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Mechanic Service Technician Fatally Struck by Order Picker Carriage — New York										Related Pages
										New York Case Report: 19NY038
Report Date: 08/10/2022

SUMMARY
At 8:15 a.m. on October 8, 2019, a 58-year-old male mechanic service technician for an equipment service and sales company was fatally crushed by the carriage of an order picker forklift. The incident occurred at a client’s site where the decedent was servicing the order picker with a co-worker. The carriage, weighing approximately 1,163 pounds (lbs.), consists of an operator platform, control console, and lift forks. The carriage can move up and down on the order picker’s mast, and the movement is actuated by a center lift hydraulic cylinder and a pair of side lift cylinders along with a set of chains and pulleys. The hydraulic pressure for the center lift cylinder was over 2,000 pounds per square inch. The center lift cylinder had a minor leak, and the decedent and the co-worker were on site to repack the cylinder (replacing the cylinder parts) on the day of the incident. To access the cylinder, they removed the control console cover and raised the carriage approximately seven feet high. The co-worker went to his van to fetch a pair of locking chains so that they could secure the elevated carriage to the mast with the chains to prevent the carriage from falling. They then realized that they had the wrong packing kit with them. They could not repack the cylinder that day since they had to go back to their shop to get the correct kit. According to the co-worker, the decedent was holding a pair of snap ring pliers while standing directly underneath the carriage that was neither chained nor blocked. At about 8:15 a.m., the decedent removed the outer snap ring from the cylinder with the pliers apparently to verify the part number. The function of the outer snap ring (aka retaining ring) is to hold and secure the oil seal of the cylinder at the rod end. While the decedent was telling his co-worker that he just wanted to look at the ring, the carriage fell quickly crushing the decedent underneath. Meanwhile hydraulic fluid sprayed over the entire dock area. The police, fire department, and EMT arrived at the scene within minutes. However, the rescuers were unable to revive the service technician who was pronounced dead at the scene.
**CONTRIBUTING FACTORS**
Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events. The NY FACE investigation identified the following key contributing factors in this incident:
The snap ring was removed from the cylinder causing the hydraulic system failure and rapid descent of the carriage.
The elevated carriage was neither blocked nor secured to prevent it from falling.
Occupant, the decedent youth, was in the silo with the sweep auger rotating and circling around the silo.
The victim was standing under elevated carriage which was neither blocked nor secured.
The cylinder was not removed from the order picker before the snap ring was removed.
Employer did not have specific standard LOTO procedures for servicing hydraulic cylinders on order pickers.
Employer did not provide employee training on specific LOTO techniques and procedures.**RECOMMENDATIONS**
NY FACE investigators concluded that, to help prevent similar occurrences:
Employers should develop specific lockout/tagout procedures for service technicians to follow when servicing lift trucks such as order pickers.
Employers should ensure that service technicians follow manufacturer’s safety requirements, and employees should strictly follow the standard safety procedure.
Employers should conduct job hazard analysis (JHA) to identify hazards and risk factors associated with lift truck maintenance and repair services.
Employers should ensure that all service technicians receive proper and adequate training on LOTO procedures.
Employers should develop checklists for high-risk maintenance tasks and require technicians to check each step and sign the checklist.
Employers should conduct periodic inspections at client sites to ensure the sites are free of hazards and workers follow the safety protocols.
Employers should implement a near miss reporting system to ensure worker safety and the compliance of company safety protocols.Mechanic Service Technician Fatally Struck by Order Picker Carriage — New York [PDF 1,131 KB]
							
					
							Last Reviewed:  October 8, 2022						Source: 	National Institute for Occupational Safety and Health
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