Wyoming FACE Investigation 92WY010
Construction Foreman Motor Vehicle Crash in Wyoming
A 42 year old male construction foreman died from preventable injuries incurred when his company pickup rear-ended a tanker trailer which had slowed on a grade on a state highway in a rural area of the state. The victim was traveling northeast on a dry three-lane asphalt highway during clear weather in daylight hours, enroute to a testing site near a coal mine. A truck-tractor, semi-trailer/trailer combination loaded with about 15,000 gallons of liquified petroleum gas was travelling ahead of the victim, and had slowed to approximately 15 mph in the rightmost northbound lane, in order to pull a 5% uphill grade on a right hand turn. The victim did not appear to take any evasive action to avoid the crash, and struck the right rear of the tanker with the left front of the pickup. Emergency services were notified either by the tanker driver or by a passing motorist. The victim was declared dead at the scene from a ruptured aorta as a result of a compressive chest injury.
Employers may be able to minimize the potential for occurrence of this type of incident through the following precautions:
On a Friday afternoon, May 15, 1992, a general contracting foreman was travelling to a testing site to oversee the spraying of a train at a coal yard. The system being tested was to reduce the amount of coal dust produced by a loaded coal car, by spraying the load with a chemical. The victim had driven approximately 70 miles from the company office by the time the incident occurred, and was about half way to his destination. The victim was driving a 4 year old company pickup behind a tanker filled with liquified petroleum gas, in the rightmost lane of a slight right hand curve on a 5% uphill grade. The tanker had slowed to 15 miles per hour and had pulled to the far right in a three lane roadway.
Through a notification agreement with Accident Records Section of the Wyoming Department of Transportation, the WY-FACE Project was notified of the incident by copy of the Investigator's Traffic Accident Report on May 21, 1992. Conversations were held with the employer and the investigating officer, and medical and coroner's reports were requested.
The task involved driving a company pickup to a worksite over 100 miles distant. The driving task may have included concern for the upcoming test that would be conducted later in the evening. The victim had overseen a test at the coal mine the previous evening, and had reservations at a motel within 15 miles of the testing site. He had finished the previous test at around 2 am, checked into his motel after the testing, and returned to his home base (136 miles away) approximately 8 hours after the test ended. The victim was driving a 4 year old company pickup to a worksite where he would oversee a test of a chemical spray on rail cars filled with coal. He had been at the site until late the previous evening and was in the office earlier in the day, and had called in over the lunch hour to talk with company workers. Witnesses to those conversations noted that the victim appeared tired but had said that he was able to drive. Around 2 hours prior to the incident, he talked with a co-worker/friend at the office. When asked if he wanted to delay the up-coming test to get some sleep, he said that he wanted to go back to his motel and sleep there before the test. The co-worker offered to have someone drive him or ride with him, and he employee declined the offer. On the basis of a long-term friendship and working relationship and the victim's safety record, the co-worker trusted him to recognize his limitations.
The employee documented and maintained his own working schedule. He was responsible for a forty-hour work week, but was authorized to prioritize his time based on his determination of best company productivity. The decision to drive back to his home community and return to the testing site was made on the victim's own authority with no requirement for prior supervisory approval.
The victim had worked for this company for nearly 3 years, and had spent the past two years in the position of foreman. The test that was being conducted was similar to the testing that the victim had been overseeing for 18 months. The family-owned company has been in business for 50 years. Safety concerns appear to be a company priority, with all employees being OSHA and MSHA safety certified. Company uniforms bear "Safety First" mottos and company brochures advertise "an aggressive in-house safety program as well as site specific safety training". The victim was safety officer, and had developed a safety manual for company use. Safe driver training was not addressed specifically, but policy prohibited an employee with either three violations or an alcohol-related offence over a three year period from driving a company vehicle. Warnings were given to employees with two violations over a three-year period. The victim had no driving violations.
Notebooks found on the front seat of the pickup cab indicate that the victim may have been reviewing them prior to impact. The positioning of the vehicles and the absence of skid marks on the road surface show that no evasive action was taken and suggest that the victim may have been asleep or distracted. While there is evidence of fatigue, the proximity of the victim's vehicle to the far right portion of the right lane of a right-hand curve gives more credence to distraction than to sleep. A combination of distraction and fatigue seem probable contributors to misjudgment of distances and failure to react.
