Date of incident: September 2020
Notice of incident number: 2020180940019
Employer: Excavating company

Incident summary
A young worker was driving a roller compactor (roller) down a slope onto a construction site when the cab tilted forward and he was thrown from the machine. The worker landed on the ground in front of the roller, which continued moving onto him, causing serious injuries.

Investigation conclusions

Cause

• Roller driven down steep slope, causing worker to be thrown from roller. The worker drove the roller down a slope with a grade of more than 70%. The manufacturer’s instructions specified 52% as the maximum incline on which the roller could be operated.

Contributing factors

• Failure to wear seatbelt. The worker was not wearing his seatbelt, which was required by both the equipment manufacturer and the employer.
• Bolts to secure operator’s cab were missing. The operator’s cab on the roller was able to tilt forward for maintenance access. The cab was intended to be secured to the frame of the machine by two bolts, which were missing. The absence of the bolts allowed the cab to tilt forward when the roller was driven down the steep slope.
• Inadequate training. The worker received a new worker orientation and reviewed the employer’s safety manual. He received hands-on training with respect to operating the roller involved in the incident and had often operated it before the incident. However, the worker should have received additional training as required under section 3.24 of the Occupational Health and Safety Regulation. The worker’s training on use of the roller was informal and was not documented, with the exception of a brief notation regarding training on completing pre-trip inspections. The use of seatbelts was covered in his orientation, but there is no evidence that it was addressed during his training on the use of the roller. The employer failed to ensure that the worker received adequate instruction in the safe use of the roller.
• Inadequate supervision. The worker’s supervisor was not on site during the work being performed on the day of the incident. After the incident, the worker expressed a lack of familiarity with the work being performed that day and confirmed that he did not wear a seatbelt when using the roller. As he was a young worker, additional supervision was warranted.
• Insufficient planning and change management. Communication from the supervisor regarding the work plan was verbal and was not documented, with the exception of some text messages between the supervisor and the prime contractor. There was an informal plan for how to access the site with the roller. The plan had to be changed due to a request from the prime contractor to excavate the area that was to be used as an access point. No one thought to build a ramp to ensure safe access to the site with the roller, nor did they think to bring the roller onto the site before excavating the area.

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