|New Jersey Case Report: 03NJ100
Released: February 15, 2005
Corrected: September 19, 2005
On November 25, 2003, a 38-year-old municipal Department of Public Works
(DPW) employee was killed when he fell from a trailer hitch while riding
a leaf vacuum that was being towed down a residential street. The victim
and his co-worker were assigned to vacuum piles of loose leaves left by
the side of the road by the residents of the town. The vacuum was a large,
diesel-powered machine mounted on a trailer and towed by a DPW dump truck.
The trailer hitch had been modified with a small, diamond-plate “seat”
for the vacuum operator while moving between the leaf piles. The victim
was sitting on this seat as the truck turned down a street and alongside
cars that were parked on the side of the road. The large rubber vacuum
hose that hung from the machine struck and damaged several of the cars.
During the collision, the victim fell from the trailer, possibly while
trying to hold or grab the loose hose. He fell to the roadway and was
run over by the trailer. NJ FACE investigators recommend following these
safety guidelines to prevent similar incidents:
- Employers should follow the recommendations in the NIOSH
Alert, Preventing Worker Injuries and Deaths From Moving Refuse Collection
- Employers should ensure that all required safety, health, and maintenance
procedures are followed.
- Employers and employees should not modify machines unless a qualified
engineer and/or machine manufacturer reviews and certifies the safety
of the modification.
- Employers should conduct a job hazard analysis of all work activities
with the participation of the workers.
On November 26, 2003, a compliance officer from the NJ Department of
Labor and Workforce Development (NJDLWD) Office of Public Employees Safety
notified NJ FACE staff of a worker who was killed in a motor vehicle accident
involving an industrial leaf vacuum. A FACE investigator contacted the
employer and arranged to conduct a concurrent investigation with the NJDLWD
investigator, which took place on December 3, 2003. During the visit,
the FACE investigator discussed the case with NJDLWD compliance officers,
interviewed the DPW representatives, and photographed a leaf vacuum almost
identical to the one involved in the incident. The incident site was also
examined and photographed. Additional information was obtained from the
police report, the medical examiner’s report, and the NJDLWD investigation
The victim’s employer was the municipal Department of Public Works
(DPW) for a New Jersey town with an approximate population of 10,700 residents.
The DPW was responsible for the maintenance of town properties, sanitation,
and leaf collection and composting. The town employed 90 employees, 11
of whom worked for the DPW. Most of the employees were unionized. The
DPWs training program was on-the-job, with new employees trained by a
supervisor or an experienced employee. Safety practices included regular
The victim was a 38-year-old white male who had worked for the DPW for
four months as a Public Works Repairer. He had 14 years of experience
with municipal sewage utilities before applying for this job through New
Jersey civil service. He held a NJ commercial driver’s license,
which allowed him to operate larger trucks and equipment. The employer
stated that the victim worked a second job as a nighttime attendant at
a gas station. The victim was a union member.
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The incident occurred in a suburban town of 17 square miles. During leaf
season, a period from October through December, residents of the town
were instructed to rake loose piles of fallen leaves to the curbsides
in front of their homes for collection. The DPW owned two self-contained
leaf collectors (leaf vacuums) to pick up the leaves, which would later
be dumped and composted. The leaf vacuums were large, trailer-mounted
machines that were towed by a township dump truck. The vacuum consisted
of a large, box-like metal container to hold the leaves, a diesel engine
attached to a vacuum impeller (rotor blade that creates the vacuum), and
a large rubber hose used to vacuum the leaves. The model involved in the
incident was rated to hold 14 cubic yards of leaves and had listed dimensions
of 9.9 feet high, 8.4 feet wide, and 15.8 feet long. An 85-horsepower,
water-cooled, diesel engine drove a six-blade, 32-inch diameter impeller
that moved 22,000 cubic feet of air per minute. A 16-inch-diameter, 8.3-foot-long
reinforced rubber suction hose was mounted on a swinging boom, which supported
the weight of the hose to make it easier for the operator to position.
The trailer was hitched to the tow vehicle with an approximately 8-foot-long
towing hitch (tounge). A hydraulic lift at the base of the machine tipped
the container backward for dumping.
1. Leaf vacuum identical to unit involved in the incident.
The victim arrived for work at 7:00 a.m. on Tuesday, November 25, 2003,
the day of the incident. He had not worked at his second job the night
before. After arriving, the victim and his coworker were assigned to collect
leaves in a nearby neighborhood, and the crew left the DPW garage at approximately
8:00 a.m. The morning passed uneventfully, and the crew emptied the truck
before returning to the garage for lunch at noon. They returned to collecting
leaves at around 12:30 p.m., with the victim operating the vacuum and
the coworker driving the dump truck. The weather was clear as the crew
continued work, filling about one quarter of the vacuum with leaves. At
approximately 2:20 p.m., the crew had just picked up a pile of leaves
when the driver noticed another pile on a nearby street. The victim, who
weighed 242 pounds, was riding on the trailer hitch and holding the vacuum
hose, which was not secured to the truck. A small piece of diamond-plate
steel had been welded to the trailer hitch, providing a seat for a worker
to sit on when traveling between piles of leaves. The driver needed to
make several turns to get to the next pile of leaves, and made a left
turn down a road with cars parked alongside the curb. As he drove past
the parked cars, the vacuum hose swung away from the machine and struck
the cars. The driver reported feeling a vibration in the truck, stopped,
and got out. He found the victim lying on the street, behind the trailer
that had run him over.
