Non-inquest findings into the death of PJR
Demographics
68y, male
Date of death
2022-04-11
Finding date
2024-04-05
Cause of death
Traumatic asphyxia due to entrapment between shipping container wall and semi-trailer axles
AI-generated summary
A 68-year-old man with 17 years' experience died from traumatic asphyxia when unloading semi-trailer axles from a shipping container at work. He failed to position the forklift tines to support the axle pack as required by procedure while removing temporary restraints. An axle pack weighing ~1 tonne rolled forward uncontrollably, trapping him against the container wall. Contributing factors included inadequate packing preventing sideways movement during transit, loosely secured red restraint links allowing pack movement, incomplete container door opening creating a pinch point, and working alone without a spotter. The forklift position impeded full door opening. Clinical/occupational lessons: safe work procedures must be explicit and enforced; high-risk tasks require two-person teams; load restraint systems need verification; environmental factors (surface gradient, door clearance) must be optimised; workers must follow established procedures even when experienced.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to position forklift tines to support axle pack as required by procedure
- Axle pack 1 rolled or slipped forward uncontrollably during removal of temporary restraints
- Working alone without a spotter
- Left-hand container door impeded by forklift tines, preventing full opening and creating pinch point
- Inadequate packing of axle packs allowing sideways movement during transit
- Loosely secured red restraint links allowing movement along wheel studs
- Wheel nut only partially screwed on, allowing red link movement
- Flimsy floor chocks providing inadequate support
- Container positioned with lateral and longitudinal grade decline
- Unclear why left-hand door was not fully opened prior to forklift positioning
Coroner's recommendations
- Safe work procedures for unloading axles from containers were subsequently amended by the business to require the activity to be undertaken with a spotter
- Enhanced clarity and safety provisions added to safe work procedures
- Specific training and instruction provided for spotter involved in unloading axles from containers
- Procedures should explicitly require that only trained workers are permitted to unload containers
- Forklift, chains or straps should be used to control loose loads and container doors
- Container doors must be opened fully and secured
- Clear guidance needed on forklift tine positioning to control load in case of movement
- Review of requirement to turn forklift off when tines positioned to address potential hydraulic creep causing unstable movement
- Unloading should be undertaken by minimum two people for door opening, red link removal, and pack removal stages
- Containers should be positioned on level ground with full swing clearance for doors and ability to secure them out of the way
Full text
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