New York Case Report 00WA041 |
Release Date: August 5, 2004 |
Summary
On August 8, 2000, a 43-year-old male public works employee died when
he was struck and run over by a dump truck that was backing up along a
city street that was under construction. A construction superintendent
was also struck and seriously injured in the incident. The city worker
was working alongside the construction superintendent at the time of the
incident. Both were standing in the street running a chalk line, when
a dump truck backed down the street and struck them. Within moments 911
was called and both victims were transported to a local medical center.
The city worker died while in transit to the medical center.
To prevent similar occurrences in the future, the Washington State Fatality
Assessment and Control Evaluation (FACE) investigative team concluded that employers
engaged in roadway construction or maintenance should follow these guidelines:
- Develop and utilize an “Internal Traffic Control Plan”
for each road construction project.
- Employers should use visual safety devices (i.e., retro reflective
barrels, delineators, portable barricades, cones) to channel construction
vehicles to separate them from workers in the work zone.
- All employees working in road construction work zones should wear
high visibility safety apparel such as high visibility vests and hard hats.
- Construction work zones and construction vehicle/equipment traffic
flow should be designed to avoid backing up vehicles/equipment as much as possible.
- Use a spotter to provide direction for trucks and heavy equipment
backing up in work zones.
- Dump trucks should be equipped with additional visual or sensing devices
to cover “blind spots.”
- Construction vehicle drivers and key work zone personnel should be
equipped with two-way portable radio communication devices to help coordinate
construction vehicle activity within the work zone.
- Careful consideration should be given to the use of cell phones when
working in construction work zones around moving equipment.
Introduction
On August 9, 2000, the Washington State FACE Program was notified by
the WISHA* (Washington Industrial Safety
& Health Act) Services Division of the death of a 43-year-old city
public works employee.
The Washington FACE Principle Investigator and the Field Investigator
met with the regional WISHA representative who was investigating the case.
After reviewing the case with WISHA, the WA FACE team traveled with the
WISHA representative to the incident site. The WISHA representative helped
locate the site of the incident, define the details of the construction
site, and the position of the people and equipment involved in this incident.
The Washington FACE Field Investigator also conducted preliminary phone
interviews and then later met with a representative of the city public
works department whose employee was involved in this incident. Phone interviews
were also conducted with the city human resources/health and safety representative
who was not available during the time of the site visit.
The incident site was a road construction work zone where a private company
had been contracted by the city to install storm drains and upgrade the sewer line.
The north-south running street was a narrow two-lane asphalt roadway
that had moderate to very low traffic flow with very little housing and
was mostly bordered by open land. There were no intersecting streets along
this road to impact the construction zone.
Because the street was lightly populated it was set up as restricted
access for construction and local vehicles only, and was blocked to through
traffic with barricades and signage at both ends of the street. On the
date of the incident, the project was in its initial phase of setting
up and preparing for excavation and laying pipe. There was a combination
construction vehicle turn around area and pipe staging area located near
the south end of the street (see Figure 1). Pipe was
also laid out parallel to the street along the sides of the area to be
excavated. A construction worker operating a back-hoe was in the process
of excavating a section of the road on the north end of the street. The
posted speed limit for this street was 25 mph. The weather that morning
was clear, dry and warm and was not considered a factor in the incident.
The two victims, the city worker and the project superintendent, were
to meet that morning to review the project’s progress and its next
phase.
The city employs about 200 people who work in various departments and
functions of city government. About 20 of those work in the public works department, including
the fatal victim. This department designs, maintains, and administers the construction
of city streets and utilities such as water, storm sewers and sanitary sewers.
The public works department supervisor who was interviewed, was not very
familiar with the safety processes that the city had in place. The city
does not have a full time safety and health person. The duties for health
and safety have been assigned to the Human Resources Manager. The city
had a joint management and labor safety committee that met on a quarterly
basis. The city also routinely held monthly tail-gate safety meetings
within its various departments.
