Date of incident: August 2021
Notice of incident number: 2021182130002
Employer: Traffic control services contractor; property development company (prime contractor); ready-mix concrete supplier

Incident summary

At a multi-unit residential construction site, a traffic control person (TCP) was directing traffic on the adjacent city roadway. A concrete mixer truck was parked on the roadway and was unloading concrete into a pump truck. When the unloading was complete, the mixer truck was driven ahead to leave the site. The TCP, who was in the path of the mixer truck, sustained fatal injuries.

Investigation conclusions

Cause

• Traffic control person was not in safe work position. The traffic control person (TCP) was positioned too close to the work area and was not in a safe location. The TCP was standing in close proximity to the concrete mixer truck and was knocked over as the truck began to leave the site. A safe work location was not established because the approved traffic control plan for the site was not being followed and the procedures the workers were using were inadequate.

Contributing factors

• Inadequate traffic control plan and procedures. Effective traffic control for the concrete deliveries was not provided. The work zone was different than what was described in the approved traffic control plan. The mixer truck was parked on an angle blocking multiple lanes, requiring a higher-risk, single-lane alternating traffic procedure. There were no effective means to prevent vehicles parking in the work zone. A safe position for TCP to stand in was not identified. As well, there was no established procedure to signal the driver of the concrete mixer truck that it was safe to move his vehicle when he was ready to leave the site.
• Inadequate safe work practices for moving mixer truck. No procedure was in place for a TCP to signal the mixer truck driver to pull out, and the driver’s employer did not have a safe work practice requiring drivers to visually check the blind spots around the truck on foot when no spotter was available.
• Inadequate supervision and instruction. The traffic control employer failed to provide the TCP with adequate instruction about the approved traffic control plan, including where to stand in a safe location. The employer also failed to instruct the TCP on her role in controlling the movement of the mixer truck. Also, the TCP did not receive adequate supervision to address the unsafe work location, nor her reported, observable fatigue and resulting impairment.
• Inadequate site orientation. Neither of the two TCPs at the site had ever worked there before. The prime contractor failed to provide the TCPs with an adequate site orientation when they arrived, including a review of the approved site-specific traffic control plan. The TCPs and the truck drivers were not provided with information about the procedure for releasing trucks from the site.
• Inadequate prime contractor coordination. The prime contractor failed to coordinate the activities of the TCPs and the concrete supplier’s workers. There should have been an established procedure for the TCP to direct the movement of the mixer trucks. Also, the prime contractor was ultimately responsible to ensure that there was an effective overall traffic control system on site.
• Inadequate systems to address worker fatigue. Neither the traffic control services contractor nor the prime contractor had established a system or procedure to address worker fatigue.