an opposing view. ASME B56.6-1992, Safety Standard for Rough Terrain Forklift Trucks, specifies that rough terrain forklift trucks may only be used as an elevated work platform if there are no other “practical options” available. Federal OSHA requires that before using a rough terrain forklift truck as a work platform that the employer must investigate other options of elevating the employee. Other options include construction of a scaffold, scissor lifts, aerial lifts or ladders. Only after determining that other options to lift the employee are unfeasible may a rough terrain forklift be used.
The deceased’s autopsy report stated there was a detectable level of cannabinoids (i.e., marijuana, hashish or hash oil) in his urine. The victim’s cannabinoid level was measured at 507 nanograms/milliliter (ng/ml). This positive result indicates probable prior use but does not correlate well in determining level of intoxication or impairment of the victim. Analysis of a single urine specimen cannot distinguish between very recent use and chronic use. In general, the greater the level of cannabinoid metabolites in urine, the greater the possibility of recent use, but it is impossible to be precise about how "recent" the use has been. Cannabinoids can be detected in urine for an average of 1-2 days or for as long as 7 days after a single cannabinoid inhalation exposure.
CAUSE OF DEATH
The medical examiner recorded the cause of death as multiple blunt force injuries. No alcohol was detected in the victim’s blood or urine. Cannabinoids were detected in the victim’s urine. No other drugs of abuse were detected in the blood or urine.
RECOMMENDATIONS/DISCUSSION
To safely elevate personnel using a rough terrain forklift
scaffold, the forks must be placed in the scaffold sleeves, the scaffold secured
against the back of the forks with a mechanical device, and the side of the
scaffold adjacent to the mast have a solid or mesh guard sufficient to protect
the passenger from contact with moving parts of the mast.
When the lift was made, the scaffold platform used with the
rough terrain forklift was only resting on the forks; the forks were placed
between the scaffold fork channels (See Figure 5). The Sky
Trak was moved to each painting position, thus the platform could also move
upon the forks. When the victim moved to the side, the center of gravity shift
caused the platform to begin to tilt off of the forks, causing the victim to
fall out of the scaffold. If the forks were reset to fit into the fork channels
and the platform secured to the forks prior to the lift, the platform would
likely not have tipped over. At the time of the incident, it is unknown if the
platform’s mesh screen was facing outward (as in the picture)
or adjacent to the mast, since the picture was taken after moving the basket
off of the victim. The safety chain and pins are on the mesh side of the platform
to enable the platform to be secured to the mast. If the platform used by the
victim had the mesh screen facing outward, the safety chain could not have been
used to secure the platform to the forks. Properly positioning the basket on
the forklift forks and securing the scaffold with the safety chain would have
likely prevented this fatality.
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| Figure 5. Fork/Sleeve Location |
The MIOSHA Scaffold Standard Rule 1243(1) requires that when
a rough terrain forklift is used to elevate personnel, a pre-lift meeting must
be held. The pre-lift meeting must occur before the employee(s) are elevated
and include all persons involved in the lift (i.e., the lift operator, signal
person, employee(s) to be lifted and the person responsible for the task to
be performed in attendance). The meeting must address the requirements and procedures
to be followed so a safe work operation may occur. An initial assessment of
the job-at-hand should include identification of the hazards involved.
The personnel involved in the lift did not have a pre-lift
meeting to discuss safe work procedures. A pre-lift meeting should have covered
the importance of properly securing the platform to the forks as well as other
requirements to perform the work.
Part 12, Rule 1243(9) states that if an employee is elevated
in a platform on a variable reach lift truck, a personal fall arrest system,
including anchorage required in Part 45, Fall Protection and Part 6, Personal
Protective Equipment is required and shall be worn when an employee is elevated.
The employee was elevated approximately 16 feet above a packed
dirt surface. If the worker had a correctly attached personal fall arrest system,
when the basket began to fall off of the forks, he would not have been on the
ground when the basket hit the ground and rolled. He would have been suspended
from the elevated boom/fork. The fatal injury may have been prevented if he
had been wearing a fall protection system.