The fatal victim had attended a number of documented safety and health
training sessions including training that was specific to highway, road and street construction
work zone hazards (e.g., certified flagger training and traffic control safety plan
training).
Because the incident resulted in a fatality and a commercial vehicle
was involved, the local city police department called in the Washington State Patrol Traffic Investigation
Division and the Washington State Patrol Commercial Enforcement unit to help in
the incident investigation and review of the truck and driver involved in the incident.
The truck involved was a 1977 Mack 3-axle dump truck. The Washington
State Patrol Commercial Vehicle Enforcement officers inspected the dump truck and found
it to be in good working condition, including the back up alarm.
The injured construction superintendent stated that he did not remember
hearing the back up alarm prior to being struck. The dump truck driver
estimated that at the time of the incident he was backing up at between
5 and 10 mph. The dump truck driver was voluntarily taken for a routine
drug screening where all findings were negative.
* The OSHA State Plan
program in Washington State.
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Investigation
On August 8, 2000, a Tuesday morning, a city public works engineering
technician left his office to travel to a work zone construction project. He was to meet with
a construction superintendent at the construction site to review activities related to
a storm water and sewer upgrade project.
The construction crew at the site consisted of the construction project
superintendent (injured victim), a back-hoe operator and two laborers.
The city worker arrived at the work zone shortly after 7:00 AM and parked
his city truck off to the left side of the road facing north, near the
mid-point of the work zone. The city worker got out of his truck and greeted
the construction superintendent.
At about the same time, one of the construction company’s dump
trucks had turned onto the street from the south. The driver was to pick
up material being excavated by the back-hoe on the north end of the work
zone (See Figure 1).
As the dump truck driver entered the construction work zone he saw the
construction superintendent heading in his direction. The driver thought the construction
superintendent wanted to talk to him so he pulled into the pipe staging area. The staging
area was used to store materials, pipe and equipment for the project.
The truck driver got out of his truck in anticipation of a meeting and
getting some instruction from the construction superintendent. The driver
then saw the superintendent stop at the city worker’s pickup truck.
At that point the dump truck driver saw no indication that the superintendent
wanted to speak with him.**
As soon as it became apparent that the superintendent did not need to
speak with him, the driver got back into his truck and prepared to back
down the street, approximately 600 feet, toward the back-hoe located at
the north end of the street. As he was backing up the dump truck, the
last thing he saw of the victims was that they were standing near the
city worker’s truck along the side of the road (Photo
1).
After greeting, the superintendent and the city worker stepped into the
middle of the street and stopped directly over a storm drain cover (manhole).
The superintendent was trying to determine the alignment for a long section of 36” storm drain pipe
that would be installed there.
The superintendent enlisted the aid of one of his laborers to help take
measurements and define the alignment for the next section of pipe. Both the superintendent
and the city worker were facing north with their backs to the dump truck.
The superintendent held one end of a string, which was run about 300 to
400 feet toward the north end of the street by the laborer. The superintendent
held the string in one hand and a can of marking paint in the other. The
city worker was overseeing the process at the request of the superintendent.
The city worker was standing next to the superintendent in the center
of the road approximately 150 ft. north of the staging area watching the string alignment
process. He was reportedly also talking on the cell phone at that time.
Neither the superintendent nor the city worker were wearing high-visibility
clothing, vests or hard hats.
At approximately 7:25 AM, the superintendent stated that he was suddenly
struck very hard around his mid-back and was knocked to the ground. At
the time of impact, the superintendent indicated that he had heard no
unusual sound and had no idea what had struck him. He then remembers “being
balled-up” and seeing the rear-axles of the dump truck rolling over
him. The superintendent was dragged by the dump truck for approximately
25 feet before coming to rest near the front bumper after the truck stopped
(Photo 2). As he tried to get up to see what had
happened, he saw a laborer coming to assist him. He directed the laborer
to check on the city worker. The superintendent noted that the truck driver
was extremely distraught and was not able to effectively provide assistance
to either victim.
