Case Studies of Accidents Involving Forklift Operations: Fuelling India's Growth Panipat Refinery

CASE STUDIES OF
ACCIDENTS INVOLVING
FORKLIFT OPERATIONS
Panipat Refinery Fuelling India’s Growth

Overview:
Case studies of 4 fatal accidents

involving forklift.
– Synopsis of Accident
– Description of Accident
– Key Findings / Observations
– Learning Points
• Summary of Key Learning Points.

CASE STUDY 1
Fatal Accident at
Waste Paper Factory.

Synopsis of Accident:
Workplace Premise: Factory repackaging

waste paper
Forklift: 3 ton (load capacity)
Work Activity: Deceased was operating the

forklift on a metal ramp to load up compressed
bales (blocks) of waste-paper into a container.
Nature of Accident: Forklift overturned and

crushed worker

Description of Accident
 The forklift was loading blocks of compressed recycled
papers ("paper bales") into a 40 ft long container stationed
at the end of the ramp. The ramp was propped up by paper
blocks. Another forklift was used to move the paper blocks
onto the ramp for loading.

 While the deceased was in the process of loading a
paper block, the forklift suddenly reversed out from
the side of the ramp and toppled off the ramp. The
deceased was pinned onto the ground by the forklift
and was killed.

Key Findings / Observations
Forklift involved in the accident.
Badly worn out tyre: evidence of

poor maintenance

1. The deceased had not undergone the Forklift Driver‘s

Training.
2. Forklift involved in the accident was poorly maintained and

there was no proper maintenance regime for the forklifts in
the workplace.
3. Unsafe work method of operating forklift on ramp propped

up by paper blocks.
4. There was no risk assessment conducted on the work

activity. There was also no safe work procedure established.

Learning Points
1. Importance of ensuring forklift operators are

trained and competent.
2. Importance of ensuring any machineries such as

forklifts are safe and without risks for workers;
proper maintenance regime for the forklifts in
the workplace.
3. Importance of conducting risk assessment to

identify and implement control measures which
include proper safe work procedure for forklift
operations.

CASE STUDY 2
Fatal Accident at
Warehouse Premise

Workplace Premise: Warehouse premise in a
distribution park.
Forklift: 3 ton (load capacity).
Work Activity: Deceased was taking stock of

goods to be transported out of the warehouse.
He squeezed through the gap between two racks
and was crushed when a forklift pushed the
racks closer to make space for more racks.
Nature of Accident: Crushed between objects

 The deceased worker was involved in tallying stock
stored on metal racks within yellow boxes.
Warehouse Premise

 The deceased worker was conducting checks in between
two metal racks just prior to the accident.
 To free up space for more cargo, a forklift operator used his

forklift to push the adjacent metal racks. The deceased worker
was trapped in between the metal racks. Deceased worker was
found dead an hour later.
Forklift’s position prior Deceased was caught in Labels on

to pushing the metal racks between the metal racks carton boxes
1. Risk assessment on such work activity was not carried

out.
2. It was a common practice for tally clerks and other

workers to work in between cargoes and containers while
forklifts were operating in close proximity.
3. Lack of entry prevention into yellow box and / or work

procedures not established to prevent such work activity
from being carried out concurrently.
4. Inadequate safety trainings and briefings to effectively

promote safety awareness among workers.

Learning Points
1. Importance of conducting risk assessment to

identify and implement control measures. for forklift
operations.
2. Proper management of forklift and human traffic in

workplace, e.g. Proper demarcated paths for human
and forklift traffic.
3. Importance of safety training and briefings to

increase safety awareness and manage workers’
behavior.

CASE STUDY 3
Fatal Accident at
Shipyard

Workplace Premise: Vehicle access road in shipyard.
Activity: Deceased was sleeping near vehicle access road

next to steel fabrication block. The road is part of a T-
junction. At around 11.55 pm, a 7-ton forklift carrying a
concrete block turned left at the T-junction into the road and
ran over the deceased.
Nature of Accident: Ran over by forklift

At near midnight, the deceased and 4 co-workers were
sleeping at an open space near fabrication block after they
had taken their supper. The 4 co-workers were sleeping near
steel fabricated block. However, the deceased slept at an
open path further away from the rest.

 The 7 ton forklift carrying a concrete block (measuring 1.5m X
1m X 1.5m and weighing about 5.4 ton) turned into that area and
ran over the deceased worker (who was lying on the path of the
forklift). The deceased worker subsequently succumbed to his
injuries in hospital.

1. Not all workers were informed about the existence of the

resting shed (just 100m away). No instruction was given
to prohibit workers from resting near the steel fabricated
blocks or other work area.
2. The operator’s vision was obstructed during operation by

the concrete block, but he continued driving forward.
3. There was no lighting around the proximity and the

operator did not switch on the 2 headlights.
4. The operator worked from 7.30am till mid-night and fatigue

may have compromised his judgment and functionality.

