TOT 1/25 Truck driver was crushed under falling cargo while unloading

Summary of the investigation report

Causes of the accident:

• Incorrect loading and securing in the country of origin: The loading of the cargo was dangerous and it was insufficiently secured, causing an immediate danger of cargo tipping over or falling during transport and unloading.
• Cutting of the load strap without ensuring stability: The truck driver cut the load strap during unloading, which caused the cargo to fall and led to a serious accident.
• Insufficient risk management and guidance: The employer company did not have sufficient instructions, training, or systematic practices for unloading, reporting dangerous situations, and risk management.
• Insufficiencies in drivers’ vocational training: Current vocational training of the drivers does not include mandatory units on securing and unloading cargo.

Recommended occupational safety improvements:

• Improving the safety of loading and unloading: The cargo must be loaded, unloaded and secured in accordance with the transportation mode requirements, observing forces incurring during road and sea transport.
• Planning and cooperation during unloading: Risk assesment must be carried out before unloading. Cooperation between the truck driver and forklift operator is a key factor in organising safe working methods and unloading area.
• Training and risk management: Company orientation and training must cover securing and unloading cargo, and exceptional situations. Risk management and reporting of hazardous situations must be systematic, and communication between different operators must be multi-directional. The vocational training must cover unloading situations more extensively.

Course of events

The truck driver transported a semi-trailer from the port to the haulier hub depot, signed in at the depot, and started to prepare the unloading of the cargo by opening the protective cover on the left side (as viewed from the rear of the vehicle), removing the support boards, and pushing away the support beam in front of the cargo. The cargo was loaded in two different loading points in Denmark, and included sheets of steel, and chipboards and other cargo positioned on FIN pallets on top of the steel sheets. After discussing the positioning of the bundle of chipboard on top of the steel sheets, unconventional securing, and broken pallet with the forklift operator participating in the unloading, the truck driver got a knife from the cab of the truck and used it to cut a load strap that was supporting the cargo on top of the pallet. As a result of cutting the load strap, the cargo started to tip over almost immediately and fell on top of the truck driver, causing the driver fatal injuries from being crushed under the heavy cargo.

Causes of the accident

Incorrect loading and insufficient securing of the load in the country of origin

Serious errors had been made in loading the cargo in the country of origin, causing immediate danger of the cargo tipping over and falling during transport or unloading. Two pallets containing chipboard, placed side by side on top of steel sheets at the second loading point, were heavy (1,650 kg each) and had been loaded incorrectly; one of the pallets was completely on top of the steel sheets and the other was only partially on top of them. The chipboard pallet that was only partially on top of the steel sheets was only supported by the load strap. The part of the pallet that went over the steel sheets had not been secured vertically to the bottom of the trailer. The load straps were only pulled over the two pallets containing chipboard. In addition, the pallet was partially broken. Other pallets had not been secured in any way. The risk of the cargo falling over was further increased by the fact that during transport, the cargo was subjected to various forces, including sea transport, which could cause the cargo to shift.

Several deliveries have been received from this supplier each week, and insufficiencies have been repeatedly observed in loading. For example, on the very day following the accident, a load that posed a risk of falling had been unloaded, where part of the cargo had already slid up against the tarpaulin wall. Dangerously loaded cargo from other suppliers have also been unloaded often. Insufficiencies are often related to the loading method, such as positioning heavy goods on top of the base load. The cargo is usually only secured with a single strap that goes across the entire cargo and presses it towards the front. In such situations, the opening of the strap can cause the cargo to shift and some of the goods to fall. Another common risk is leaning a load against the rear door, which can cause the door to hit the person opening it or cause the cargo to fall.

Employees have therefore been repeatedly exposed to the risks caused by improper loading.

Cutting of the load strap without ensuring stability of the cargo

The truck driver used a knife to cut the load strap that was supporting the broken pallet. Surveillance camera footage showed that when the load strap was cut, the driver was standing next to the cargo and turned their back to it immediately after the load strap was cut. As a result of cutting the load strap, the cargo started to fall almost immediately and fell on top of the truck driver.

The decision to cut the load strap was probably influenced by the fact that the load strap ratchet was located on the opposite side of the vehicle from the planned unloading direction. Opening the ratchet would have required opening the cover on the other side as well. At the unloading site, there would have been space to open the cover from the other side of the vehicle, but not to unload it. On the other hand, the decision to cut the strap may have been influenced by the tight transport schedule, which is common in the industry.

