Kentucky Case Report: 07KY008 |
Report Release Date: January 22, 2008 |
Summary
In the Spring of 2007, a 32-year-old Hispanic male carpenter (decedent) died when he fell from a
homemade platform (extended approximately seven feet in the air) after it detached from a
telehandler (forklift). The decedent and two other carpenters were framing a new construction,
single-family residence located on a hillside which was rough and steep. The three carpenters
were framing the wall at the rear corner of the house which was high because of the sloping
terrain. To reach the area, the crew decided to use a homemade platform as a makeshift scaffold.
A fourth worker operated a rough-terrain forklift and elevated the platform with the three
carpenters holding the wall to be framed up in the air. The forklift operator lifted the unsecured
platform and at approximately seven feet in the air, the platform fell off the forks. Two of the
carpenters fell off the platform, which fell on the edge of the foundation above the men’s heads.
The decedent fell off the left end of the platform which struck him in the head. Emergency
medical services were summoned to the scene. Upon their arrival they found the other two
carpenters who had fallen together alive and requiring medical attention. They were transported
to a nearby hospital and later released. Emergency medical service personnel found the third
carpenter to be without vital signs and contacted the local coroner who arrived and declared the
carpenter dead at the scene.
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Picture of homemade platform involved in this incident. Notice railing and cleats. |
To prevent future occurrences of similar incidents, the following recommendations have been
made:
- Companies should not attempt to build any ”homemade” type
personnel platform for a forklift, all personnel platforms must comply with ANSI / ASME
standards and the OSHA regulations.
- Those who use a personnel platform on a rough terrain forklift must
use approved fall-protective equipment.
- Scaffolding should be used in difficult-to-reach framing locations.
- Personnel should not be transported by material hoists.
- Forklift operators should be trained by a competent person to operate
forklifts correctly and safely.
- Employers with multicultural workers should design safety training in
languages suited for the company workforce.
- General contractors should ensure through contract language that all
subcontractors implement appropriate safety and health programs and training specific to the
work to be performed.
- Small business owners should institute and enforce drug testing
policies.
Background
The privately owned construction company where the deceased was employed had been in
business for approximately four to five years. The company specialized in framing and
carpentry and employed eight workers. The decedent had been employed by the company for
four years as a carpenter. According to an employee, the decedent had 10 years of construction related
work experience. The company conducted safety toolbox talks with their employees.
Investigation
In the Spring of 2007, the Kentucky Fatality Assessment & Control Evaluation program was
notified by a construction professional of a fatality involving a Hispanic construction worker.
The FACE team went to the scene, took photographs and interviewed an employee of the
construction company where the Hispanic was employed. The coroner’s and the Kentucky
Occupational Safety and Health reports of the incident were obtained.
On the morning of the fatality, three Hispanic carpenters were framing a new, multi-story,
single-family house. The terrain of the building lot was hilly, steep and rough with the backside
of the lower level of the house open out of the slope. At approximately 7:30 AM, the three men
were to erect a section of wall above the foundation of the lower level in the back left side of the
house. According to an employee, the carpenters typically would have used ladders to reach the
area to be framed. Because the terrain was rough and steep, and the work area was higher than
the ladders could reach, it was decided to use a homemade materials platform to perform the
task. The platform was constructed of wood, had railing on three sides with cleats on the bottom
of the long side with railing. The cleats had been inserted on the railing side for stability when
lifted. The operator of the forklift had inserted the forks under the long side of the platform
without the cleats. This caused the platform to rest on top of the forks and be more unstable.
The platform was not secured to the forklift.
The forklift operator elevated the three carpenters on the platform while they were holding the
wall to be set in place. When the platform reached approximately seven feet high, it slipped off
the forks and tumbled the three men to the ground. Two of the carpenters fell close to the house
under the right side of the platform which fell on the edge of the foundation of the house. The
third carpenter was struck by the left side of the platform as it slid to the ground. One of the
workers called emergency medical services. The fire department and police arrived. Upon their
arrival, they found the two carpenters alive and the third carpenter without vital signs. Both of
the injured carpenters were transported to a nearby hospital where they were treated for their
injuries. The local coroner arrived and declared the third carpenter dead at the scene.
