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Case No.1

A forklift operator was caught between the mast and the head guard while trying to straighten a loose load

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[Circumstances of Incident]

On the day of the accident, the operator visited a subcontractor to pick up some products and came back to the office at roughly 4:20 in the afternoon. Following a supervisor's instruction given at the office on the second floor of the building to deliver other products for the next time, the operator entered the warehouse to pick up the products.

At the time, three persons were working in the office, including the supervisor and two other seconded workers. The operator entered the warehouse alone.

Another worker later went to the warehouse to confirm that the products to be delivered, and found the operator lying unconscious on the forklift with blood coming from his mouth. The worker rushed to the office to call an ambulance, which took the victim to a hospital. The operator died at about six o'clock in the evening from a crushed chest and neck.

The following can be cited as the causes of this accident.

1. Direct causes
(1) When leaving the driver's seat of the forklift, the operator must lower the fork to the lowest position, stop the engine by turning off the switch and firmly applying the brakes. However, the operator left the driver's seat without taking any of these required steps.
(2) Despite the fact that daily operations frequently required the use of forklifts, the company employed only one qualified operator. The victim of this accident, who was not a qualified operator, operated the forklifts when the qualified operator was absent.

2. Indirect causes
(1) The engine key of the forklift was kept inserted at all times, thereby allowing any unqualified worker to operate the machine.
(2) The working environment in the warehouse was not suitable for safe cargo-handling operations by forklift as the lighting was inadequate and the passageways were narrow.
(3) Long and thin rolls of paper were loaded on the fork without adequate spacing, which result in unstable rolls shifting on the fork.

[Type of business] Printing
[Type of accident] Caught or trapped
[Number of victims] One fatality