Quebec's workplace health and safety board (CSST) has blamed Octane Racing Group, the organizer of Montreal's Grand Prix, and the automobile club from which it draws volunteers for the death of Mark Robinson, 38, during the Formula One event last June.

Volunteer marshall Robinson – a ten-year veteran of the Grand Prix – was killed when he slipped beneath the wheels of a forklift truck as he was helping to move a disabled race car to the pit at the end of the June 9 race in Montreal.

In a detailed report on the circumstances and causes of Robinson's death, illustrated by photographs provided by spectators' cell phones, the CSST concludes that there was inadequate training of volunteers in the operation of the forklift equipment and that the manufacturer's instructions for safe operation of the forklift truck were ignored.

CSST investigator Ramdane Djedid said the accident happened at 3:38 p.m. — right after the race ended — as Robinson and his crew tried to get Estaban Gutierrez' Sauber Formula One car off the track before spectators poured onto the Gilles Villeneuve raceway.

Robinson and another volunteer rigger were running on either side of the disabled car, which was suspended high in the air by a single hook. Each rigger hung onto the rear of the car with a short strap, in an effort to stabilize the swinging vehicle as the forklift truck moved forward.

Directly in the forklift's path

About 60 metres from the pit, Robinson's radio slipped off his belt, leaving it dangling behind him, still attached to his headphones by a long cord. Djedid said that slowed him down just enough to send him under the wheels of the forklift truck.

"The fundamental problem is that when he dropped the radio, he found himself directly in [the forklift's] path," Djedid said.

The report makes it clear that had the forklift truck's operating manual been followed, Robinson would have never found himself in the path of the vehicle.

Among the report's findings:

The forklift truck is never to be driven faster than at a walking pace when a load is suspended from it. In fact, the vehicle was travelling seven times faster than that — at 11 kilometres per hour — or "about the pace of a young adult jogger in very good condition," Djedid said.

The load is never to be lifted more than 300 mm (11.8 inches) off the ground. In fact, the disabled race car was dangling at five times that height — close to Robinson's eye level.

No one is permitted close to the forklift truck when it's moving. A pictogram in the instructions makes it clear riggers must use long straps to stabilize the load, keeping them well away from the forklift truck's wheels. In fact, Robinson and his fellow volunteer rigger were directly in front of the vehicle, and the driver's view of them was obscured by the dangling race car.

A load is to be suspended by at least two hooks, and the hooks must be equipped with safety clasps to prevent the load from slipping. In fact, Gutierrez' car was suspended by a single strap to an open hook.

Grand Prix staff told CSST investigators the reason the forklift truck was moving so quickly and carrying the race car at a precarious height was to prevent spectators from grabbing for the car once they got onto the raceway at the end of the event.

"This is why the race car was elevated so high and why the forklift went so fast," Djedid said. However, the CSST did not blame spectators in any way for what occurred.

'Never again,' Octane president promises

The CSST has ordered Octane Racing Group — the organizers of Montreal's Formula One event — to train its volunteers to regulatory standards, and to make sure its equipment is properly maintained and operated as specified in the manufacturer's instructions.

Both Octane and the Île Notre-Dame Automobile Club, to which Robinson belonged, face fines of between $15,698 and $62,790.

The exact amount of the fine is to be determined in the coming weeks.

The president of Octane, François Dumontier, said it was the first time the Grand Prix organization had been hit by a fine for a CSST violation.

"It's a tragedy," said Dumontier. "The family lost a son. The big family of Formula One lost a worker. Those workers are working for their passion — they're volunteers."

"We're going to work closely with the CSST to make sure that doesn't happen again at our track."

He said the measures may include keeping spectators off the track until it's deemed safe at the end of a race.