The Naval Safety Center (NAVSAFECEN) is a center of excellence for modern data analytics to predict and prevent mishaps. As safety directly impacts both materiel and operational readiness, our ability to provide predictive data is critical to preserving warfighting capability across the Navy and Marine Corps.
As the Navy and Marine Corps’ safety advocate, NAVSAFECEN collaborates with stakeholders across all warfare communities to provide relevant information and data to develop leading indicators of risks and hazards.
NAVSAFECEN recently responded to a request from Naval Supply Systems Command to conduct an assessment analyzing reported fleet forklift mishap data to identify potentially deficient forklift risk management designs and measure current risk mitigation levels.
Forklifts are used daily to perform essential cargo movement onboard ships, from pier side operations to underway replenishments. Forklifts provide efficient cargo movement that would not be safe or possible using only working parties and human lift. Maintaining appropriate human risk controls to operate these machines is essential to prevent injury and avoid damaging critical shipboard systems and supplies.
NAVSAFECEN analysts compiled shipboard forklift mishap data from safety reports submitted in the Navy’s current mishap reporting tool, Web-Enabled Safety System (WESS). The available data from 2014 to present revealed 83 percent of the shipboard forklift mishaps are occurring due to the following factors:
- 18% Forklift Crew Error
- 21% Performing Forklift Maintenance (MX)
- 39% Safety Observer Failure
- 21% During Forklift Tine Adjustment
Knowledge Management (KM) afloat analysts assessed each reported ship class: ADC, CVN, LHA, LHD, LPD and LSD. The data revealed that during the given timeframe, only six total forklift mishaps occurred during all of the operations onboard hospital, LHA, LPD, and LSD ship classes. Given the numbers and frequency of forklift operations necessary to successfully complete amphibious missions, combined with the smaller operational quarters onboard these ship classes over the six-year timeframe, analysts realized safety underreporting must be considered.
Looking into the top four mishap categories, the reported mishaps were caused from the following:
- Forklift Crew Error. Either the crew did not adhere to the safety calls of their safety observer, or the forklift was operated in a manner that resulted in inadequate clearance for operation or caused a nearby pallet strike;
- Forklift Maintenance. Mishaps occurred during forklift maintenance and resulted in finger cuts, smashed fingers while lifting the battery, electrical shocks tightening battery terminals, and cleaning;
- Tine Adjustment. A forklift’s tines or forks are normally very heavy and used to counterbalance the forklift’s center of gravity. As written, tine adjustment mishaps may have all been preventable, citing the tines’ weight as a “common denominator” to each injury, with the injuries occurring due to a person trying to make tine adjustments alone;
- Safety Observer Failure. These mishaps occurred due to the safety observer’s actions, either being out of position to safely observe the ongoing forklift operations, or losing control of the forklift operations by being unable to “emergency” stop unsafe forklift operations.
The current risk controls for shipboard forklifts results in the successful mitigation of 46% of shipboard forklift operational risk and yields a 54% risk design shortfall. This shortfall, coupled with human error factors, increases the vulnerability for incurring mishaps. Individual units must place focused emphasis on identifying and mitigating these risks and practice deliberate procedural compliance.
The KM analysts used their Safety Management Systems (SMS)-based risk assessment model to “zero in” their analysis on the existing procedural guidance and human error management tools – or risk controls – the fleet uses to help mitigate the risks of shipboard forklift operations. By reviewing the primary procedural guidance and human error management tools provided to the fleet to standardize and define general forklift operations, forklift operator training and forklift team training, they were able to determine the larger root causes of reported shipboard forklift mishaps and provide potential solutions for risk design shortfalls. The KM analysts reviewed the following instructions and management tools:
Navy Safety & Occupational Health Program Manual for Forces AFLOAT, OPNAV 5100.19, Section C, Chapter 2, Dry Cargo Operations, Stores Handling, and Rigging, contains solid general forklift safety procedures. Conversely, the Navy Safety & Occupational Health Program Manual (OPNAV 5100.23) states “…the movement of materials in storage facilities using forklift trucks, overhead cranes and powered hand trucks, where materials are stacked above three feet in height…” represent a Job Hazard Category of ‘B,” and a “Moderate” Hazard Level. However, no other forklift procedures exist among any other written safety procedures nor is a reference made to use NAVSUP Publication (P)-538 for “all other forklift operation requirements” to help guide forklift users to necessary procedures; therefore, OPNAV 5100.23 was not included in the risk design for the Fleet’s forklift operations.
