Hazard

Employees were exposed to the hazard of being struck by a lift truck with damaged safety devices and impaired operator visibility.

Process

A lift truck with a front-end attachment is used to load rolls of coiled steel onto a flatbed trailer.

Activity at time of incident:

Two employees were standing near a lift truck when the operator of the lift truck placed a load of coiled steel rolls on the flatbed trailer and began backing up.

Incident Description

Setting:

A longshoreman is operating a lift truck equipped with a front-end attachment to transport rolls of coiled steel from a storage area to a flatbed trailer at a longshoring terminal. The operator is assisted by a checker. As the loading operation is almost finished, the facility's assistant operations manager arrives at the site and walks to a location within 50 feet of the rear corner of the lift truck (on the driver's side). He motions to the checker, who walks towards him, passing behind the rear of the lift truck. Both employees then stand with their backs to the lift truck, in an area bordered by stored rolls of coiled steel. Meanwhile, the lift truck operator, who has just finished placing a roll of coiled steel on the flatbed trailer, backs up from the flatbed trailer at an angle towards the lift truck operator's left.

Incident:

While backing up away from the flatbed trailer, the lift truck operator failed to see the two employees standing at the rear of the truck. The vehicle first struck the assistant manager in the back (pushing him to the side), and then struck the checker, apparently with the driver's side rear tire. After being knocked to the ground, the checker was caught under the lift truck, dragged, and killed. The assistant operations manager had unsuccessfully attempted to grab the checker, then ran to the front of the lift truck and yelled for the operator to stop the vehicle. However, by that time the lift truck had driven over checker's body.

Relevant Factors:

The driver's side cab window and both rearview mirrors on the lift truck were damaged. Instead of replacing the broken window, the employer installed a piece of cardboard over the broken section. The right rearview mirror was missing altogether, and the left rearview mirror mount was bent, causing the mirror's view to be blocked by a post on the cab. There was evidence of rust in the bent portions of the right side mirror as well indicating the damage was not recent. For the operator to see the area he was backing into, he would need to look out the cab door, which would have required him to get out of his seat.

The assistant operations manager claimed that he and the victim were standing at a distance of about 50 feet from the lift truck, stating that he could see the operator through the left side door of the lift truck cab and presumed that the operator could see them. The lift truck operator disputed the location of these employees, stating that they were standing just off to the left rear of the lift truck in his blind spot.

The lift truck's audible backup alarm was in proper working order. The assistant operations manager heard the lift truck's alarm but failed to move in response to it. He stated that after hearing the backup alarm all day long, he became unconcerned about its warnings.

The lift truck operator was the only employee who operated the lift truck involved in the incident. He had worked for the employer for nine years and operated the lift truck daily. The operator had not been instructed to perform pre-operation inspections of the lift truck nor did he report the defects to anyone. After the incident, the employer returned the lift truck to service without repairing the damaged rearview mirrors or window.

Applicable Standards and Control Measures

• 29 CFR 1917.43(c)(5): Powered industrial trucks - Maintenance. "Powered industrial trucks shall be maintained in safe working order. Safety devices shall not be removed or made inoperative . . . Trucks with . . . a safety defect shall not be operated."

This hazard might have been prevented by repairing or replacing the damaged rearview mirrors and the broken window in the lift truck cab, thus providing the operator with a clear view to the rear. This hazard could also have been prevented by conducting routine inspections of the lift truck before each use, maintaining the equipment in safe working condition, and immediately taking it out of service when defects made it unsafe to operate.

Other Relevant Standards and/or Control Measures

• 29 CFR 1917.1: refers to 1910.178(l) Powered industrial truck - Operator training. "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."

The lift truck operator, through initial and periodic refresher training, must observe all safe operating procedures. Additionally, safe access routes and work areas should be established for employees who must pass through or work in areas where lift trucks are operating.

Employees on foot would be more visible to vehicle operators if they were wearing high visibility vests and if strobe lights were placed on the lift truck.