The truck driver picked up the city worker’s cell phone from the
ground and tried to call for help. He had difficulty in using the cell
phone and handed it over to the laborer. The laborer called 911 for assistance.
Both the local fire department’s EMS and the local police department
arrived at the scene within 5 minutes of the call.
The EMS team attended to the two injured workers. The superintendent
suffered severe injuries to his back, hands, and left leg. The city worker was more seriously
injured. EMS personnel found that the city worker had a weak pulse, was
bleeding from the head and mouth and was not responsive.
The city worker died while in transport to a nearby medical facility.
** No one on the site had two-way radios for communication.
Cause of Death
The medical examiner listed the cause of death as cranial and cerebral
trauma due to, or as a consequence of a pedestrian/vehicle accident.
Recommendations/Discussion
Recommendation #1: Develop and utilize an “Internal Traffic Control
Plan” for each road construction project.
Discussion: The hazards related to construction and
public vehicle exposures were greatly reduced in this project, primarily
because the following factors: 1) the type of construction activity, 2)
the road closure restricting traffic, and 3) the low number of both construction
workers and construction vehicles working or traveling through the work
site. Even with restricted and low volume of traffic on this quiet city
street, one person died and another was seriously injured.
This incident demonstrates the importance of having an “Internal
Traffic Control Plan” (ITCP). An internal traffic control plan should be developed prior to
any on-site construction activities and revised as needed during the project.
The ITCP defines processes and procedures for worker safety within the
work zone. The elements of the ITCP should indicate where and how construction
equipment, vehicles, and workers on foot interact within the work zone.
The ITCP doesn’t have to be a complex document but one that briefly
describes work zone activities in relation to safe practices to be used
for workers and construction vehicle movement within the work zone. The
ITCP should contain a coordinated procedure that defines the communication
process for equipment and truck drivers as they travel through the work
site including the process for backing up equipment and vehicles. This
is especially true in situations when vehicles are traveling though areas
of the work zone where workers are on foot.
Other items that should be included in the ITCP are:
• The use of temporary internal traffic control safety devices,
• The use of construction vehicle spotters,
• The use of high visibility clothing, vests, hard hats, and
• A communication plan and safety review with non-construction
personnel working
within the work zone (i.e., the city worker, local residents etc.).
It is important that the ITCP be clearly understood by all workers. The
plan should define the work areas, hazards, and potential emergency situations
and hazard prevention methods related to the construction work zone.
Recommendation #2: Employers should use visual safety devices (i.e., retro
reflective barrels, delineators, portable barricades, cones) to channel
construction vehicles to separate them from workers in the work zone.
Discussion: Both workers on foot and construction vehicles
and equipment are necessary parts of any highway, road or street construction
project. The National Institute for Occupational Safety and Health (NIOSH)
in their studies1 indicate that almost
half of all work zone fatalities occur inside the work area and involve
construction machinery, with the majority of those worker fatalities as
the result of dump trucks backing over the workers on foot. Elements of
the ITCP should define how to separate workers on foot from construction
vehicle traffic while in the work zone. This can be done by using temporary
traffic control devices such as retro reflective portable barrels, cones,
and portable lightweight fold up barricades.
Although these temporary devices are not as effective as positive protective
barriers (i.e., concrete barriers/jersey barriers) they are more practical for short duration
worker exposures and can be quickly set up and taken down when the short
duration job is completed.
Please note, the use of any traffic control safety devices should meet
Washington State Dept. of Transportation, WISHA, County and Municipality
and Manual on Uniform Traffic Control Devices (MUTCD) guidelines. The
employer should also review the use of these devices with the manufacturer
for appropriate application in and around highway and roadwork zones.
Recommendation #3: All employees working in road construction work zones
should wear high visibility safety apparel such as high visibility vests
and hard hats.
