Hazard

Worker was exposed to a tip over hazard when he was backing a container on a chassis into a parking slot at a marine terminal.

Process

Semi tractors with attached chassis were transporting off-loaded containers from a vessel to a parking slot on the terminal. Workers would drive a container and chassis from the vessel to a designated slot in the yard, pick up an empty chassis from another slot, and return to the vessel to receive another container.

Activity at time of incident:

The semi tractor driver was backing an attached container and chassis into a parking slot at the terminal.

Incident Description

Setting:

A semi tractor driver was working on a marine container terminal. He was working "against a vessel", transporting containers as they were unloaded from the ship to parking slots in the yard. He was backing a container on a chassis into an empty parking slot with containers on both sides of the slot that he was attempting to use.

Incident:

[The incident was not observed directly so actions were deduced by investigation.] The driver started to back his unit into the parking slot. He maneuvered his semi tractor into a 90-degree angle (jackknife position) with the container and chassis aboard. The chassis and container overturned. The back wheels of the semi tractor acted as a fulcrum as the semi tractor cab lifted off the ground. The semi tractor broke away from the overturned container and chassis, and its front wheels slammed on the ground. The driver was thrown into the steering column and the interior of the cab. The driver was found unconscious in the cab and later died at the hospital.

Relevant Factors:

The cab remained intact and the driver remained in the cab; however, the driver was not wearing a seatbelt. The driver was backing up blind sided into the slot. The semi tractor went into a jackknifed position, decreasing its stability. The moveable hydraulic fifth wheel was elevated to the highest position, which raised the rig's center of gravity. The backing speed and steering maneuvers are unknown; however, the speed, acceleration, and braking of the backing maneuver could have contributed to the rig's instability. The container's cargo shifted when it tipped over. It is unknown if the cargo shifted during maneuvering. However, if the cargo moved or shifted during the backing maneuver, this may have contributed to the rig's instability.

Applicable Standards and Control Measures

• 29 CFR 1917.43(b)(6): Only stable and safely arranged loads within the rated capacity of the truck shall be handled.
• 29 CFR 1917.44(d): The employer shall direct motor vehicle operators to comply with any posted speed limits and other traffic control signs or signals, and written traffic instructions.
• 29 CFR 1917.44(f): Vehicular routes, traffic rules, and parking areas shall be established, identified, and used.
• 29 CFR 1910.178(l): Operator Training.

Control Measures

These hazards could have been prevented if the driver:

• using a seatbelt.
• approaching the parking lot on the visible side.
• backing up in a gentle "S-curve", preventing a jackknifed position.
• keeping the fifth wheel as low as possible.
• conducting the backing maneuver slowly and smoothly.

For more information see Video #3 - Longshore worker killed by yard tractor tip-over (www.nmsa.us)