The driver had also previously transported and unloaded cargo sent by the Danish company in question. According to the forklift operator, they had previously resolved problems related to unloading cargo together with the driver, and in this situation they had also discussed the unconventional securing of the cargo and the broken pallet with the driver just before the incident. However, based on the surveillance camera footage, it appears that the driver was unaware that the load was falling, as they turned their back to the load immediately after the strap was cut.

Insufficiencies in risk management at the employer company

Several insuffiencies were identified in the occupational safety risk management at the employer company, both in terms of risk identification and risk management.

A risk assessment conducted prior to the accident had identified the danger posed by falling, tipping over, and collapsing goods, but no concrete measures had been defined in the documentation to control them. The risk assessment did not take into account the use of load securing equipment and forklifts during unloading.

According to the instructions provided in the driver’s manual, the driver must follow safe work practices, such as properly securing the load and safe handling of goods. However, the manual does not contain separate instructions on how to open load straps, the order of unloading, or the use of forklifts and cooperation between drivers and operators during unloading. No clear guidelines for unloading unconventional loads were prepared. The driver involved in the accident had vocational training, but it did not include training in securing and unloading cargo. Other load handlers were also not familiarised with matters related to unloading, and no guidelines had been drawn up for cooperation during unloading. The company had organised voluntary training on load securing over a weekend, but the driver involved in the accident had not participated in the training. No other training on unloading and handling cargo had been arranged.

The company did not have a systematic procedure in place for investigating hazardous incidents and accidents. No tool or defined procedure for reporting safety observations was defined. Management had been informed of the dangerous loads, but no action had been taken and the matter had not been pursued. An internal general report of the events was prepared for this accident, but it did not address the risks mentioned here and the related corrective measures.

Deficiencies in managing safety in the logistics chain

Deficiencies hindering unloading operations and endanger the safety of the workers involved have been repeatedly observed in cargo loading operations. In order to unload dangerously loaded cargo, it has been necessary, for example, to make emergency lashings to straighten the load before unloading and to unload cargo in an illogical order. Management at the employer company feels that filing complaints with the shipper has been pointless, as the loading method has not been changed despite previous feedback. The shipper was also notified of the accident, but there is no information about the measures taken as a result.

There are also insufficiencies in freight data. In this case, the freight or cargo declaration did not mention the two heavier pallets or provide information about the location of the load strap ratchet on the other side of the vehicle. Furthermore, the contents of the cargo were not clearly indicated in the documents in question. The investigation revealed that drivers generally do not always know the contents of detachable trailers, and they do not systematically check freight or cargo declarations. Interpreting documents can be challenging due to possible incomplete information, language, or poor condition. Tight schedules can also contribute to freight declarations not being read. In order to ensure safe working methods, accurate information about the contents of the cargo and the details of loading would be particularly important in situations described here, where loading often involves shortcomings that could compromise unloading.

The improper loading, unconventional securing, and broken pallet could have been detected at several stages (loading sites in Denmark, ports, and during transport), but the unstable load made it all the way to the terminal. The flow of information between operators and established practices have not been organised to remedy these shortcomings.

Due to limited resources, authorities are unable to carry out continuous and comprehensive inspections. Inspections carried out at ports are considered challenging because resources are limited and ships are unloaded quickly.

Spot checks carried out by the authorities have revealed significant shortcomings in the securing of loads, particularly in detachable trailers and articulated vehicles, where the shifting of cargo caused by sea travel has not been taken into account at the point of departure.

The most common discrepancy is an insufficient number of load straps or insufficient tension, as well as inadequate load support. The problems are particularly pronounced in older detachable trailers, where the number of attachment points for the tarpaulins is often insufficient.

According to the authorities, more attention should be paid to loading and securing loads at the point of departure to ensure that it is properly secured. Authorities receive occasional reports from the roadside regarding dangerously loaded or fallen cargo.

Recommended occupational safety improvements

Operations in loading and unloading sites

To prevent injuries to persons and damage to goods, cargo must be properly loaded and secured.

Loading and securing must be carried out in accordance with the requirements of the modes of transport used, and particular attention must be paid to the forces affecting the load during sea transport. The load must be distributed evenly so that the weight distribution does not cause loss of control of the vehicle or risk of tipping over. The load must be secured in such a way that it cannot slide, tip over, fall, or otherwise cause an accident. Each loading unit must be supported and secured using appropriate securing equipment, such as load straps and supporting beams, so that the load remains in place under all conditions. Lashings must comply with current standards, and be intact and correctly tightened.

Unloading must be planned and organised in such a way that it does not pose a hazard to workers. The unloading instructions must be visual and clearly worded, and the working methods described in them must be followed. The lashings should only be removed once the cargo has been properly secured and controlled. Workers must remain at a safe distance. To ensure safety, appropriate aids must be used to prevent the load from shifting or falling. It is also important that drivers check the freight and cargo declarations at the start of the journey.

