Incident Investigation – Case Study

Case Studies 561

CASE III

A tool truck driver, making his routine crib stops, picked up a crib attendant. The attendant had requested a ride to another part of the plant because he knew the driver would be going in that direction.

The truck driver deviated from his aisle route and angled through a cleared but darkened area. This area was being prepared for new machinery installa- tion, and at that time of night was not fully lighted.

The attendant, who was sitting on the right side of the cab, suddenly noticed that the truck was headed for a steel building column. Before he could warn the driver, the left front corner of the truck struck and glanced off the column.

The impact threw the driver against the column and about 15 ft (4.6 m) away from the truck. The truck continued for approximately 50 ft (15.3 m) before the rider could get behind the wheel to apply the brakes and bring the truck to a stop.

The driver suffered a skull fracture, concussion, and severe injuries to the left arm and chest. He was taken immediately to the local hospital, where he died from a blood clot about three weeks later.

What could have been done to prevent this incident or similar incidents in the future?

Guide and Background Information for Case III Explain to the group, if asked, that these trucks are not designed to carry pas- sengers. In order for a rider to sit on the seat, the driver must move over, which puts him in an awkward position.

Following are other pertinent facts: • The aisles were not marked in this particular area. • The area was not “roped off” and there were no signs to indicate equipment

was being installed. • The truck was not equipped with a seat belt. • The incident happened on the second shift (about 10 p.m.). • The machinery installation had been going on for an extended period of

time. • There were no rules concerning riders. • The driver was experienced.

©2009 National Safety Council.

562 Supervisors’ Safety Manual

Possible Solutions for Case III 1. The driver’s failure to stay within the main aisle was an important factor

in the incident. Properly marked aisles might have prevented the driver from taking a short cut.

2. When there are properly marked aisles, truck drivers should be instructed and trained in proper procedures.

3. Better illumination might also have prevented the incident. Because the installation had been going on for some time, the area should have been properly illuminated.

4. The area could have been roped off or marked. 5. A rigidly enforced rule against “no riders” should have been instituted. 6. Installation of seat belts in equipment of this type is a possibility, but

because of the nature of the work, not generally done.

Summary Stress to the group that the incident was caused by a combination of factors: • The unsafe conditions were poor lighting, unmarked aisles, and lack of

signs. • The unsafe procedures were the driver’s “short cutting,” and picking up a

rider. The lack of a rule against riders did not exonerate the driver because he had to make room for the rider and had to be aware that he was not in the best position to control the truck. The rider also must have been aware of the situation when he moved into the seat.

©2009 National Safety Council.