At 8:00 p.m., on Thursday, Nov. 16, 2017, a traffic maintenance crew consisting of three workers were tasked with closing the eastbound left lane of a four-lane interstate in preparation of setting up a road construction site within a populous city.
On the night of the incident, the three workers picked up traffic cones from the westbound lanes of the same interstate that had been placed several days before closing the left lane. The employees placed the cones in the beds of the three work trucks they were operating and drove to the left shoulder of the interstate travelling eastbound. Each work truck had operating brake lights, rotating strobe lights, and a 14-light split arrow Manual on Uniform Traffic Control Devices (MUTCD) type-D arrow board mounted on them. The arrows were all flashing to the right, indicating to oncoming traffic the need to merge before the lane ended.
When the workers arrived at the assigned area, the first employee parked his work truck on the left shoulder of the interstate, exited the vehicle and rode with the victim who was operating the second work truck to a second location. The victim then instructed the operator of the third work truck to continue up the interstate. It is unknown the exact distance between the first and second work trucks as well as the distance between the second and third work trucks due to both being moved before emergency services arrived. In an interview with police, the operator of the first work truck noted that there was ‘some distance’ between the trucks. The third co-worker had pulled far enough forward that he was unaware of when the incident occurred.
The victim drove his work truck onto the left shoulder with a portion of the vehicle’s rear protruding into the left lane. After the victim parked, he and his co-worker both exited the vehicle with the purpose of ‘staging the cones’. The cones would be placed on the left shoulder, spaced at distances of every other white lane marker. It was the intention of the workers to have the cones in position so that at 9:00 p.m. later that night, when the construction contractor would instruct the workers to close the lane, the employees would then move the cones from the shoulder into the left lane closing it to traffic.
As the victim’s co-worker was standing on the driver side of the truck, fully on the shoulder, the victim walked around to the rear passenger side of the truck. As he was preparing to brief the co-worker on their expected work activities, the victim was struck from behind by a compact SUV that was unable to merge into the middle lane in time to avoid the crash. The victim was crushed between the SUV and his work truck and then pushed under the work-truck.
When law enforcement officers arrived, they found the victim under the work truck and pulled the truck forward. Once the truck was moved, the officers observed that the victim had severe injuries to both legs. One of the officers retrieved a tourniquet and applied it to one of the victim’s legs, but did not have a second tourniquet. When emergency services arrived at the scene five minutes later, the employee had succumbed to his injuries.
The cause of death was blunt force injuries sustained in pedestrian vs motor vehicle collision.
CONTRIBUTING FACTORS
Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH investigators identified the following unrecognized hazards as key contributing factors in this incident:
- Lack of hazard recognition.
- Unsafe driving practices.
- No physical barrier between moving vehicles and workers.
- Lack of laws regarding advanced warning systems.
RECOMMENDATIONS
Perform a job hazard analysis of the worksite.
The Occupational Safety & Health Administration (OSHA) states that JHAs should take priority on the following types of jobs: jobs with the highest injury or illness rates; jobs with the potential to cause severe or disabling injuries or illness, even if there is no history of previous accidents; jobs in which one simple human error could lead to a severe accident or injury; jobs that are new to your operation or have undergone changes in processes and procedures; and jobs complex enough to require written instructions. Had a job hazard analysis been performed, it is likely the employer would have recognized the potential hazard of having employees performing work while standing on an interstate highway.
Operators of motor vehicles should always practice safe driving actions and habits when in, or approaching, work zones.
According to the Federal Highway Administration, in 2017, 799 people died in work zone accidents; 658 were motorists, 132 were workers3. In the same year, Kentucky saw 15 work zone fatalities4. In order to reduce the amount of work zone injuries and fatalities, the Federal Highway Administration (FHWA) recommends the following driving tips to maintain driver and worker safety:
1. Know the work zone signs
2. Pay attention to other drivers
3. Stay focused. Avoid distraction
4. Expect the unexpected
5. Keep your cool. Be patient.
Due to the efforts of the FHWA, work zone fatalities fell from 1,058 in 2005 to 586 in 2010, a decrease of 44.5%. Had the driver practiced the recommended driving actions and habits, it is possible they may have noticed the cones that had already been placed on the shoulder, as well as the work trucks with the flashing yellow arrows, and avoided the accident.
Law enforcement should be present to aid in traffic control when workers are attempting to close lanes on the interstate.