MIOSHA has two construction safety standards that specifically
address forklift operator training. MIOSHA Construction Safety Standard Part
13 Mobil Equipment, Rule 1926.602 – Material Handling Equipment (d) Powered
industrial truck operator training details the training requirements for all
powered industrial trucks. Part 12, Rule 1245, Operator training details the
operator training requirements specific to using a rough terrain forklift to
elevate employees. Before being allowed by the employer to operate the forklift
independently, the trainee must demonstrate proper operation of the forklift
and perform the functions necessary for a particular job. When the employee
performance demonstrates effective training and appropriate skill level, the
employer must issue a valid operator permit to use the rough terrain forklift
to elevate employees.
The employer did not train the forklift driver in accordance
with the above referenced standards and the driver did not have a valid operator
permit. With appropriate training, the driver should have recognized the unsafe
conditions of an unsecured platform resting on the forks. Operator training
would have included the importance of setting fork width to accommodate the
task to be performed.
MIOSHA requires under Part 1, General Rules that an employer
shall develop, maintain, and coordinate with employees an accident prevention
program. An employer must provide instruction and safety training to an employee
in the recognition and avoidance of conditions or procedures that are causing
or likely to cause serious physical harm or death. A copy of the accident prevention
program must be available at the worksite. The company had a comprehensive written
program that was not enforced and implemented at the worksite.
Although it cannot be determined if the deceased was under the influence of cannabis, many studies have concluded that cannabis use reduces coordination, impairs balance, perception, judgment, memory and learning. Cannabis use interferes with the ability to perform simple or complex tasks, and slows a user’s reflexes. Many drugs, such as over-the-counter medications, alcohol and other illegal substances may affect an individual’s performance, reaction time and judgment. Individuals should not engage in hazardous activities while under the influence or taking medications that may put them at risk of injury.
RESOURCES
MIOSHA Standards cited in this report can be directly accessed from the Consumer and Industry Services, MIOSHA website www.michigan.gov/dleg/0,1607,7-154-11407_15368---,00.html.(Link updated 12/11/2007)
The Standards can also be obtained for a fee by writing to the following address: Department of Consumer and Industry Services, MIOSHA Standards Division, P.O. Box 30643, Lansing, MI 48909-8143. MIOSHA phone number is (517) 322-1845.
MIFACE (Michigan Fatality and Control Evaluation), Michigan State University (MSU) Occupational & Environmental Medicine, 117 West Fee Hall, East Lansing, Michigan 48824-1315. This information is for educational purposes only. This MIFACE report becomes public property upon publication and may be printed verbatim with credit to MSU. Reprinting cannot be used to endorse or advertise a commercial product or company. All rights reserved. MSU is an affirmative-action, equal opportunity employer. 8/20/03
To contact Michigan State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.
APPENDIX A
OSHA JOB SAFETY ANALYSIS
| To improve the quality of the MIFACE program and our investigation reports, we would like to ask you a few questions regarding this report. | |||
| Please rate the following on a scale of: | |||
| Excellent | Good | Fair | Poor |
| 1 | 2 | 3 | 4 |
| What was your general impression of this MIFACE investigation report? | |||
| Excellent | Good | Fair | Poor |
| 1 | 2 | 3 | 4 |
| Was the report… | Excellent | Good | Fair | Poor |
| Objective? | 1 | 2 | 3 | 4 |
| Clearly written? | 1 | 2 | 3 | 4 |
| Useful? | 1 | 2 | 3 | 4 |
| Were the recommendations … | Excellent | Good | Fair | Poor |
| Clearly written? | 1 | 2 | 3 | 4 |
| Practical? | 1 | 2 | 3 | 4 |
| Useful? | 1 | 2 | 3 | 4 |
| How will you use this report? (Check all that apply) | |
| O | Distribute to employees/family members |
| O | Post on bulletin board |
| O | Use in employee training |
| O | File for future reference |
| O | Will not use it |
| O | Other (specify) __________________________________________ |
Thank You!
Please Return To:
MIFACE
Michigan State University
117 West Fee Hall
East Lansing, MI 48824
FAX: 517-432-3606
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