Discussion: Neither the superintendent nor the city
worker in this incident was wearing high visibility clothing, vests or
hard hats. It is extremely important for workers to wear highly visible
clothing and other highly visible safety equipment such as vests and hard
hats when they are working in a construction work zone. Making workers
more visible to construction vehicles operating in the work zone is an
important part of helping reduce injuries and fatalities within the work
zone. At a minimum, it is suggested that all workers wear at least ANSI
/ISEA1 107-1999 class 2 retro reflective
vests and a highly visible hard hats.
Recommendation #4: Construction work zones and construction vehicle/equipment
traffic flow should be designed to avoid backing up vehicles/equipment
as much as possible.
Discussion: A high number of fatalities and serious
injuries (as reported by NIOSH1) occur
when construction vehicles (especially dump trucks) are backing up within
the work zone and strike workers.
Truck drivers and construction vehicle drivers should avoid backing up
in a construction zone. This is especially true when there is no spotter
available or the construction site isn’t designed to provide a controlled
or channelized area for backing up. The work zone and its related tasks
and procedures should be designed to avoid vehicles driving in reverse
while entering, exiting, and driving through the work zone.
The typical construction equipment and vehicle mirrors do not give the
driver the whole picture behind them. Blind spots still exist. Conditions and the location
of personnel can change very quickly within the work zone and not anticipating those changes
can result in serious consequences, as it did in this incident. A lot can happen in
just a few seconds. The driver last saw the victims standing near the city worker’s truck
along the side of the road and then just moments later they were struck
by the backing dump truck.
The FACE investigation showed that the truck did not have to back up
from the staging area but could have driven closer to the back-hoe, made
a turn and positioned the dump truck near the back-hoe without backing
up through the entire work zone.
Recommendation #5: Use a spotter to provide direction for trucks and heavy
equipment backing up in work zones.
Discussion: A good option to better manage trucks and
other construction equipment that need to back up within the work zone,
is to use a spotter. A spotter can help the truck driver and/or equipment
operator safely maneuver in, out of, and through the work zone. The spotter
provides the "vision" that the driver does not have when backing
up and helps reduce their “blind spots.”
A spotter, with proper precautions for their own personal safety,
can help the construction vehicle driver maneuver through the obstacles and changing conditions
of a work zone, as well as help the driver to be alert for non-construction pedestrian and
vehicle traffic traveling through the work zone.
When using a spotter, it is of the utmost importance that the safety
of this worker be taken into account. The spotter needs to be trained
and educated in the duties of a spotter, including identifying the hazards
and hazard control methods while performing those duties. The spotter
needs to wear a distinctive and highly visible safety vest (ANSI/107-1999
Class 2 minimum). The spotter needs to be out of vehicle traffic lanes
and out of the direct path of the moving/backing construction vehicle’s
movement. If the spotter is not visible to the truck driver, then the
driver should stop until positive visual contact with the spotter has
been made. The driver should not move the vehicle unless they get an all
clear sign from the spotter.
The superintendent or one of the laborers could have acted as a spotter
for the dump truck driver in this incident. A flagger should not act as a spotter, as this
would take them away from their primary traffic control duties.
Recommendation #6: Dump trucks should be equipped with additional visual
or sensing devices to cover “blind spots.”
Discussion: There are a variety of vision enhancement
and/or object and people detection systems that can be used to help drivers
when they are backing up their vehicles in work zones. Some of this equipment
uses radar, sonar and ultrasonic devices. Rear vision video cameras are
also available that can provide the driver with a clear view of what is
behind him or her. Many of these camera systems are currently in use in
both construction and non-construction applications.2
NIOSH is also currently evaluating a number of these systems.3
Currently many commercial and personal vehicles are equipped with object
proximity sensors that sound an alarm, and in some cases have visual indicators
for the driver, when an object or person is near the rear of a backing
vehicle. The Forewarn Back-up Aid4 is a
radar-based obstacle detection-system that couples ultrasonic sensors
with a single-beam radar sensor in the rear bumper. This combination offers
the longest rear-sensing detection range currently available - up to 16.4
feet (5 meters). The large detection area extends Back-up Aid's useful
speed range-from parking speeds (generally less than 2 mph) to normal
reverse speeds (about 7 mph).
