Coroner's Finding: Joshua John Dingjan
Deceased
Joshua John Dingjan
Demographics
24y, male
Date of death
2013-11-07
Finding date
2024-02-15
Cause of death
Blunt trauma to the head, neck and chest sustained when a forklift toppled onto its right side crushing the deceased
AI-generated summary
Joshua John Dingjan, aged 24, was fatally crushed when a Mitsubishi forklift overturned while he was attempting to unload a 1.9-tonne steel pack from a delivery truck parked perpendicular to the factory on a slope of approximately 9.9 degrees on 7 November 2013. The load shifted on the steel tynes as Dingjan began to swing it down the slope, causing the forklift to topple onto its right side. Dingjan sustained blunt trauma to his head, neck and chest and was not wearing a seatbelt. Contributing factors included: the truck's unusual parking position on the slope (normally trucks parked parallel to the factory); absence of written policies or designated loading zones directing safe unloading practices; lack of enforcement of seatbelt use; poorly packaged steel (not on dunnage/pallet, resting directly on metal tynes, prone to slipping); and inadequate communication of safe practices to all employees. The coroner found that explicit directions not to unload on slopes and consistent seatbelt enforcement would likely have prevented this death. No mechanical faults were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Forklift load shifted on steel tynes due to uneven loading and slope
- Truck parked perpendicular to factory on sloping driveway rather than parallel to factory
- Steel pack not secured to pallet or dunnage, resting directly on metal tynes making it prone to slip
- Unloading attempted on a slope of approximately 9.9 degrees
- Absence of written policies on safe forklift use and loading/unloading procedures
- No designated loading/unloading zone clearly marked or communicated to delivery drivers
- Lack of enforcement of seatbelt use by forklift operators
- Insufficient communication between employer and delivery companies about safe parking positions
- Inadequate formal training and supervision provided to employees on slope hazards
- Forklift operator not wearing seatbelt
Coroner's recommendations
- All drivers of forklifts should use any seatbelt provided when operating a forklift
- An operator of a forklift ought not load or unload a truck on a slope, gradient or turn. These manoeuvres should always be carried out on a level surface
- All packs of steel should be attached to a pallet or dunnage so a pack of steel can be safely loaded onto and unloaded from any truck without slipping
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