The Kentucky Fatality Assessment and Control Evaluation (FACE) Program is tasked with investigating fatalities and making recommendations to ensure they do not occur again. This is one of their recent cases.
On Thursday, Sept. 26, 2019 at approximately 8:00 p.m. the involved company notified the victim, a 42-year-old male construction workers, of a job assignment that would need to be completed the next day. His task was to travel to an out-of-state location to obtain building materials for an in-state job site.
To complete the job in a timely manner, the victim would have to depart his home by 2:00 a.m. the next morning. After receiving the assignment, the victim and his spouse departed a local sporting event at approximately 8:45 p.m. in hopes of obtaining as much sleep as possible. After arriving home, the victim’s spouse stated he made preparations for the trip and went to bed at 10:00 p.m.
According to the spouse, she woke the victim up at 1:30 a.m. on Friday, Sept. 27 and he departed shortly after at 2:00 a.m. in a company-owned, 2013 Chevrolet Silverado. He was traveling on a major, four-lane interstate en route to the destination to pick up supplies when he failed to notice that traffic had stopped due to an earlier collision.
Approximately five hours into the trip, just before sunrise at 7:07 a.m. traffic on the interstate was at complete stop due to a six-vehicle, fatality collision had occurred nearly six-hours earlier.
Although this section of the highway was straight, for unknown reasons the victim failed to observe the stopped vehicles. As a result, the pickup truck driven by the victim struck the rear, left bumper of a semi-trailer at an estimated speed of 70 mph. The force of the impact severely damaged the driver’s portion of the cab. According to police reports, the victim was not wearing a seat belt at the time of the collision. No decelerating scuffs or skid marks were present at the scene which suggest the victim did not attempt to brake prior to the impact.
According to the death certificate, the cause of death was multiple blunt force trauma sustained in a motor vehicle collision.
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. National Institute for Occupational Safety and Health (NIOSH) investigators identified the following unrecognized hazards as key contributing factors in this incident:
- Advanced warning signage
- Fatigue-related work schedule
- Failing to wear seat belt.
RECOMMENDATIONS
1. Warning devices should be utilized to alert motorists of slow or stopped traffic.
This crash was a secondary collision. Traffic was at a complete stop due to the initial collision which occurred six hours earlier. Although it is unclear whether or not warning devices were utilized, the Federal Emergency Management Agency (FEMA), states that lack of advanced warning devices is a key contributing factor to the occurrence of most secondary collisions. Changeable message signs (CMS) continue to be one the most effective measures in preventing secondary collisions. They provide a versatile means of communicating information to drivers and can be invaluable in alerting oncoming traffic to an emergency incident. According to FEMA, For CMS to be useful, the message must be concise and clear.
CMS used on roadways with speed limits of 55 miles per hour (mph) or higher should be visible from one-half mile under both day and night conditions. The message should be designed to be legible from a minimum distance of 600 ft. for nighttime conditions and 800 ft. for normal daylight conditions. When environmental conditions that reduce visibility and legibility are present, or when the legibility distances stated in the previous sentences in this paragraph cannot be practically achieved, messages composed of fewer units of information should be used and consideration should be given to limiting the message to a single phase.
Each message shall consist of no more than two phases. Each phase shall consist of no more than three lines of text. The minimum time that an individual phase is displayed should be based on 1 second per word or 2 seconds per unit of information, whichever produces a lesser value. The display time for a phase should never be less than 2 seconds. The maximum cycle time of a two-phase message should be 8 seconds.
Messages should be concise, clear, and provide relevant information. All messages are printed in capital letters.
The highway department would deploy such signs in hopes of preventing a secondary collision occurring. In this particular situation, the secondary collision occurred nearly six-hours after the preliminary collision which provided ample opportunity for such warning devices to be deployed. To protect and warn the motoring public, warning devices such as CMS should be deployed.
2. Employers should be aware of and avoid work schedules that may contribute to worker fatigue.
The company contacted the victim at approximately 8:00 p.m. the night before the incident, only six hours prior to the 2:00 a.m. departure time that the employee would have to leave by in order to complete the task in the time-frame requested by the employer. According to Federal Motor Carrier Safety Administration (FMCSA), fatigue is the result of physical or mental exertion that impairs performance. Driver fatigue may be due to a lack of adequate sleep, extended work hours, strenuous work or non-work activities, or a combination of other factors.
The Large Truck Crash Causation Study (LTCCS) reported that 13% of commercial motor vehicle (CMV) drivers were considered to have been fatigued at the time of their crash. The FMCSA further states that if possible, a commercial driver should not drive while the body is naturally drowsy: between the hours of 12 a.m. to 6 a.m. and 2 p.m. to 4 p.m. Drowsiness may impair a driver’s response time to potential hazards, increasing the chances of being in a crash.
The combination of the victim failing to obtain adequate rest and beginning work at a time when the body is naturally drowsy likely contributed to his inability to recognize stopped traffic. Companies should be aware of, and avoid, scheduling drivers to work during these high-risk time periods when fatigue is most likely.
3. Employers should assure workers obtain adequate rest and educate workers on the dangers of operating vehicles while fatigued.
According to the victim’s spouse, he only obtained 3.5 hours of sleep prior to beginning work the next morning.
According to a study by the Centers for Disease Control and Prevention (CDC), 1 in 25 adults report they have fallen asleep while driving within the last 30 days. In 2014, the National Highway Traffic Safety Administration (NHTSA), stated there were 846 fatality collisions due to drivers falling asleep behind the wheel, equating to 2.6% of all fatality collisions during that year. In addition to the fatal collisions, falling asleep while driving was determined to be the contributing factor that led to an additional 37,000 injury collisions and 45,000 property damage collisions. Much of driving is repetitive in nature, which can lead to a lack of awareness of even the most obvious warning signs of fatigue.
Based on the accident investigation, the lack of skid marks, and no evidence of crash evasion maneuvers, fatigue was likely a contributing factor to the crash.
As a best practice, companies who operate company vehicles or require employees to drive should assure workers obtain adequate rest by offering flexible work schedules. Additionally, employers should conduct frequent awareness training focused on the dangers associated with driving while fatigued. Drivers should be educated on the warning signs of fatigue, how to recognize them, and provided strategies to combat fatigue.
4. Employers should consider installing driver-facing cameras to monitor seat belt usage.
According to the death certificate, the victim was not wearing a seat belt at the time of the crash. The company does have a strict, zero-tolerance seat belt policy that applies to not only the driver, but all occupants in the company vehicle as well; however, this policy is unenforceable, as workers are often alone in the vehicle with no way to know if they are abiding. Employers should consider installing driver-facing cameras in all company vehicles to monitor seat belt usage.
According to SmartDrive, a vehicle safety and transportation intelligence provider, installing driver facing cameras allow companies to identify and eliminate risky driving behaviors, such as failing to wear seat belt. Identifying a risky behavior proactively presents the opportunity for drivers to be coached on the undesired behavior. SmartDrive states that some fleets have experienced safety improvements of up to 84%.