It is recommended that when new trucks and equipment are purchased, visual
and/or object sensing devices should be purchased as well. These sensing
devices can also be installed on older trucks and equipment.
Recommendation #7: Construction vehicle drivers and key work zone personnel
should be equipped with two-way portable radio communication devices to
help coordinate construction vehicle activity within the work zone.
Discussion: In an active and changing road construction
work zone, effective communication is an important element for the safe
completion of the project. It is recommended that the project supervisors/superintendents
and the construction vehicle drivers and other key personnel be equipped
with two-way radios. The radios can be used to not only provide for the
exchange of important project information, but they can also be used to
send and receive warnings of hazards.
In this instance the truck driver could have contacted the superintendent
and asked if he wanted to talk with him. If not, the driver could have told the superintendent
to stand clear as he was backing down the road or he could have asked
for someone to act as a spotter as he backed down the road. The superintendent
also could have called the dump truck driver to let him know that he and
others would be working in the middle of the road marking a section of
the storm sewer and to not back down the road until they were done.
The ability to communicate effectively should be a standard part of a
work zone operating safety plan. Both construction vehicle and equipment drivers need to be
able to communicate with workers on foot so that both parties can safely
interact with each other in a busy work zone. Two-way radios can help
provide greater control of this activity and can help provide quick and
clear instruction to both the workers and drivers during routine production
activities and in hazard or emergency situations.
Recommendation #8: Careful consideration should be given to the use of
cell phones when working in construction work zones around moving equipment.
Discussion: Serious safety issues have been identified
with the use of cell phones while driving. According to the National Highway
Traffic Administration (NHTSA)5 “driver
distraction” is a contributing factor in at least 20-30 % of all
motor vehicle collisions.
A recent study by the University of Utah6
claims that cell phone use while driving, significantly interferes with
drivers’ attention to their surroundings. They have labeled this
phenomenon “inattention blindness,” where the focus of the
driver’s attention is on making a phone call or having a phone conversation
and not on driving tasks. They indicate that the phone conversations turn
attention away from the “external environment.”
It was noted in the investigation of this incident that, the city worker
was talking on his cell phone at the time of the incident. Both victims were also standing in
the middle of the road facing away from the on-coming dump truck.
It is possible that the victim was distracted by talking on, or dialing
his cell phone and may have been subject to “inattention blindness”
similar to motorists while on the cell phone and thus not aware of the
“external environment” of the work zone hazards. The superintendent,
who the victim was standing next to, may have also been distracted by
his task. It is recommended that cell phone use guidelines be established
for use by those who may be at risk from hazards (i.e., construction vehicle
and equipment traffic) while within the work zones. The guidelines should
not only define where the cell phone should not be used, but also define
appropriate areas where their use would be safe within the work zone.
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Acknowledgements
In conducting this work zone fatality investigation, the Washington State
FACE investigation team requested that the contents of this report be
reviewed by key representatives from the labor and business communities
involved and Washington State and Federal worker safety agencies, prior
to its publication.
Though we are not able to acknowledge specific individuals for their
invaluable input into this document, we would like to recognize the following
for their help and support to the FACE process:
• The Employer involved in the incident
• WISHA enforcement
• WISHA Policy & Technical Services staff
• Federal Face Program Management (NIOSH)
• Safety & Health Assessment & Research for Prevention
(SHARP)
• WA and Northern Idaho District Council of Laborers
• Seattle Public Utilities
• Washington State Attorney Generals Office
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Appendix - Backup Alarms
One issue not discussed in this report was backup alarms. These are generally
standard equipment on most construction vehicles. However, the ITCP should
include procedures for verifying that all trucks and equipment within
the work zone have audible backup alarms and that they are functioning
correctly. The alarms must also be loud enough to be heard above the construction
and environmental noise at least 15 feet from the back of the vehicle.
A guideline is that an alarm should be 10 decibels louder than the background
noise. This is an important consideration, as intermittent noise such
as the operation of machinery could significantly raise the background
noise level and negate the utility of a backup alarm.
