Date of incident: November 2012
Notice of incident number: 2012156680235
Employer: Auto service and repair shop

Incident summary

A commercial truck mechanical labourer was lying on the floor under a tandem axle truck tractor, changing a universal joint. The right tires needed to be rotated to provide access. The worker used the floor jack to raise the right tires slightly, and then another worker started the engine to release the air brakes so the tires could be turned. However, the tractor moved forward and came off the jack. The worker under the tractor was pinned between the floor and the U-bolts on the leaf spring on the rear left side of the tractor. He died as a result of serious injuries.

Investigation conclusions
Causes

• Worker pinned under leaf spring U-bolts when working in the bight: The worker was pinned between the floor and the leaf spring U-bolts and was fatally injured when the tractor moved forward. He was underneath the rear axle when the engine was started. The worker was not in care and control of the vehicle he was working on.

Underlying factors

• Lack of training and supervision: No documentation could be found confirming the employer's assertion that safety and supervision are addressed on site. The conditions of the mechanic shop and lack of experience with the task indicate a general lack of training, instruction, and supervision.
• Lack of system or plan to conduct the work safely: Neither worker had been trained or educated in safety relating to working on the tractor involved in this incident. They had no safe work procedure, system, or plan to conduct the work safely.

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