Employees were exposed to the hazard of being struck/crushed while standing beneath an elevated and improperly loaded lift truck.


Material handling using a lift truck with a paper roll clamp attachment to transport cargo.

Activity at time of incident:

Repairing shrink wrap cocooned around two wood pulp paper rolls stacked on top of each other.

Incident Description


A break bulk cargo ship was being loaded with 2-roll units of processed paper pulp. The two rolls were cocoon wrapped together in clear polyethylene packaging to form a unit weighing approximately 2,000 pounds. Each individual roll was approximately 60 inches in diameter and 19 inches high. The units (each consisting of 2 rolls) were stacked in the terminal warehouse. The rolls were stacked one on top of the other with their flat sides parallel to the ground, and their axis vertical (similar to stacking tires). Powered industrial trucks (PITs) with flat clamp attachments designed for flat-sided cargo grasped the 2-roll units on their round side for transport to the dock. The load was placed on a steel pan at the dock and then loaded onto the ship by a crane. While some workers were loading the 2-roll units onto the ship, others were on dock tape patching damaged cocoon wrap on the bottom of the 2- roll units.


At the time of the accident, the PIT operator maneuvered the truck into the area on the dock where the workers were repairing the damaged wrap and elevated the load approximately six feet above the dock surface. A six foot high support stand called a core plug stand was available to safely hold the load aloft, but not used. The operator left the truck and went under the elevated load to help the two dock workers tape torn sections of the polyethylene wrap on the bottom of the lower roll. While the operator was patching under the load, the bottom roll dropped out of the clamp, fatally crushing him. The other two workers were standing to the side of the roll when the incident occurred.

Relevant Factors:

Following the incident, it was determined that both the lift truck and the roll clamp were inspected and maintained in proper working order. However, the clamps that were attached to the PIT were the wrong clamps for this particular operation. The model clamp used on the PIT was manufactured for flat sided rolls rather than round sided. Therefore, when the truck operator (who was an experienced industrial truck operator) picked up the load, it was not fully engaged. On this particular lift, the top roll was securely clamped, however, only 2 inches of the 19 inches of the bottom roll was engaged. This was not secure enough to hold the weight of the lower roll when suspended above the employees repairing the shrink wrap.

The stevedoring company had been using the wrong clamp attachment for this operation, with what they believed was the implied approval of the manufacturer's representative. The representative had observed the loading of this cargo, but failed to report that the clamp being used was not correct for this operation.

Applicable Standards and Control Measures

  • 29 CFR 1910.178 (l)(4)(ii)(A): Powered industrial trucks - Operator training - Refresher training and evaluation. "The operator has been observed to operate the vehicle in an unsafe manner."

This hazard could be prevented by not standing or passing under an elevated portion of any lift truck whether it is empty or loaded.

  • 29 CFR 1917.43(b)(3): Powered industrial trucks - General. "When PITs are left unattended, the load engaging means shall be fully lowered, controls neutralized and brakes set."

This hazard could be prevented by the operator remaining in the cab, or lowering the load onto a stand which would have fully engaged the load safely.

  • 29 CFR 1917.43(e)(3): Powered industrial trucks - Fork lift trucks - Forks. "Forks, fork extensions and other attachments shall be used only in accordance with the manufacturer's recommendations."

This hazard could be prevented by using the correct clamps for the appropriate load. In this instance round clamps designed to grasp the load on the round side should have been used.