A coronial inquiry into the death of 44-year-old Darren Lamb, who was killed when a shipping container fell onto him, has exposed deadly gaps in forklift inspection regimes.
The father-of-seven and husband of twenty years arrived early to work at Conroy Removals’ Dandenong South premises on the day of his death, where he was used a Hyundai 130D-7E forklift to move a six metre wide shipping container, weighing nearly four tonnes, from a stack of containers.
A colleague arriving at the site later observed that the four-tonne container was stacked at an odd angle and reported this to two managers. All three men rushed to the scene and discovered that the container was resting on top of the cabin of Mr Lamb's forklift, crushing the cabin. Mr Lamb had sustained fatal chest injuries.
WorkSafe investigators reviewed CCTV footage that showed the mast of the forklift significantly tilt backwards causing the shipping container to fall of the roof of the cabin. WorkSafe's engineering unit (WEU) found that the bolts that hold the forklift mast in the mast mounting hooks had failed, potentially because of the design of the mast attachment - unlike most forklift models, the mast bolts were in the direct load path.
The WEU also found that while Conroy Removals’ hired forklifts were regularly serviced in accordance with the Australian Standard and manufacturers' recommendations, these documents didn't provide sufficient guidance around the frequency of inspections, critical components, what needed to be identified during inspections, and how issues could be rectified.
The WEU's principal engineer stated that many forklift owners, mechanics and service agents prioritised the inspection and maintenance of mechanical components over structural components like mast bolts. The Australian Standard guidance also falls short on directing how often forklifts should be inspected, critical components that need consideration during servicing and what to identify during an inspection and how that can be found.
Victorian Coroner Therese McCarthy called for the Australian Standard for powered industrial trucks to be amended to "incorporate more detailed inspection requirements and establish mandatory inspection frequencies".
She also recommended that the Victorian OHS Regulations 2017 be amended to explicitly require employers to keep records of inspections and maintenance carried out on forklifts.
Currently, such record-keeping is mandated for plant like cranes, boilers, lifts and amusement structures, but not for forklifts or industrial trucks. The equivalent provisions in the national model WHS Regulations and the harmonised jurisdictions similarly exclude forklifts.
The Coroner found this issue was troubling when considering that "structural and mechanical defects in equipment can present differently and carry different safety risks".
"Where progressive symptoms of mechanical issues may be identified by reduced performance in the operation of equipment, structural defects may remain latent until identified by way of targeted inspection," she said.
"These risks underscore the importance of prescriptive maintenance specifications that clearly identify the categories of defects capable of detection and the appropriate method for their detection, so that the scope and quality of inspection and maintenance are not left to individual judgement or variations in practice."
Coroner McCarthy concluded that Mr Lamb's death arose from "his operation of a faulty or malfunctioning forklift in the course and scope of his employment".
The forklift was not routinely inspected for structural defects that should have been, but weren't, outlined in the Australian Standard, she said.
Mr Lamb's death was preventable, the Coroner stressed.
If inspection guidelines become "more fulsome in regard to the relevant standards", and forklifts are properly inspected for structural defects, it "is possible that future fatal incidents could be averted", she said.
Three recommendations were made by the Coroner – for Australian Standards to clarify inspection requirements and frequency, to require records of forklift and industrial truck inspections and maintenance, and for WorkSafe to run a safety campaign to inform owners and operators of these obligations.
Read more: Finding into death without inquest of Darren Jeffrey Lamb