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FACE Report: Forklift operator crushed by loaded pallet

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Case report: #20OR010
Issued by: Oregon State Fatality Assessment and Control Evaluation Program
Date of report: Dec. 7, 2020

On Feb. 28, 2020, a forklift operator died after being crushed by a loaded pallet of soft drink cans. The pallet, which weighed about 2,000 pounds, was on the top layer of a pallet row. Pallet rows were oriented back to back, with the front of the pallet row showing a barcode label on each pallet. The warehouse inventory management system directed the operator to pull pallets from a row that didn’t contain any product. For unknown reasons, the operator pulled four pallets from the back of the adjoining row, destabilizing the top layer of pallets. While the operator was cleaning up some cases that fell off one of the pulled pallets, the top layer pallet fell onto him from a height of approximately 20 feet, causing multiple and massive internal injuries to his head and body. The forklift operator worked the swing shift full time at the warehouse, as well as another job that started at 6 a.m., for a total of about 70 hours a week. Investigators believe fatigue caused by lack of sleep may have adversely affected the operator’s judgment.

To prevent similar occurrences, employers should:

  • Ensure warehouse layout and pallet stacking procedures incorporate sufficient engineering controls to prevent distracted employees from inadvertently destabilizing multilayer pallet rows.
  • Ensure safe pallet-stacking procedures are written and accessible, and include instructions on how to perform spot checks on pallet rows.
  • Ensure employee training program includes training about the hazards of working around potentially unstable pallets.
  • Treat sleep deprivation as a workplace hazard, especially for swing- and night-shift employees.

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