A forklift driver was reversing the vehicle at a company compound when he failed to check the rear view mirror and struck a woman walking behind.
General worker See Lay Heo, 53, suffered massive haemorrhages and fractures to the base of her skull. She died on Dec 28 last year, two days after the incident at her workplace, MC Packaging, in Gul Circle.
In his findings yesterday, State Coroner Marvin Bay acknowledged her priceless gifts.
She had donated her kidneys, liver, heart and corneas. He said the gifts impacted and changed the lives of the recipients, who would otherwise be without hope of living a normal life.
At an inquest into her death, the court heard that forklift driver Subramaniam Suppaiyya, 54, was tasked that morning to move pallets of empty milk powder formula cans from the production area to the storage area.
The accident occurred while he was reversing the vehicle to move a pallet of some 800 empty rejected tins to the production area for sorting. He had testified that he saw no one behind his vehicle. He checked by turning his head to the left, and then the right.
But he did not look at the rear view mirror before reversing, resulting in Madam See being struck. He realised something had happened when he felt an impact and saw her lying unconscious on the floor behind the forklift.
Other workers rushed over when they heard Mr Subramaniam shouting for help. Two employees then performed cardiopulmonary resuscitation on Madam See until paramedics arrived.
Parallel investigations by the Ministry of Manpower (MOM) showed that Mr Subramaniam's usual manner of operating the forklift did not conform to safety guidelines.
An MOM senior investigator also noted a 66cm-wide grey line painted on the ground of the production floor that was intended as a demarcated walkway for the company's workers and visitors.
But no procedures had been adopted for workers to use the grey line as a designated walkway.
"Indeed, investigations confirm that the workers had not been given any specific instructions to use the grey line as a walkway to access different parts of the can line production floor," said the coroner.
He said Madam See had been likely crossing from Mr Subramaniam's blind spot.
"The investigation also determined that Madam See, from her position, would have had a clear line of sight to detect the presence of the reversing forklift, but had persisted to walk across the production floor," said the coroner.
He found her death to be a "truly unfortunate industrial misadventure".
Her death also underscored the inherent dangers in failing to implement a thorough and functional work process to segregate, and regulate, human and forklift traffic, on a production floor that is used by both human and vehicular traffic at the same time.
Police or other enforcement action against Mr Subramaniam and MC Packaging will be reviewed after the completion of the coroner's proceedings.