In 2003, Kentucky legislators passed Kentucky Revised Statute (KRS) 189.930, known to many Kentuckians as the ‘Move Over Law’. Section five of the law reads, “Upon approaching a stationary emergency vehicle or public safety vehicle, when the emergency vehicle or public safety vehicle is giving a signal by displaying alternately flashing yellow, red, red and white, red and blue, or blue lights, a person who drives an approaching vehicle shall, while proceeding with due caution: (a) Yield the right-of-way by moving to a lane not adjacent to that of the authorized emergency vehicle… or (b) Reduce the speed of the vehicle, maintaining a safe speed to road conditions, if changing lanes would be impossible or unsafe.” If the police department’s workload allowed, an officer could have been present, engaged the vehicle’s light bar, and placed the cruiser between the first and second parked work-trucks.
If the operator of the vehicle had seen an officer’s flashing lights, it’s possible they may have attempted to merge into the middle lane and out of the path of the victim.
The Manual on Uniform Traffic Control Devices (MUTCD) should consider revising requirements for short-duration and mobile work to align with Traffic Incident Management Training.
The Kentucky Labor Department conducted a fatality inspection that concluded on April 30, 2018. During the inspection, the assigned Certified Safety and Health Officer (CSHO) did not recommend a citation because the applicable law that was incorporated by reference into 1926.200(g)(2) does not provide a requirement for any advanced warning during short-duration or mobile work.
During the CSHO’s review of the case, it was determined that the applicable standard for the employees was CFR 1926.200(g)(2), which states, “All traffic control signs or devices used for protection of construction workers shall conform to Part VI of the MUTCD, 1988 Edition, Revision 3, or Part VI of the MUTCD, Millennium Edition, incorporated by reference in Sec. 1926.6.”
To determine work duration, Section 6G.026 of the MUTCD was reviewed, and because the workers were placing cones on the shoulder and then moving, the duration was defined at mobile - work that moves intermittently or continuously. Once the work duration had been defined, the CSHO looked at MUTCD Section 6G.03 Location of Work6. This standard states that, “When the work space is within the traveled way, except for short-duration or mobile work, advance warning shall provide a general message that work is taking place, shall supply information about highway conditions, and shall indicate how motor vehicle traffic can move through the temporary traffic control zone.” The company in this case had gone above and beyond the standard by having rotating strobe light, brake lights, and an arrow board that acted as an advanced warning system. The standard as written does not require any advanced warning system that would undoubtedly make this type of work unsafe. To prevent similar incidents from occurring, the MUTCD should consider revising their requirements concerning short-duration and mobile work to align with Traffic Incident Management Training.
Traffic Incident Management (TIM) is a training developed by the Federal Highway Administration that addresses the safety needs of those workers who may render aid, clear roadways, maintain traffic flow, or conduct accident reconstruction. In the TIM training, those employees performing activities on the roadway use block positioning using a ‘lane plus one’, with the shoulder counting as a lane. Block positioning means using a large, easily visible vehicle with flashing lights in order to give workers an appropriate amount of space needed. In the incident, the employer provided three large work trucks with flashing arrows. The first and second trucks were both parked on the shoulder, leaving the employees in a vulnerable position of working in the left lane. Had the employers been required to park the second work truck in the left lane in a block position, it is possible the driver of the SUV who struck the victim would have seen the vehicle blocking the left lane and either stopped or merged into the middle lane.
Workplace Health and Safety Programs
NIOSH encourages employers concerned about drug use among their workforce to implement health and safety policies and programs to both offer services and support to their workers, as well as take steps to create and maintain safe and healthy workplace environments. The form of a workplace health and safety plan or program will vary depending on the work setting and many other considerations.
WORKPLACE DRUG TESTING
If workplaces include drug testing as part of such programs, the testing should be performed as part of an overall plan or program intended to assist workers who struggle with drug use, including those with any substance use disorder7. Allowing workers confidential access to screenings, support and treatment should be an important part of such workplace programs.
Employers can also take other steps to prevent and treat addiction in the work environment:
1. Develop and/or maintain proactive and comprehensive occupational safety and health practices and programs to eliminate unsafe working conditions and prevent worker injury or illness.
2. Identify providers that offer evidence-based treatment for injured workers, including the adherence to opioid prescribing guidelines.
3. Provide adequate leave and other benefits after workplace injury including flexibility in scheduling and receiving medical care, support during recovery, and return to work.
4. Take steps to manage workplace stressors and job insecurity to the extent possible.
5. Take steps to decrease the stigma associated with substance misuse through awareness building and supervisor training.
6. Educate workers about how drugs impair work activities, including driving, and encourage them to notify their employers if they are taking medications that may affect their ability to work safely so that a safe solution can be determined.
7. Develop and communicate clear drug-related workplace policies that include an offer of assistance to workers.
8. Offer EAP services, or other psychological, social, and family support when needed.