Learning Points
1. Proper management of forklift and human traffic in

workplace, e.g. Enforcement of designated resting
area for workers
2. Importance of safety training and briefings to increase

safety awareness and manage workers’ behaviour.
3. Proper lighting for forklift operations at night.
4. Issue of fatigue -adequate hours of rest for workers

CASE STUDY 4
Fatal Accident at
Construction Site

Workplace Premise: Circular vehicle ramp of a light industrial
building under construction.
Work Activity: A worker (the deceased) was driving the forklift

down a circular vehicle ramp from the 4th level towards the 3rd
level. The forklift suddenly swerved and overturned at the 3rd
level. The deceased was pinned by the forklift and he died on
the spot. There was no load on the forklift.
Nature of Accident: Forklift overturned and crushed worker

Forklift operator had not undergone the Forklift Driver's
Training.

 The forklift was moving down the circular vehicle ramp when
it suddenly overturned and pinned down the deceased.


1. The forklift involved in the accident, belonged to the main

contractor and was poorly maintained, though there is an
existing maintenance regime established.
2. The deceased was an employee of the plastering and brick-

laying works sub-contractor. He had not undergone the
Forklift Driver's Training.
3. There are insufficient trained forklift operators with respect

to number of forklifts.
4. There was no risk assessment conducted on forklift

operations.

Learning Points
1. Control and management of sub-contractors: Ensuring

forklift operators are trained and competent.
2. Sufficient trained forklift operators to number of forklifts.
3. Importance of effective implementation of maintenance

regime for the forklifts in the workplace.

Summary of Key Learning Points
1. Risk assessments is important even for simple forklift

operations.
2. Competency of forklift operators is critical to the safe operation
of forklift– Procedures / system should be established to
ensure operation of forklift by authorized, trained persons for
own workers and subcontractors.
3. Control measures to effectively manage forklift and human
traffic within the workplace are critical for ensuring the safe
movement of workers.
4. Safety orientation, training and briefing are important in
promoting safety awareness and vigilance among workers
working in the vicinity of forklifts.
5. Proper maintenance regime should be established and
effectively implemented for forklifts and other machines in
workplace.

CONCLUSIONS
 All accidents are preventable.
 Be proactive: it is up to YOU to
prevent it.

THANK YOU

Case Studies of Accidents Involving Forklift Operations: Fuelling India's Growth Panipat Refinery

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CASE STUDIES OF

Panipat Refinery Fuelling India’s Growth

Case studies of 4 fatal accidents

• Summary of Key Learning Points.

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Workplace Premise: Factory repackaging

Forklift: 3 ton (load capacity)

Work Activity: Deceased was operating the

Nature of Accident: Forklift overturned and

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Forklift involved in the accident.

Badly worn out tyre: evidence of

Panipat Refinery Fuelling India’s Growth

1. The deceased had not undergone the Forklift Driver‘s

2. Forklift involved in the accident was poorly maintained and

3. Unsafe work method of operating forklift on ramp propped

4. There was no risk assessment conducted on the work

Panipat Refinery Fuelling India’s Growth

1. Importance of ensuring forklift operators are

2. Importance of ensuring any machineries such as

3. Importance of conducting risk assessment to

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Forklift: 3 ton (load capacity).

Work Activity: Deceased was taking stock of

Nature of Accident: Crushed between objects

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

 To free up space for more cargo, a forklift operator used his

Forklift’s position prior Deceased was caught in Labels on

1. Risk assessment on such work activity was not carried

2. It was a common practice for tally clerks and other

3. Lack of entry prevention into yellow box and / or work

4. Inadequate safety trainings and briefings to effectively

Panipat Refinery Fuelling India’s Growth

1. Importance of conducting risk assessment to

2. Proper management of forklift and human traffic in

3. Importance of safety training and briefings to

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Workplace Premise: Vehicle access road in shipyard.

Forklift: 7 ton (load capacity)

Activity: Deceased was sleeping near vehicle access road

Nature of Accident: Ran over by forklift

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

1. Not all workers were informed about the existence of the

2. The operator’s vision was obstructed during operation by

3. There was no lighting around the proximity and the

4. The operator worked from 7.30am till mid-night and fatigue

Panipat Refinery Fuelling India’s Growth

1. Proper management of forklift and human traffic in

2. Importance of safety training and briefings to increase

3. Proper lighting for forklift operations at night.

4. Issue of fatigue -adequate hours of rest for workers

Panipat Refinery Fuelling India’s Growth

Panipat Refinery Fuelling India’s Growth

Forklift: 3 ton (load capacity)