Driver death shows why LOTO for vehicles is required

Lack of proper training, lockout/tagout procedures major root causes of incident

Posted June 1, 2018

In a tragic sequence of events, a truck driver was killed while trying to manually release frozen brakes. While several factors contributed to the incident, investigators say lack of proper training and lockout/tagout procedures were major root causes.

What happened

While the incident was not witnessed, investigators believe that upon realizing the brakes were apparently frozen, the victim procured a hammer and metal bar with which to manually release the brakes. The truck was left running at idle speed with the transmission in gear. (The truck was equipped with an automatic transmission and torque converter that allows the truck to remain stationary while in gear. The truck’s transmission control did not have a “park” position. The parking brake was not engaged.)

Investigators believe that the operator then crawled under the truck with the tools to forcibly free the frozen brakes. He successfully released the brakes, which allowed the truck to move forward. As the truck moved, the victim’s clothing became entangled in the universal joint (u-joint) on the revolving drive train. The victim was lifted off the ground and pinned against the frame of the truck causing the drive shaft to stop rotating. The compression of the victim against the frame led to his death by asphyxiation.

It was estimated that the truck moved a total of eight feet from where it was originally parked.

What could have prevented the tragedy?

Investigators made four recommendations to prevent the incident.

  1. All employees should be trained in appropriate safety procedures associated with the equipment they are hired to operate. Employees should receive appropriate training on the operating hazards and safe maintenance of equipment. In this incident, the victim failed to follow several safety rules found in the equipment operator manual in the company’s safety program. The operator manual states when performing maintenance the engine should be turned off and the wheels chocked. The manual also states not to wear loose clothing.
  2. The employer should revise the lockout/tagout program to include/revise the risks and procedures for working on energized equipment. OSHA’s lockout/tagout standard (29 CFR 1910.147) is intended to prevent the unexpected release of stored energy during servicing of equipment, including motor vehicles. An effective lockout/tagout would have provided for notification of working on energized machinery. This procedure might have involved another person to engage the brakes and/or resulted in a more timely rescue of the victim through immediate dialing of 911. Alternative methods for locking out the truck when the brakes cannot be set should include chocking the wheels and other means to prevent the truck from moving.
  3. Workers must not attempt tasks for which they have not received proper training. The victim in this incident was a part-time truck driver, and there was no indication that he had been trained as a mechanic qualified to release frozen brakes. Upon discovering that the brakes had seized, he should have notified appropriate maintenance personnel rather than attempting the repair alone. The host facility should institute a driver policy to remind and enforce such rules when drivers arrive to transport trucks to customers.
  4. Equipment should be appropriately maintained in good operating condition. This situation could have been caused by improper maintenance of the truck’s air drying system. This system is intended to remove moisture from the brake system air lines in order to avoid situations such as frozen brakes. Air drying systems utilize filters which must be replaced on a periodic schedule.

This article was written by Travis Rhoden of J. J. Keller & Associates, Inc.


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