Safety Issues



The Truck Operator Who Died 

The semi-truck driver who died was in his 50s and had been employed with the company for approximately one month. For at least 10 years prior to his employment with this employer, he had been a long haul truck driver for another company. The employer was contracted by the dairy to deliver milk from area farmers. The decedent was wearing a black coat, black sweatshirt and black baseball cap, and blue pants. 


The Incident Scene

The incident scene was a loading area at a dairy processing plant. Several tankers were parked in the loading area. The facility had adequate outdoor lighting. The dairy plant had changed procedures and reduced the number of tankers the employer was permitted to have at the facility. This procedural change created some confusion for the decedent’s employer. The trucking firm had three immediate issues to deal with: 1) Figure out which drivers and tankers could be on site, 2) which tankers had to be moved off site and, 3) the location of the off-site storage. One shagger was assigned to transport clean, empty tanks to the staging area where an incoming driver could hook up and take the empty tank to a farm for filling. 


The Investigation

On the night of the incident, in addition to his regular duties at the plant, the shagger was also transporting empty tanks to the drop yard to reduce the number of tanks. The firm sent an email to all of the firm’s truck drivers to let them know of the change in procedure but not all drivers had read the email. Several drivers, including the deceased were present at the processing facility. To expedite the process of unhooking/hooking trailers, several of the drivers present worked together to move truck/tankers in and out of the dairy’s staging area. The decedent and one of his coworkers (Coworker 1) unhitched the newly arrived tanker from the incident tractor. Standing on the north (driver) side of the tractor/tanker, Coworker 1 unhooked the hoses and electric pigtail while the decedent, standing on the south (passenger) side, lowered the landing dolly legs. Coworker 1 stated that he observed the decedent positioned away from the tractor/tanker unit. He stepped forward to inform the tractor driver it was all clear and to pull ahead. The tractor driver stated he looked out his windows and checked his mirrors prior to pulling forward. For reasons unknown, the decedent had entered a blind spot on the passenger side; he was positioned behind the cab and its muffler system and in front of the rear tandem wheels of the tractor. Another truck driver observed the positioning of the decedent and honked his horn to warn the driver and decedent but it was too late. As the tractor pulled ahead, the tractor ran over him. 



Blind spot training should include hazards associated with their role as a driver and as a pedestrian.

Always wear a high visibility vest/clothing when a pedestrian around moving vehicles, especially at night and/or in dimly lit areas.

Management should develop a procedure to document firm-wide communication has received and employees have acknowledged the receipt of the communication.

Develop and implement an emergency action plan with a checklist of agency contacts.

When a change in a firm’s procedure affects suppliers, the firm should allow suppliers adequate time to institute and communicate changed procedures.

Safety Issues is presented by the National Institute for Occupational Safety and Health (NIOSH) in partnership with the National Truckers Association (NTA), with major contributions from State partners funded by NIOSH through the Fatality Assessment and Control Evaluation (FACE) Program.  The goal of the FACE program is to prevent occupational fatalities across the nation by identifying and investigating work situations at high risk for injury and then developing and disseminating prevention strategies to those who can intervene in the workplace. State partners who contribute Safety Issues postings based on recent investigative reports are California, Iowa, Kentucky Massachusetts, Michigan, Oregon, New Jersey and Washington.

This month’s safety issues is based on an investigative report from Kentucky Face Program.  The complete detailed Michigan FACE INVESTIGATION REPORT: 14MI122 includes additional case information, recommendations and discussion.  This report can be found at  Further information on the Michigan FACE Program, including additional Michigan FACE Investigation Reports, Hazard Alerts, and fatality summaries can be accessed at

The Safety Issues and Investigation Reports which are the products of NIOSH Cooperative State partners are presented here in their original unedited form from the states.  They are intended for educational purposes only.  The findings and conclusions in each report are those of the individual Cooperative State partner and do not necessarily reflect the views or policy of the NIOSH.