According to the coroner’s report, wind may have also contributed to the incident. Ambient
temperatures that day ranged from 24 degrees Fahrenheit to 54 degrees Fahrenheit.
Cause of Death
The death certificate states the cause of death was due to “blunt impact of head with skull
fractures and evisceration of brain”. Toxicology results detected cocaine, cocaethylene, and a
presumptive presence of cocaine metabolites, and benzodiazepine.
Recommendations and Discussion
Recommendation No. 1: Companies should not attempt to build any ”homemade” type
personnel platform for a forklift, all personnel platforms must comply with ANSI / ASME
standards and the OSHA regulations.
Discussion: ASME standards allow a company to construct and attach a personnel platform to a rough terrain
forklift. There are rigorous guidelines for this, and it is, therefore, preferred that individuals
consult with the forklift manufacturer for assistance, or better, purchase a factory-made and
approved personnel platform designed for their particular machine.
Requirements for an approved personnel platform include proper size, approved guard rails,
rated anchor points for attachment of lifelines, and a safe method to secure the platform to the
forklift. OSHA frequently writes citations for inadequate / home-made personnel platforms,
deferring to the restrictions written into machine operator's manuals, which usually forbid using
a homemade personnel platform on a forklift. Usually, the manufacturer’s operator manual
provides some guidance on this issue, therefore, companies desiring a personnel platform for a
forklift should to study their options carefully. In addition, personnel platforms must be securely
anchored to the forks of a machine.
Recommendation No. 2: Those who use a personnel platform on a rough terrain forklift must
use approved fall-protective equipment.
Discussion: Approved equipment in this case would be a full body harness, and lifeline which does not
permit a fall of more than six feet. This ruling applies to all extended boom machines, for they
have the potential of bouncing a worker up and off the platform, even if the platform is equipped
with permanently-mounted guard rails. Exceptions to this rule are for scissor lifts, which have
permanently attached guard rails. These machines use hydraulic-powered mechanical linkages to
slowly raise and lower the work platform, minimizing the potential to bounce a worker up and
off of the platform. In this case, the victim was not wearing any type of fall protection, and was
working near an unprotected edge of the personnel platform.
Recommendation No. 3: Scaffolding should be used in difficult-to-reach framing locations
Discussion: Construction workers should use appropriate tools to perform tasks. In this case, properly erected scaffolding would have provided an appropriate, safe and secure platform for the
carpenters to frame the wall of the house. Some common types of scaffolding the workers could
have used are system, or tubular. Scaffolding should only be erected under the guidance of a competent person. The Occupational Safety and Health Administration defines a competent
person as “one who is capable of identifying existing and predictable hazards in the surroundings
or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has
authorization to take prompt corrective measure to eliminate them”. 29 CFR 1926.451(f)(7)
states the competent person is “to select and direct employees who erect, dismantle, move, or
alter scaffolds.” The terrain on the job site involved in this incident was steep. The rough terrain
forklift had to be positioned on the ground at an angle to the house. This would have
made elevating the platform on the level difficult. Scaffolding should have been erected so the
carpenters could reach the area to be framed and work from a secure level platform. Also, 29
CFR 1926.451(f)(12) states the competent person is “to determine if it is safe for employees to
work on or from a scaffold during storms or high winds and to ensure that a personal fall arrest
system or wind screens protect these employees. (Note: Windscreens should not be used unless
the scaffold is secured against the anticipated wind forces imposed.)”
Recommendation No. 4: Personnel should not be transported by material hoists.
