Inspection Detail

Inspection: 120300389 - Leiner Health Products

Inspection Information - Office: Long Beach District Office

Investigation Summary

At approximately 8:30 p.m. on May 21, 1998, Employee #1, age 18, was operating a 1994 Crown electric stand-up rider truck, model #RR3020-35, SL #1A145706, manufactured on August 12, 1994, at the loading dock in the shipping department warehouse of Leiner Health Products. His supervisor that day had instructed him specifically about packaging the proper product mix of the employer's medicinal products. Employee #1 was standing inside the rider truck approximately 20 ft from the edge of the loading dock, watching several coworker/packers working on the lower level of the loading dock area, where the truck/trailers were parked to be loaded and off-loaded. He saw that the packers were selecting an incorrect mix of products, as per his supervisor's instructions, and drove toward the edge of the dock intending to discuss this with them. He had driven approximately 10 ft when he tried "plugging" the vehicle to stop it, a procedure in which the vehicle is slowed and stopped by quickly throwing it into the opposite gear, in this case into reverse. Plugging failed to slow him down the first time, and he tried it again, without success. He was now close to the edge of the dock and stepped on the brake, which also failed to stop the vehicle. Employee #1 cried out that the brakes did not work and, as he was about to go off the dock, tried to leap from the lift truck. His exit was blocked when his head hit the overhead guard, and he and the forklift fell 4 ft off the dock. As he landed, his left foot became trapped under ROPS bar, resulting in amputation of his toes and, subsequently, part of his foot. Employee #1 was transported to Harbor UCLA Hospital and the transferred to Long Beach Memorial Medical Center five days later. The Crown truck was not equipped with brakes adequate to bring the vehicle to a complete and safe stop. According to the manufacturer's instruction and training manual (p. 13), the plugging method was not to be used for emergency stops. Moreover, according to the manufacturer, manual plugging created longer stopping distances than ordinary pedal braking. However, post-accident investigation showed that braking with the plugging method actually resulted in a shorter stopping distance. According to the manufacturer's training manual, the truck was in conformance with OSHA code 1910.178. Employee #1 had been working for the employer since September 1997, first as a temporary worker and, since November 15, 1997, as a regular full-time employee. He had been trained by the employer in forklift operations, and forklift driving was his normal job.

Keywords: AMPUTATED, IND TRK OPERATOR, BRAKE, EQUIPMENT FAILURE, INDUSTRIAL TRUCK, FALL, LOADING DOCK, FOOT