Amazon’s fulfillment centers are dealing with a plague of serious worker injuries resulting from the relentless pace at which employees are tasked with completing orders, according to a new report from the Atlantic and Reveal from the Center for Investigative Reporting.

The report found that injuries go beyond those associated with fatigue and repetitive stress. One worker experienced herniated discs and a back sprain that left her unable to perform her job. In another case, workers experienced dizziness and vomiting after a gas leak and were required to use their personal time off to recover.

In one tragic case, a worker was reportedly crushed to death by a forklift.

Surveying 23 of Amazon’s 110 fulfillment centers nationwide, the report found that the rate of serious injuries for those facilities was more than double the national average for the warehousing industry. The surveyed Amazon facilities saw 9.6 serious injuries per 100 full-time workers in 2018, versus an industry average that year of just four.

The report noted that while some of Amazon’s warehouses were at or below the industry average, some saw unusually high numbers of injuries, including one in California’s Inland Empire that recorded 422 injuries last year, or four times the industry average.

The troubling results come as Amazon is preparing for Black Friday, Cyber Monday, and the busy Christmas season that will see a huge volume of packages shipped nationwide.

Amazon has long sought to dispel reports that its warehouse workers face dangerous and dehumanizing conditions. An embarrassing report last year alleged that some Amazon warehouse staffers in the U.K. were urinating in bottles because bathrooms were too far away.

The e-commerce giant recently launched a TV commercial touting the perks that its warehouse workers enjoy, including healthcare, tuition reimbursement, and a transgender-friendly environment.

The company also created a “Fulfillment Center Ambassadors” program intended to spread positive messages about the company via social media.

But the reality is reportedly a good deal darker. The Atlantic reported that while Amazon instructs workers on the proper way to do their jobs, workers face daunting expectations and sometimes have to break the safety rules to keep up.

Some workers face mandatory 12-hour shifts, while centers are often filled with seasonal hires who are unfamiliar with the pace of work. Last year, weekly injury counts spiked during Cyber Monday and Prime Day, according to data that the Atlantic and Reveal found in company logs.

The unrelenting pressure comes from leadership, with managers rewarded for ever-larger numbers. “It incentivizes you to be a heartless son of a bitch,” one former senior operations manager told the publication.

Workers reportedly face termination if they don’t meet strict quotas. The report cited one worker, who is a disabled veteran, facing a quota of handling 385 small items or 350 medium items each hour. A shortfall of just 1.55 percent prompted his final written warning before termination.

Amazon had hoped that the introduction of robot technology would lower injury rates. But the report found that at a center in Tracy, California, the serious-injury rate there nearly quadrupled, going from 2.9 per 100 workers in 2015 to 11.3 in 2018 after robots were implemented.

Conditions have gotten so bad in some locations that workers have gone on strike.

Amazon workers at a warehouse in Shakopee, Minnesota, walked off the job in July during one of the company’s two “Prime Day” summer promotions.

The unrelenting pace shows no signs of slowing down.

Amazon CEO Jeff Bezos, who is the world’s richest man, said in the company’s most recent earnings report, “We are ramping up to make our 25th holiday season the best ever for Prime customers.”

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