A potential problem with backup alarms is “habituation,”
or becoming too accustomed to the alarm, resulting in less attention to
the signal. A method of counteracting this could be to investigate options
for altering the backup alarm sound frequency or presentation to reduce
the effect of habituation. Care should be taken, however, to make sure
that the alarm is still quickly recognized as a backup alarm if changes
to the standard “beeping” signal are made.
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References
- Pratt, Stephanie G., Fosbroke, David E., Marsh, Suzanne M. Building
Safer Highway Work Zones: Measures to Prevent Worker Injuries From Vehicles
and Equipment. Cincinnati, OH. National Institute for Occupational
Safety and Health, April 2001.
- Trout, Nada D., Ullman, Gerald L., Devices and Technology to Improve
Flagger/Worker Safety/Research Report 2963-1F. College Station
Texas: The Texas Transportation Institute, The Texas A&M University,
Texas Department of Transportation. 1997.
- “Selection of Systems to Monitor Blind Areas Behind Sanding
Trucks”, National Institute for Occupational Safety and Health,
Spokane Research Laboratory, Prepared for the Washington State Department
of Transportation by Todd M. Ruff, October 30, 2000.
- Delphi Corporation’s Safety Warning System. http://www.delphi.com/products/auto/safety/warning/ (Link no longer valid - 7/11/2007)
- Royal, D. National Survey of Distracted and Drowsy Driving Attitudes
and Behaviors: 2002 / Volume 1 – Findings Report. The Gallup
Organization. Submitted to National Highway Traffic Safety Administration.
March 2003.
- Strayer, David L., Drews, Frank A., and Johnston, William A. “Cell
Phone-Induced Failures of Visual Attention During Simulated Driving.”
Journal of Experimental Psychology: Applied, Volume 9, Number 1, March
2003.
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Bibliography
- Safety Standards for General Safety and Health, Chapter 296-24
WAC, State of Washington, Department of Labor and Industries.
- Safety Standards for Safety Standards for Construction Work,
Chapter 296-155 WAC, State of Washington, Department of Labor and Industries.
- Employee Protection in Public Work Areas, Chapter 296- 45-52530
WAC, State of Washington, Department of Labor and Industries.
- Part VI Manual on Uniform Traffic Control Devices (MUTCD), Part
VI Standards and Guides for Traffic Controls for Street and Highway
Construction, Maintenance, Utility and Incident Management Operations.
1988 Edition of MUTCD, Revision 3, September 1993 U.S. Department of
Transportation, Federal Highway Administration.
- Work Zone Traffic Control Guidelines. M54-44, Washington
State Department of Transportation, Field Operations Support Center, May 2000.
- Trout, Nada D., Ullman, Gerald L., Devices and Technology to Improve
Flagger/Worker Safety/Research Report 2963-1F. College Station
Texas: The Texas Transportation Institute, The Texas A&M University,
Texas Department of Transportation. 1997.
- Graham, Jerry L., Hinch, John, Stout, Dale, Lerner, Neil, Maintenance
Work Zone Safety. Washington, DC: National Research Council, Strategic
Highway Research Program, 1990.
- Highway Work Zone Safety. Washington State Department of
Transportation, January 1994.
- Recarte, Miguel. Nunes, Luis M. “Mental Workload While Driving:
Effects on Visual Search, Discrimination, and Decision Making,”
Journal of Experimental Psychology: Applied, Volume 9, Number 2, June
2003.
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Figure and Photographs
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Figure 1. Layout of work zone.
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Photo 1. Incident site after completion
of the job.
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Photo 2. Incident site and dump truck. |
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Washington FACE Program/SHARP
To contact Washington
State FACE program personnel regarding State-based FACE reports, please
use information listed on the Contact Sheet on the NIOSH FACE web site
Please contact In-house
FACE program personnel regarding In-house FACE reports and to gain
assistance when State-FACE program personnel cannot be reached.
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