The victim was driving on dry blacktop, 3 lane roadway, in clear weather during daylight hours. Prior to the crash, the victim was following a tanker loaded with about 15,000 gallons of liquified petroleum gas, which had slowed to around 15 mph on an upgrade curve, and which was travelling in the right northbound lane, providing a free lane for faster traffic to pass safely on the left. Road shoulders were gently contoured, milepost/delineator posts were forgiving, and no unforgiving structures or bridge abutments were present.
The tanker that was struck was placarded for hazardous materials transport and clearly labeled as a carrier of liquid petroleum gas. The tanker had pulled to the far right of a passing lane to allow faster traffic to pass on the left. The roadside was graded to allow for escape as necessary on the right shoulder and barrow area in the event of a otential crash-avoidance maneuver. There were no bridge abutments or other structures in the area to create hazards to normal traffic operation. The company vehicle was equipped with lap and shoulder belts, which were not in use at the time of the crash.
The vehicle contained standard safety equipment for a 1988 American made pickup meeting Department of Transportation requirements. The victim was not wearing the driver equipped seatbelt available in the vehicle. The impact of the crash drove the victim's chest into the steering column, crushing parts of the steering wheel and dash.
The impact crushed the front end, engine compartment, and the top of the passenger compartment. The victim apparently flew into the windshield of the pickup, bending the steering wheel and impacting the top of the dashboard with his head and chest.
No hazardous spills occurred. Crash debris was cleaned up and the roadway was restored to normal traffic operation. The vehicle was transported by wrecker to a scrap yard. The victim apparently died immediately from blood loss resulting from massive chest injuries. Emergency medical services were requested as a coroner transport.
CAUSE OF DEATH
The Medical Examiner listed the cause of death as a ruptured aorta from compressive chest injury.
This incident could have been prevented by closer attention by the victim to driving conditions. The victim was apparently fatigued or distracted, and took no action to avoid the crash. It appeared to have been avoidable, as the tanker had pulled to the far right, allowing faster traffic to pass in a posted passing lane; and as the right shoulder was graded and sloped to allow for evasion to the right. There was no evidence on the roadway of any attempt to apply brakes or otherwise avoid the crash.
Companies whose employees drive on behalf of company business should include safe driving procedures in safety regulations and rules. Periodic update training, such as the National Safety Council's Defensive Driving Course could be provided on an annual basis, or concurrent with renewal of driver's license or company car license renewal. Review of driving records in the interest of lowering insurance rates also serves as an important safety function.
Personnel involved in travel should be required to use seat belt protection whenever they are driving company vehicles. Seat belt reminders and interlocks should be available and maintained and seatbelt use should be enforced.
Procedures for travel to and from test locations should be reviewed on a periodic basis to insure that drivers are reminded of the hazards associated with over-the-road travel. Special concern should be given to such areas as fatigue and distraction. Common procedures regarding the operation of heavy equipment by persons who show signs of fatigue or distraction should be emphasized for operators of over-the-road vehicles.
FATAL ACCIDENT CIRCUMSTANCES AND EPIDEMIOLOGY (FACE) PROJECT
The National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), performs Fatal Accident Circumstances and Epidemiology (FACE) investigations when a participating state reports an occupational fatality and requests technical assistance. The goal of these evaluations is to prevent fatal work injuries in the future by studying the working environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury, and the role of management in controlling how these factors interact.
States participating in this study include: Georgia, Indiana, Kentucky, Maryland, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia.
NIOSH Funded/State-based FACE Projects providing surveillance and intervention capabilities to show a measurable reduction in workplace fatalities include: Alaska, California, Colorado, Massachusetts, New Jersey, Minnesota, Missouri, Wisconsin and Wyoming.
Additional information regarding this report is available from:
Wyoming Occupational Fatality Analysis Program
522 Hathaway Building - 2300 Capitol Avenue
Cheyenne, WY 82002
Please use information listed on the Contact Sheet on the NIOSH FACE web site to contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.