Mechanic Crushed by Rollaway Container Chassis

Details

• Corporate Authors:
  Washington (State). Department of Labor and Industries
• Description:
  On May 6, 2021, a 62-year-old semi-truck mechanic died when he was crushed by a rollaway container chassis. The previous day, he began repairs on the chassis, which was parked outside of the employer's maintenance shop. He disconnected the airlines to its airbrake chambers, which engaged the parking brake, and left it outdoors for the night. The next day, he coupled a yard tractor to the chassis and tried towing it indoors to avoid the rain. The chassis would not move as its parking brake was still engaged. The mechanic stopped and exited the tractor leaving it parked on a downgrade with the engine running, parking brake released, and wheels unchocked. He told another mechanic to reconnect the chassis' air lines so its parking brake could be released. He then kneeled between the chassis' wheels and waited while the other mechanic worked. When the air lines were reconnected, the restored air pressure released the chassis' parking brake allowing gravity to pull the tractor and chassis combo downhill. The mechanic was crushed by the wheels of the rolling chassis while the other mechanic, who was still under the chassis, was almost struck by the axles. CONTRIBUTING FACTORS: Key contributing factors identified in this investigation include: Parking brake not engaged when necessary. Wheels not chocked during vehicle repair operations. APP lacked vehicle parking brake and wheel chocking requirements. APP had ineffective progressive discipline policy. RECOMMENDATIONS: Washington FACE investigators concluded that, to help prevent similar occurrences, employers should: Install electronic parking brake systems that automatically apply the parking brake when the driver has not set it before exiting the cab. Develop APP to include vehicle rollaway hazard identification, assessment, and prevention procedure requirements. Develop APP to have progressive discipline policies that effectively address vehicle safety rule violations and prevent hazardous operation. [Description provided by NIOSH]
• Subjects:
  Accident Prevention Accidents Accidents, Occupational Mortality Occupational Health Safety Staff Development
• Keywords:
  Accident Prevention Equipment Operation Equipment Operators Fatalities Mechanics Safety Education Safety Practices Training Truck Drivers Trucking Worker Safety

  More +
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Publisher:
  Washington State Department of Labor and Industries
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Case Studies
• Place as Subject:
  OSHA Region 10 ; Washington
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-19
• NIOSHTIC Number:
  nn:20066154
• Citation:
  Olympia, WA: Washington State Department of Labor and Industries, 52-53-2022, 2022 Sep; :1-19
• Federal Fiscal Year:
  2022
• Performing Organization:
  Washington State Department of Labor and Industries
• Peer Reviewed:
  False
• Start Date:
  20050701
• Source Full Name:
  Mechanic crushed by rollaway container chassis
• End Date:
  20260630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:f1dd4d7960b44987a19458a5c3cbf936d5cee06578d9efad91be60bdc2857ee7589334d083c89d2ce3d74173996fe63dcad1b89c516d0aacf6d45bad35a6a992
• Download URL:
  https://stacks.cdc.gov/view/cdc/229128/cdc_229128_DS1.pdf
• File Type:
  [PDF - 1.15 MB ]