Discussion: Employees should be trained to follow OSHA Standard 29 CFR 1926.552(b)(1)(ii) which states “no person shall be allowed to ride on material hoists except for the purposes of inspection and
maintenance”. Due to the terrain of the ground and the location of the area of the house to be
framed, the material hoist was used to elevate the three workers and the wall to erect and secure
it on the foundation. Appropriate scaffolding would have provided more solid footing, and
would have allowed the workers more room to maneuver the wall and secure it safely into place.
Recommendation No. 5: Forklift operators should be trained by a competent person to operate
forklifts correctly and safely.
Discussion: It is unknown if the operator of the forklift had been properly trained to operate the forklift used
in this incident. 29 CFR 1926.602(d) refers to CFR 1910.178(l): Powered industrial trucks,
operator training that states, “the employer shall ensure that each powered industrial truck
operator is competent to operate a powered industrial truck safely, as demonstrated by the
successful completion of the training and evaluation specified in this paragraph (l). Sections
which specifically apply to this incident are: 29 CFR 1910.178(l)(3)(i)(G) that states the
operator should understand fork and attachment adaptation, operation and use limitation of the
forklift. Forklift operators should be trained to understand the importance of using cleats and the
stability they provide when elevating platforms. The cleats were located on the outside of the
platform with the rail so that when elevated, the open side of the platform was away from the
forklift. Typically this platform was used to hoist building materials to/from the ground. In this
incident, the platform was lifted from the opposite side so the railing was away from the forklift.
This created the illusion that the three men had a railing to protect them from falling off the
platform. 29 CFR 1910.178(l)(3)(ii)(A) and 29 CFR 1910.178(l)(3)(ii)(G) state the operator
should understand the “surface conditions where the forklift will be operated” and “ramps and
other sloped surfaces that could affect the vehicle’s stability”, respectively. Rough terrain forklift
operators should be trained to recognize hazardous terrain which would include grade, and
roughness of terrain. 29 CFR 1910.178(l)(3)(ii)(B) states that the operator should understand the
“composition of the loads to be carried and load stability”.
Forklift operators should be trained to recognize proper weight distribution of the loads they are
elevating with the forks. This would include recognition of unstable weight at the end of the
forks of the forklift and the hazardous condition this creates. Forks should be opened as wide as
possible to provide stability to the platform. Forklift operators should be trained to recognize the
hazards of not securing personnel platforms being elevated by forklifts. 29 CFR
1926.602(1)(viii)(A) states that when personnel are being elevated on a platform, it should be
“firmly secured to the lifting carriage and/or forks”. Therefore, forklift operators should be
trained to ensure platforms being used to elevate workers are properly secured to the mast. Also,
the platform should be equipped with an appropriate guardrail with a locking gate. Elevated
personnel should have controls on the platform that allow them to shut off power to the forklift.
And, the forklift operator should not leave the controls of the forklift so that the elevated
personnel can give instructions to the operator.
Recommendation No. 6: Employers with multicultural workers should design safety training in
languages suited for the company workforce.
Discussion: According to a company employee, toolbox talks were conducted. It is unclear if the subject matter covered all pertinent aspects of the tasks the employees were to perform, or if they were
held on a regular basis. Employers should conduct safety training so that it is understood by all
employees regardless of their ethnicity and education level. This training should include worker
rights, how to recognize and avoid hazardous situations, and task-specific safety rules (such as
wearing goggles and appropriate gloves). The competent person on the job site should be able to
communicate with non-English speaking workers in a manner that ensures all parties understand
the safety issues and how to work safely. Non-English speaking workers should have avenues of
clear and concise communication to notify supervisors of hazardous situations that occur on the
job site.
Recommendation No. 7: General contractors should ensure through contract language that all
subcontractors implement appropriate safety and health programs and training specific to the
work to be performed.