2. Identical leaf vacuum and pickup truck.
The driver saw a pedestrian on the street and asked her to call the police.
He then called the DPW garage with the truck radio. DPW supervisors responded
to the scene, followed by the police and EMS. They found the victim unresponsive
with injuries to his head and chest. He was transported to the local hospital
emergency room, where efforts to resuscitate him were unsuccessful. He
was pronounced dead in the emergency room at 2:55 p.m.
1. Police graphic illustration of incident (descriptive comments
This incident was investigated by the local police, the regional Serious
Accident Response Team, the NJDLWD, and the Medical Examiner’s office.
These investigations found a number of factors that may have contributed
to this incident, including the following:
- The driver involved in the incident was driving with an expired license.
- The leaf vacuum was not registered with the NJ Department of Motor
- The leaf vacuum trailer had a number of maintenance defects, including
inoperative brakes, an inoperative trailer break-away device (which
activates the brakes if the trailer detaches), under-inflated and flat
tires, and burned-out signal lights. (Police)
- An unauthorized retrofit was made by welding a piece of steel diamond-plate
onto the trailer hitch as a seat. A manufacturer’s warning label
stating not to ride on the tongue had been removed. (NJDLWD)
3. Warning labels on identical trailer.
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Discussion: After analyzing a number
of deaths involving sanitation workers, NIOSH published an alert warning
of the hazards of working on and around refuse collection vehicles. Although
this incident did not involve a garbage truck, many of the NIOSH recommendations
apply to this situation. These recommendations include developing a procedure
for safely riding and backing the vehicles, only moving the vehicle when
the workers are in sight, and developing a signaling system for communicating.
It was noted that the DPW already followed some of these procedures.
Recommendation #2: Employers should ensure that all required safety, health,
and maintenance procedures are followed.
Discussion: In this case, investigators
from various agencies found a number of deficiencies in the maintenance,
safety, and licensing procedures in the operation of the leaf vacuum.
This included poor machine maintenance, no follow-up on driver’s
licenses and registrations, and improper modifications to the machine.
To prevent this, NJ FACE FACE recommends that the employer develop and
implement a comprehensive safety program that includes procedures that
address these issues. As this small DPW is part of a larger town bureaucracy,
it may be beneficial for the different agencies in the town to jointly
develop this safety program so that all town employees may be covered.
Recommendation #3: Employers and employees should not modify machines
unless a qualified engineer and/or machine manufacturer reviews and certifies
the safety of the modification.
Discussion: The leaf vacuum in this
incident was improperly modified by welding a piece of steel diamond-plate
to the trailer tounge, providing a seat for the operator. Following their
investigation of this incident, the NJDLWD Office of Public Employees
Safety conducted a survey of all the municipal DPWs in New Jersey State.
They found 83 instances of missing warning labels, issued 36 citations
for lack of training, and found two similar modifications to other leaf
vacuums. This indicates a widespread hazard. The NJDLWD ordered these
problems corrected. NJ FACE strongly recommends against modifying any
machine without first consulting with a qualified engineer and the machine’s
manufacturer. This will help prevent damage, injury, legal liability,
and death from improper or poorly designed modifications.
Recommendation #4: Employers should conduct a job hazard analysis of all
work activities with the participation of the workers.
Discussion: To prevent incidents
such as this, we recommend that employers conduct a job hazard analysis
of all work areas and job tasks with the participation of the employees.
A job hazard analysis should begin by reviewing the work activities that
the employee is responsible for and the equipment that is needed. Each
task is further examined for mechanical, electrical, chemical, or any
other hazard the worker may encounter. The results of the analysis can
be used to design or modify the standard operating procedures for the
job. Additional information on conducting a job hazard analysis is included
in the Appendix.
