Killed by a forklift or a high vis vest?
Fatal injuries have a ripple effect throughout an organization – least of all the painstaking task of performing an investigation without placing blame on employees. What’s the true cause of an incident when a forklift strikes a worker wearing the wrong-colored vest? Worker behavior may play a role, but the issue usually lies much deeper.
Look for systemic patterns
A pattern of incidents at one battery construction site is a great example of how individual decisions and company safety systems intertwine to determine the outcome of daily events. OSHA’s report on the March 2025 death of a company CEO showed that while individual decisions played a role, the fatality occurred within a broader pattern of systemic safety failures at the construction site.
According to Agency findings, the employee chose to cross a roadway while wearing a black vest instead of the required high visibility vest, which drastically reduced the employee’s visibility. At the same time, a site forklift driver was reportedly talking on the phone while operating the vehicle which also contributed to the result of the incident.
OSHA’s conclusions made clear that organizational systems and controls, not just the individuals’ choices, were the primary shortcomings. Multiple companies on site failed to enforce safety rules, maintain traffic controls, or ensure proper operator behavior. For example, the forklift driver’s employer received the largest fine for exposing workers to struck-by hazards and failing to ensure operators followed basic safety practices such as speed limits, phone use, use of spotters, and horn use when visibility was obstructed.
The report reflected an even larger pattern, finding that the employee’s death was one of many safety incidents at the construction mega site, which had recorded dozens of previous traumatic injuries, multiple fatalities, and at least 15 OSHA investigations. Previous incidents included falls, other forklift injuries, a conveyor entrapment, a pipe explosion, and a fatal crushing incident earlier in 2025. This track record should have been an early warning that system-level safety gaps and inconsistent safety management were key contributors, far outweighing any single person’s decisions.
Stomp out systemic failures
While individual decisions like walking into a traffic zone or operating equipment while distracted may influence an incident, they rarely tell the whole story. Root causes usually reflect deeper underlying weaknesses in the organization’s safety systems, such as:
- Fragmented safety oversight that leads to inconsistent enforcement of safety rules, policies, PPE requirements, and behavioral expectations;
- Inadequate traffic and equipment controls that invite a mingling of vehicles with pedestrians or dangerous forklift operational habits;
- Breakdowns in communication between workers including unreported injuries, language barriers, or inadequate signage that results in workers missing warnings or misunderstanding proper procedures; and
- Normalized incidents or near misses, which eventually become serious incidents and fatalities and result in a reactive rather than proactive safety culture.
These conditions can quickly create an environment where ordinary human mistakes are far more likely to lead to severe or fatal outcomes. Employers need to look beyond the individual employee decisions and investigate which systemic failures allowed the decision to become deadly. This is where OSHA regulations help.
Leverage OSHA regulations
You’ve likely heard the saying, “OSHA regulations have been written in blood” meaning someone (or many someones) have been seriously injured in the workplace which resulted in regulations aimed at protecting others from a repeat of similar situations.
Since OSHA was established nearly 55 years ago, its standards and enforcement efforts have helped save more than 712,000 workers’ lives. Even so, employers must continue to identify and strengthen gaps in their safety programs and systems to shield workers from the consequences of inevitable human decisions.
Employers shouldn’t just use OSHA regulations as a means for compliance but to actively protect workers by controlling hazards and setting clear expectations for safe work. Standards such as 1910.147 (Lockout/Tagout), 1910.1200 (Hazard Communication), 1926.501 (Fall Protection), and 1910.178 (Powered Industrial Trucks) give employers concrete requirements for preventing injuries and keeping employees safe on the job. Filling systemic safety gaps by using these standards can prevent thousands of serious injuries and fatalities every year. As demonstrated with this forklift struck-by fatality, most workplace deaths stem from hazards that OSHA rules are designed to control.
Key to remember: Serious incidents and fatalities are rarely caused by individual decisions but by broader system failures like insufficient safety oversight, inconsistent rule enforcement, and poor worksite communication. Employers can prevent these incidents by leveraging regulatory compliance to identify and correct weaknesses in their safety systems.