NAVSUP P-538. Management of Materials Handling Equipment (MHE) and Shipboard Mobile Support Equipment provides the primary guidance for “…the management, maintenance, and safe use of industrial MHE and their approved attachments, and Shipboard Mobile Support Equipment (SMSE) at U.S. Navy units ashore and afloat.”
NAVEDTRA 43100-6T. The analysts looked at the Personnel Qualification Standard (PQS) Catalog to determine if a general forklift operations PQS was available to help “train the trainers” using an organized and standardized methodology that was not developed in the NAVSUP P-538 – and possibly provide a template to help local commands with various forklift devices to develop local job qualification requirements (JQRs) and enable operational and HFM standardizations. However, research revealed there is no stand-alone forklift PQS for the Fleet. There are elements of forklift use standardization embedded in other PQS’, but not contained – and therefore not content managed – solely for managing the diverse skill sets required to safely operate forklifts.
LHA/LHD NATOPS Manual (NAVAIR 00-8T-106). Analysts looked at the type command’s (TYCOM) procedural guidance for shipboard forklift operations and team cargo procedures based on the lack of existing team forklift operations procedures and HFM standardization present in 5100.19F, P-538 and 43100-6T. Forklift operations were discussed relating to night vision devices and U.S. Army H-47 helicopters. A stand-alone section for general cargo handling and staging, non-ship’s company forklift operator qualification requirements, forklift team operations, general forklift operations, or a minimum safety standards framework for PQS or local JQR design are not contained in this NATOPS.
Based on the assessment, the analysts made the following recommendations.
1. Develop a Forklift Operation Safety Training Video. It may seem too basic, but developing a shipboard forklift operation safety video would help accelerate the understanding of safe forklift (and other) MHE equipment and complement all existing afloat forklift training that is otherwise “hidden” by being embedded in specific rate manuals. This serves a few purposes:
A – Not just one rating operates shipboard forklifts, and training should not require added “extra effort to locate the right training” for Sailors to learn and operate forklifts safely and for leadership to use to develop local procedures;
B – Supervised unsafe forklift operations for visual presentation, from pre-op checks and designing a cargo movement plan to actual forklift operator “typical mistakes” could ultimately be a part of the training video content, allowing a real-time and accurate – but safely staged – reenactment of unsafe conditions. This will prove invaluable in “what not to do” as Sailors start training to operate forklifts onboard ships.
2. Develop a General Forklift Operation NAVEDTRA. A general forklift operation NAVEDTRA would provide the Fleet with a tool that provides forklift guidance organized into a more humanly learnable fashion. Integrating a NAVEDTRA with a Forklift Operation Safety Training video would immeasurably strengthen the fleet’s local forklift operation procedures.
3. NAVSUP P-538, Revision 7. During this assessment, the development of NAVSUP P-538 Revision 7 was confirmed through liaison with NAVSUP WSS Mechanicsburg, making the development and deployment of recommended changes in this risk assessment possible before the revision was completed. As 83% of reported shipboard forklift mishaps are occurring as a direct result of the current procedural guidance in place to prevent forklift mishaps – making these critical changes will best serve the fleet’s operational readiness.
As noted earlier, forklifts are used daily to perform essential cargo movement onboard ships. Updating our procedures and visual aids are but one aspect of the training methodology. Ultimately, forklift operators and safety observers must ensure they comply with instructions, initial and recurrent training and local guidance to avoid that next potential mishap.
For access to the full assessment, contact the Naval Safety Center at NAVSAFECEN_CODE521_MEDIACOMMS@navy.mil