Cooperation between driver and forklift operator in planning operations and assessing the associated risks is a key factor in ensuring occupational safety.

The driver’s responsibility is to relay information about how the load is secured, weight distribution, and any special considerations, while the forklift operator must make sure that the aids and lifting techniques used are suitable for loading or unloading. Cooperation also enables the safe organisation of the unloading area, for example, by directing traffic and identifying danger zones.

Driver training, orientation, and instruction

It is important to include instructions and guidance on unloading cargo in the company’s own orientation and training program. Clear instructions must be drawn up for opening trailers and containers, and in particular for sea transport, a load strap or chain must be used to secure the door to prevent the load from tipping over or falling on the driver. In addition, the strength of the wind must be taken into account when opening doors and tarpaulins. Before unloading, the condition of the load must be checked and any potential risks assessed, including cargo that has shifted or is in danger of tipping over. If necessary, the cargo must be supported or secured with a forklift before removing the lashing. The orientation must include practices for assessing last-minute risks so that the importance of ensuring safety is understood in all stages of the work. When choosing an unloading site, consideration should be given to lighting, ground slope, congestion, load-bearing capacity of the ground, anti-skid measures, other possible traffic, and people within the area of influence.

Current vocational training of the drivers does not include mandatory units relating to cargo securing or unloading, which increases risks, particularly in challenging and exceptional circumstances. During training, it is also important to address load shifts during transport and risks related to unloading and the unloading site. Training should cover unloading situations more extensively, including opening doors, handling difficult cargo, etc. It is also important to cover load securing and possible reloading during transport within these training courses. In addition, training should include instruction on safe working methods related to cooperation between drivers and forklift operators. Special attention should be paid to the unloading of cargo arriving via sea transport.

Developing risk management within transport companies and logistics chains

Employers have a legal obligation to systematically identify and investigate factors in work and working environment that may pose a risk to the safety and health of employees. When identifying and assessing hazards, consideration should also be given to situations that deviate from planned activities, actions that contravene the employer’s work instructions, the impact of the activities of external parties, and factors related to cooperation and interaction between different parties.

In addition, the individual characteristics and circumstances of employees, such as work experience and qualifications, must be taken into account when identifying and assessing hazards. Based on the results of the risk assessment described above, measures must be taken in the workplace to eliminate and minimise risks.

It is recommended that in unloading situations such as those described above, a last-minute risk assessment procedure also be applied to ensure the availability of sufficient resources, equipment and safe conditions before starting unloading. To support this practice, an unloading checklist should be introduced and drawn up to be applicable to the unloading of cargo and factors related to the conditions at the workplace in question.

Before opening doors and load straps and unloading cargo, workers involved in unloading must consider the hazards associated with the work for each load, for example, by using the following supporting questions:

Investigating discrepancies and learning from them is a key tool in safety management and continuous improvement. There must be agreed procedures and tools for reporting and investigating dangerous situations, and they must be known to all staff. Reporting hazardous situations should be as easy as possible for employees, and employers should provide prompt feedback on reports. It is a good practice to review hazardous situations and the lessons learned from investigating them not only with your own staff, but also with external parties who contributed to the occurrence of the discrepancy.

In terms of planning the unloading and occupational safety, it is extremely important that those performing the work have as comprehensive advance information as possible related to the contents of the cargo, the structure of the load, the methods of securing it, and any risks associated with unloading. Based on this information, it is possible to plan the order of unloading, select the right tools, and ensure the safety of the unloading site. Work safety during unloading is significantly improved if the shipper provides the recipient with real-time images of the load being transported. The images can be used to identify risks related to falling or shifting cargo, as well as damaged materials, prior to unloading.

In order to ensure the safety and smooth running of material loading, transport, and unloading, it is important that the roles and responsibilities of the various parties are clear and that communication between the different operators is effective. Information flow must be multi-directional; those involved in loading must communicate with the transport company about factors related to transport and unloading (including discrepancies related to loading), and the transport company must communicate with the shipper about any discrepancies related to loading they have observed.

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This investigation report is freely available for use, provided that appropriate source references are given. The investigation report is based on a confidential investigation report prepared by the TOT 1/25 investigation team, which contains detailed information about the accident. A confidential report may be disclosed for research purposes in accordance with a written request for information and a protocol specified for that purpose. All communications relating to this investigation report and the investigation of the case should be sent by email to TOT-tutkinta@tvk.fi.