It is essential that employers obtain accurate information on health,
safety, and applicable OSHA standards. NJ FACE recommends the following
sources of information, which can help both employers and employees:
U.S. Department of Labor, Occupational Safety
& Health Administration (OSHA)
Federal OSHA will provide information on safety and health standards on
request. OSHA has several offices in New Jersey that cover the following
Hunterdon, Middlesex, Somerset, Union, and Warren counties
Telephone: (732) 750-3270
Essex, Hudson, Morris, and Sussex counties
Telephone: (973) 263-1003
Bergen and Passaic counties
Telephone: (201) 288-1700
Atlantic, Burlington, Cape May, Camden, Cumberland, Gloucester, Mercer,
Monmouth, Ocean, and Salem counties
Telephone: (856) 757-5181
Web site: https://www.osha.gov/
New Jersey Public Employees Occupational
Safety and Health (PEOSH) Program
The PEOSH act covers all NJ state, county, and municipal employees. Two
state departments administer the act; the NJ Department of Labor and Workforce
Development (NJDLWD), which investigates safety hazards, and the NJ Department
of Health and Senior Services (NJDHSS) which investigates health hazards.
PEOSH has information that may benefit private employers.
NJDLWD, Office of Public Employees Safety
Telephone: (609) 633-3896
Web site: http://lwd.dol.state.nj.us/lsse/employer/Public_Employees_OSH.html
(Link updated 3/26/2013)
NJDHSS, Public Employees Occupational Safety & Health Program
Telephone: (609) 984-1863
Web site: http://www.state.nj.us/health/eoh/peoshweb/
New Jersey Department of Labor and Workforce
Development, Occupational Safety and Health On-Site Consultation Program
This program provides free advice to private businesses on improving safety
and health in the workplace and complying with OSHA standards.
Telephone: (609) 984-0785
and_Health_Onsite_Consultation_Program.html (Link updated 3/26/2009)
New Jersey State Safety Council
The NJ State Safety Council provides a variety of courses on work-related
safety. There is a charge for the seminars.
Telephone: (908) 272-7712
Web site: http://www.njsafety.org
Other useful internet sites for occupational safety and health information:
The CDC/NIOSH Web site
- USDOL Employment Laws Assistance for Workers and Small Businesses.
http://www.nsc.org/Pages/Home.aspx - National Safety
Council. (Link updated 11/17/2009)
- NJDHSS FACE reports.
- CDC/NIOSH FACE Web site
- Job Hazard Analysis. US Department of Labor Publication #
OSHA-3071, 1998 (revised). USDOL, OSHA/OICA Publications, PO Box 37535,
Washington DC 20013-7535.
- NIOSH Alert: Preventing
Worker Injuries and Deaths From Moving Refuse Collection Vehicles.
NIOSH publication # 97-110, NIOSH Publications Dissemination, 4676 Columbia
Parkway, Cincinnati OH 45226. Telephone 1-800-356-4674.
Corrections to FACE Report 03-NJ-100
September 19, 2005
Shortly after releasing this report, NJFACE staff was made aware of some
inaccuracies in our reporting of the details of the incident. The FACE
investigator who authored this report re-examined the documentation for
this investigation and confirmed these errors. In an effort to release
the most accurate information possible, we are making the following changes
and corrections to the original report:
Leaf vacuum and trailer: The report stated that the trailer that the
victim fell from was improperly equipped with a diamond-plate “seat”
and was lacking the required warning stickers. This was incorrect. The
trailer that the victim was riding on was not equipped with a seat and
did have the required warning stickers. The DPW’s second leaf vacuum
and trailer had these modifications. This error was due to confusion in
reading the serial numbers that identified the two units.
Township size: The town was described in the report as being 17 square
miles in size. This is inaccurate, as the town is only 1.08 square miles.
This information was obtained from a township directory, which specified
the town as having 1.08 square miles of land area and 15.75 square miles
of water area, for a total of 16.83 (rounded to 17) square miles.
New Jersey FACE Program
Fatality Assessment and Control Evaluation (FACE)
Investigation # 03-NJ-100
Staff members of the New Jersey Department
of Health and Senior Services, Occupational Health Service, perform FACE
investigations when there is a report of a targeted work-related fatal
injury. The goal of FACE is to prevent fatal work injuries by studying
the work environment, the worker, the task and tools the worker was using,
the energy exchange resulting in the fatal injury, and the role of management
in controlling how these factors interact. FACE gathers information from
multiple sources that may include interviews of employers, workers, and
other investigators; examination of the fatality site and related equipment;
and reviewing OSHA, police, and medical examiner reports, employer safety
procedures, and training plans. The FACE program does not determine fault
or place blame on employers or individual workers. Findings are summarized
in narrative investigation reports that include recommendations for preventing
similar events. All names and other identifiers are removed from FACE
reports and other data to protect the confidentiality of those who participate
in the program.
NIOSH-funded state-based FACE Programs include: Alaska, California, Iowa,
Kentucky, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, New
York, Oklahoma, Oregon, Washington, West Virginia, and Wisconsin.
This NJ FACE report is supported by Cooperative Agreement # 1 U60 OH0345-01
from the Centers for Disease Control and Prevention (CDC). Its contents
are solely the responsibility of the authors and do not necessarily represent
the official views of the CDC.
To contact New
Jersey 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.