Inspection Detail

Inspection: 109386.015 - Gm Logistics

Inspection Information - Office: Honolulu Area Office

Investigation Summary

At 4:00 p.m. on November 16, 2011, a work crew consisting of five employees gathered at the work site to commence the removal of a 40 TMC bus from Lot Number 5103-1 and transport it to Formosa Recycling Facility, located in Harmon Guam. In order to accomplish this task, Employee #1 utilized a 1990 SkyTrak(R) Model 9038 forklift, VIN 9038-OCO692. Using the SkyTrak 9038 forklift, Employee #1 positioned the forks under the chassis of the bus and lifted it approximately 2 feet. Upon maneuvering the forklift backwards, the employee transported the bus to the east end of the property where he gradually lowered it onto the ground. According to Employee #2, upon setting the bus on the ground, he noticed someone signaling to Employee #1, who was operating the lift, to stop. Shortly thereafter, Employee #2 witnessed another employee gathering metal studs and paint from the inside of the bus. Observing the remaining contents within the bus, Employee #1 noticed glass, metal and other debris inside the bus. He then decided to lighten the load of the bus by removing the glass, metal and debris. In order to accomplish this, Employee #1 repositioned the forklift towards the front of the bus and positioned the forks below the front end. According to another employee who witnessed, lifting the front end of the bus would allow debris to slide out towards the back of the bus onto the ground thereby lightening the load. Employee #1 gradually lowered the forks and maneuvered the forklift backwards. Upon performing this action, the forklift became unbalanced and started to tip over towards the right side (east). As the forklift started to tip over, Employee #1 grasped the sides of the cab and prepared to jump off the left side (east) of the forklift. Using hand gestures, Employee #2 was signaling the Employee #1 to stay in the cab. Instead, Employee #1 grasped the sides of the cab and jumped off the forklift and landed straight down, onto the ground. As Employee #1 landed onto the ground, the forklift rolled back towards him, pinning his head and chest area between the right rear tire and the ground. Employee #1 was killed by massive chest trauma.

Keywords: Chest, Crushed, Industrial Truck, Roll-Over