Discussion: General contractors should ensure that all subcontractors have safety and health training programs in place that address the tasks their workers are assigned to perform through contract
language that requires all subcontractors to identify how they intend to implement a site-specific
safety and health program before the initiation of work. The subcontractors’ contract should
contain clear and concise language describing which party is responsible for a given safety or
health issue. Any differences should be negotiated before work begins. Once the provision for
these responsibilities has been established, the respective parties should ensure that the
provisions of the contract regarding safety and heath are upheld through regular inspections of
the work site.
Recommendation No. 8: Small business owners should institute and enforce drug testing
policies.
Discussion: Small business owners can get assistance to develop drug policies from the Associated General
Contractors of America Association (AGC) which has signed an alliance with OSHA, MSHA and the Working Partners for an Alcohol- and Drug-free Workplace Program (Office of the
Assistant Secretary for Policy Working Partners). This program provides “the construction
industry with information, guidance, and access to training resources that will help them
understand the benefits of drug-free workplace programs and protect employees' health and
safety. The Alliance particularly focuses on educating workers on safety and productivity
hazards created by the abuse of alcohol and other drugs in the workplace.”
References
- 29 CFR 1926.451(f)(7)
- 29 CFR 1926.552(b)(1)(ii)
- 29 CFR 1926.602(d)
- 29 CFR 1910.178(l)
- United States Department of Labor, Occupational Safety and Health Administration,
“Drug Free Workplace Alliance”
http://www.osha.gov/dcsp/alliances/drug_free/drug_free.html
- United States Department of Labor, Occupational Safety and Health Administration, “A
Guide To Scaffold Use In The Construction Industry”, OSHA 3150 2002 (Revised)
http://www.osha.gov/Publications/OSHA3150/osha3150.html
- National Institute of Occupational Safety and Health, Fatality Assessment and Control
Evaluation Program, “Hispanic Construction Laborer Dies and Two Coworkers Are
Injured After Falling 10 Feet From an Unsecured Box on the Forks of a Forklift - North
Carolina” http://www.cdc.gov/niosh/face/In-house/full200305.html
- American National Standards Institute, American National Standard for Manually
Propelled Elevating Ariel Platforms, ANSI/SIA A92.3-2006,
http://webstore.ansi.org/RecordDetail.aspx?sku=ANSI/SIA%20A92.3-2006
- American National Standards Institute, ANSI B56.6-2002[8.24.1(b)]
- Rental Equipment Register, “Raising the Bar on Training”,
http://rermag.com/mag/equipment_raising_bar_training/index.html
- Code of Federal Regulations 2001 edition. 29 CFR 1926.602(c)(1)(viii). U.S. Printing
Office, Office of the Federal Register, Washington, D.C.
- Swartz G. [1999]. Forklift safety-a practical guide to preventing powered industrial truck
incidents and injuries. 2nd ed. Rockville, MD: Government Institutes, A Division of ABS
Group Inc.
- NIOSH [1999]. NIOSH Alert: preventing injuries and death of workers who operate or
work near forklifts. Cincinnati, OH: U.S. Department of Health and Human Services,
Public Health Service, DHHS (NIOSH) Publication No. 2001-109.
- Equipment Manufacturers Institute. Rough terrain forklift. Chicago: Illinois. Form
#RT85-2.
Acknowledgements
Business Owner
Kentucky State Police
Kentucky Vehicle Enforcement
Local Coroner
Local Road Department
Photographs
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Picture of side used to lift homemade platform. Notice there are no cleats for forks on this side.
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Corner of house where carpenters were to erect the wall. The concrete wall was not there at time
of incident. |
Kentucky FACE Program
The Kentucky Fatality Assessment & Control Evaluation Program (FACE) is funded by a grant from the Centers for Disease Control and the National Institute of Safety and Health. The purpose of FACE is to aid in the research and prevention of occupational fatalities by evaluating events leading to, during, and after a work related fatality. Recommendations are made to help employers and employees to have a safer work environment. For more information about FACE and KIPRC, please visit our website at: www.kiprc.uky.edu
To contact Kentucky
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.
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