Fatality Assessment and Control Evaluation (FACE) Program
Engineering Technician Dies When Backed Over by Cement Mixer
On July 29, 2004, a 40-year-old male engineering technician was struck and killed on a road-building project by a cement mixer that was traveling in reverse. The road surface was compacted aggregate and crushed limestone and had a slight incline. There were two cement mixers in the immediate vicinity. Cement mixer #1 was unloading cement into a curb-paving machine ("mule"). Cement mixer #2 had already completed unloading its cement into the mule and was being washed out by the driver. To determine if the mixer #1’s concrete was within specifications, the victim took a sample that weighed approximately 600 pounds from chute and loaded the concrete into a wheelbarrow. The victim pushed the wheelbarrow past the driver side of mixer #1, and as he came to the rear of mixer #2, he turned sharply south, to his right to get to his truck. The victim’s back was facing mixer #2. At approximately the same time, the driver of mixer #2 finished washing out his mixer, entered the cab, activated his backup alarms and began to move in reverse to leave the job site. See Figure 1. It appears that the victim heard the backup alarm from mixer #2 because a witness stated that he increased his pace to attempt to get out of the way of the mixer. It appears that the victim either tripped or lost control of the wheelbarrow and was struck and backed over by mixer #2. The victim was transported to a local hospital where he was declared dead.
On July 29, 2004, a 40-year-old male engineering technician was struck and killed on a road-building project by a cement mixer that was traveling in reverse. On July 29, 2004, the Michigan Occupational Safety and Health Administration personnel who had received a report on their 24-hour-a-day hotline at 1-800-858-0397 that a work-related fatal injury had occurred that day notified MIFACE investigators of the fatality. On May 25, 2005, the MIFACE researcher interviewed two professional engineers at company headquarters. MIFACE visited the location of the incident on the same day. MIFACE reviewed the autopsy results, death certificate, police report and pictures, and the MIOSHA citations. An individual who investigated this incident contacted MIFACE and provided MIFACE with incident investigation information.
The company for whom the victim worked was a civil engineering company and materials consultant who provided assistance in the planning, design and site evaluation of a specific site. The company also acted as a project consultant, providing materials testing and evaluations to meet project specifications. The company employed over 200 people nationally. At this office, they employ three engineers and nine technicians. The victim was first hired as a temporary summer worker. He rejoined the company after three months away, and had worked for the company approximately one and one-half years. According to the company engineers, he had an additional 15 years of experience working in the capacity of “inspector.” The company provided one-on-one, on-the-job training for new employees that covered both task and situation specific training. The employees had to demonstrate competence in field and laboratory work before they were allowed to work unsupervised. The company had a hazard communication program. The company had an accident prevention program and employees had received safety training from company employees and construction trade organizations. Company personnel conducted site visits, and had group meetings with topics that included both technical and safety issues. If the site conditions demanded it, employees received training concerning specific safety requirements that were applicable.
The MIOSHA investigation resulted in the issuance of one Serious violation of the Construction Safety and Health Division General Rules, Part 1, Rule 114(2)(d): The company’s accident prevention program did not address the recognition and avoidance of hazards. The requirement to work around and near heavy equipment, large trucks and jobsite conditions create serious hazards to the health and well being of exposed employees.
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A private developer was building a road and the city was overseeing the road-building project. The road being built ran east-west, and an existing intersecting road ran north-south. The city inspector overseeing the project subcontracted the victim’s employer and the firm was called whenever necessary to provide services including field work, such as the concrete testing, and laboratory tests. There had been several months of preparatory work. At this point in the project, the road surface was compacted aggregate and crushed limestone. The road was approximately 28-30 feet wide. The curb being laid was on the north side of the road and was approximately two and one-half feet wide.
The firm received a call from the inspector indicating concrete testing was necessary. The victim’s work shift began at 8:00 a.m. The victim collected his equipment and supplies from the company’s laboratory, put them in his pickup truck, and drove to the site.
Curbs were being laid by a slip form paving machine or “mule.” This machine is an extrusion-type of machine, and does not use a permanent form for the concrete. Concrete is discharged from the mixer via the chute directly into the mule. The mule lays the curb at approximately 2000 feet/day and must stay moving. Therefore, when a cement mixer is empty, it moves out of the way and another mixer takes its place. The mule and mixer #1 were laying curb on the north side of the road. They were moving east – this required mixer #1 unloading the cement into the mule to be traveling in reverse. The backup alarm was operational. A cement mixer that had previously unloaded its cement, cement mixer #2, had moved to the south side of the road and was being washed out by the driver.
The incident occurred around 11:00 a.m. The victim parked his truck on the southwest corner of the existing crossroad, at the base of the incline of the road under construction. This allowed him to push the empty wheelbarrow up the incline and take the full wheelbarrow down the incline. He took the wheelbarrow to cement mixer #1 and asked for the load ticket. After he gathered the information, he unloaded approximately 600 pounds of concrete from the chute. The victim proceeded back to his truck so he could conduct the quality checks. See Figure 1. The victim pushed the wheelbarrow past the driver side of the mixer #1, and as he came to the rear of mixer #2, he turned sharply south, to his right, to get to his truck. At approximately the same time, the driver of mixer #2 finished washing out his mixer, entered the cab, activated his backup alarms and began to move in reverse to leave the job site.
The driver of cement mixer #2 stated he looked in both mirrors and backed up very slowly with his foot on the brake. All safety features of mixer #2 were in good operating order. According to the police report, a witness thought that the victim heard the backup alarm because he quickened his pace in what looked like an attempt to get out of the way of the mixer. The victim either lost his balance or tripped and fell toward the wheelbarrow. The passenger side rear tire of mixer #2 struck the victim on his right side, and ran over him and the wheelbarrow.
The driver of mixer #2 heard someone yell over his radio that he should stop. Emergency response was called, and the victim was transported to a nearby hospital where he died. When police checked the location of the cement mixer #2 door-mounted mirrors, they found them to be properly adjusted.
An alternate route, although construction vehicles would have to be moved, was available for mixer #2 to leave the jobsite. The unpaved road under construction continued to the west. After the vehicles were moved, mixer #2 could have driven forward to the west, and followed the road to exit the jobsite instead of exiting the jobsite in reverse.
After this incident, the victim’s company has mandated the use of reflective vests when their employees are on road construction projects.
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Cause of Death
The cause of death as listed on the death certificate was multiple injuries. Toxicological tests indicated that the victim was negative for alcohol in his blood and positive for cannabinoids in his urine.
Employers should ensure that workers on foot remain clear of moving equipment by developing and utilizing an “Internal Traffic Control Plan” for each highway and road work zone project.
The “Internal Traffic Control Plan” (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 plan must also take into consideration the changing aspects of a work site and possible emergency situations that might occur.
Due to the size of the road area, it would have been difficult for the driver of mixer #2 to pull forward and turn his mixer around so that he could drive out of the area instead of back out of the area. Although there was an alternate route that would have allowed him to drive out instead of back out, possibly due to construction vehicles in the way, the mixer driver did not take it.
In order to conduct the quality checks, the victim needed to park his vehicle in an area where he would not have to move to get out of the way of the construction activity. Parking the vehicle on an adjacent road provided an uninterruptible location, but he parked his truck in the direction of flow for the curb-paving operation. Although it was certainly easier to move a full wheelbarrow downhill, it also placed him in the flow pattern for exiting construction vehicles. The victim’s truck, if parked in a different location would have enabled him to gather the concrete sample and take the sample from the mixer chute and not be in the flow of traffic.
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