Date of incident: October 2013
Notice of incident number: 2013110750771
Employer: Traffic control company

Incident summary

Loaded gravel trucks with pup trailers were delivering gravel to a paving site. The truck driver involved in the incident was not aware that a third certified traffic control person (TCP) had joined the crew and was positioned at the entrance to a parking lot. He drove past the entrance and stopped his truck. The TCP started to direct a car leaving the parking lot and stepped out with her back to the gravel truck. The truck driver checked his side mirrors but did not see the TCP, and began to reverse. The TCP was struck by the reversing truck and sustained severe crushing injuries. The TCP succumbed to these injuries.

Investigation conclusions

Cause

• Worker struck by a reversing gravel truck: A certified TCP was struck by a reversing loaded gravel truck and sustained fatal crushing injuries.

Underlying factors

• Worker stepped out behind the truck: The TCP stepped out behind the stationary gravel truck as she helped the driver of a car attempting to exit an apartment building parking lot. By keeping her back to the truck and remaining in the truck driver's blind spot, she contravened her training and the safe work procedures of her employer. It is possible that the TCP stepped behind the truck because she assumed it would only be moving forward.
• Truck driver reversed the truck: The truck driver believed it was safe to reverse. He did not know the TCP was at the entrance to the parking lot. When he drove past the parking lot entrance, he did not see the TCP, and the car was not yet positioned to leave the parking lot. Since the truck driver had just driven up to his location moments before and had not encountered any hazards, he believed that reversing the truck, following his own tracks, was a safe manoeuvre.
• Prime contractor responsibilities not fulfilled: The actual prime contractor believed that another firm was the prime contractor at the worksite. As a result, no proper planning took place, and the responsibilities of the prime contractor were not fulfilled. The lack of a clearly identified prime contractor, however, does not absolve any contractor from the responsibility of ensuring its work is planned and coordinated in a safe manner.
• Lack of planning: The paving company did not properly coordinate or plan the work or involve the workers present in that planning. No one at the worksite was aware that the project supervisor had requested a third TCP. As a result, there was no plan to place the additional TCP in a safe and effective location. The late arrival of the third TCP also meant she could not participate in any planning or safety meetings, had they taken place. As well, the foreman did not hold a tailgate safety meeting or site safety orientation, and the traffic control supervisor did not complete a traffic control plan to deal with the traffic coming and going from the apartment buildings.
• Lack of communication: The project supervisor did not communicate to anyone that he had arranged for a third TCP to come to the worksite or his reasons for doing so. The truck drivers were informed only about how they were to enter and exit the worksite. They were not informed about hazards related to traffic coming and going from the apartment buildings and were not given any plan or procedures to safely deal with this traffic. They were not told about the number of TCPs present on site or their anticipated locations and duties. The foreman had radio contact only with the truck drivers and no other workers. The equipment operators and the TCPs had to communicate with all workers, including the truck drivers, using eye contact and hand signals. Better planning or a tailgate meeting would have afforded workers the opportunity to develop a more effective communication strategy.

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