Investigation Report Worker Fatally Injured Struck by Motor Coach December 9, 2015

Transcription

1 Investigation Report Worker Fatally Injured Struck by Motor Coach December 9, 2015 Report No-F-OHS D1EC October 2016 Page 1 of 6

2 The contents of this report This document reports s investigation of a fatal accident in December It begins with a short summary of what happened. The rest of the report covers this same information in greater detail. Incident summary A motor coach operator dropped off workers at a T-intersection at the worksite. As the motor coach moved forward to complete a left turn at the intersection, a worker crossing the road was struck and caught underneath the vehicle. The worker suffered fatal injuries as a result. Background information North West Redwater Partnership (NWR) was the site and facility owner of the Sturgeon Refinery Project. NWR processed diluted bitumen into useable products. The Sturgeon Refinery Project was located approximately 45 kilometres north-east of Edmonton, AB. An agreement was established between NWR and Diversified Transportation Ltd for the supply of on-site busing services to the NWR project. Diversified Transportation Ltd (Diversified) was part of the Pacific Western Group of Companies and Canadian owned. Diversified was a full service bus transportation company with operating subsidiaries in Alberta, British Columbia, Saskatchewan and Ontario. Diversified s Edmonton division provided a service to NWR by transporting employees to the NWR worksite from neighbouring communities. The motor coach operator was employed by Diversified. The motor coach operator had a class 1 operator license. The motor coach operator s abstract had no violations for the past three years. The motor coach operator had training in construction safety training system, pre and post-trip inspection, close quarters maneuvering, and had completed the Pacific Western evaluation and Diversified orientation. The motor coach operator had received a NWR project safety orientation. The equipment coordinator was employed by Aecon. The equipment coordinator had one year of experience with Aecon. The equipment coordinator provided first aid and contacted 911 after the incident occurred. The health, safety & environment specialist (HSE specialist) was employed by NWR. The HSE specialist had completed the external orientation by NWR. The HSE specialist had over 20 years of experience in the industry. The HSE specialist was a regular passenger on the motor coach bus. The HSE specialist was the injured worker. Page 2 of 6

3 Equipment and materials The Diversified motor coach involved in the incident was a 2008 Motor Coach Industries Coach. The motor coach was driven by a Diversified employee. Before being accepted on site, the motor coach passed an internal Diversified inspection on May 23, A B C Figure 1. Photos of the incident scene. The incident occurred on a private roadway at NWR, looking north at Bus Stop # 2: (A) indicates the motor coach at the T-intersection in its post incident location; (B) Pedestrian crosswalk signage; and (C) Red traffic cones marking walkways. Page 3 of 6

4 A B C D E Figure 2. Overview of the T-intersection at the NWR Partnership Site on Central Drive Lane: (A) Diversified motor coach; (B) Designated walkways; (C) Pedestrian crosswalk signage; (D) Motor coach route of travel; (E) Bus Stop # 2. Photograph provided by the RCMP Westlock Traffic Services. Page 4 of 6

5 Sequence of events At approximately 4:03 a.m., Wednesday, December 9, 2015, a Diversified motor coach operator prepared the motor coach for the day. The motor coach operator cleaned the windshield, mirrors, and headlights and completed the pre-trip inspection sheet. The motor coach operator turned on the headlights of the motor coach, travelled on route 1C East and picked up passengers in Edmonton, Alberta. The motor coach arrived at the NWR gate # 1 at 6:30 a.m. The motor coach operator dropped passengers off at Bus Stop # 11, 12, 13 and 17. The remaining passengers were dropped at Bus Stop # 2 on Central Drive Lane at approximately 6:44 a.m. NWR s facility light poles system was set to activate at dusk and remain on until dawn. The motor coach operator pulled up to Bus Stop # 2 (Figure 2). The motor coach operator activated four way flashers, applied the brakes, opened the motor coach door and let 11 passengers off the motor coach including the HSE specialist. The motor coach operator observed all the passengers were clear of the motor coach and clear of the crosswalk directly in front of the motor coach. The motor coach operator turned off the four way flashers, turned on the left signal light, scanned left in the side mirror, and scanned in front and to the right side of the motor coach. The motor coach operator looked ahead along the gravel road and proceeded to turn left at the T- intersection. The motor coach operator checked the left and right mirrors for a second time and proceeded to turn left. The motor coach operator heard a thump and saw a shadow drop in front of the motor coach. The motor coach operator applied the brakes and heard banging at the motor coach door. The operator opened the motor coach door and noticed the HSE specialist was lying on the ground at the bus s front right tire. The HSE specialist asked the motor coach operator to back up the motor coach as it was on the HSE specialist s legs. The motor coach operator backed up the motor coach, applied the brake and went to help the HSE specialist. The equipment coordinator arrived to help and contacted 911. The motor coach operator initiated emergency call by radio. NWR Emergency Medical Services (EMS) and Sturgeon County Fire attended the scene along with Redwater Royal Canadian Mounted Police (RCMP). NWR EMS transported the HSE specialist by ambulance to the on-site NWR medical facility. Shock Trauma Air Rescue Service (STARS) air ambulance landed adjacent to the NWR medical facility and transported the HSE specialist to the University of Alberta Hospital. Page 5 of 6

6 The HSE specialist had numerous fractures requiring surgery. The HSE specialist passed away from injuries on December 9, 2015, at the hospital. Completion A review for enforcement action was completed on March 16, 2016, and it was determined that prosecution or an administrative penalty were not appropriate based on the circumstances surrounding this incident. This file was closed on June 29, Signatures ORIGINAL REPORT SIGNED October 26, 2016 Lead Investigator Date ORIGINAL REPORT SIGNED November 30, 2016 Manager Date ORIGINAL REPORT SIGNED December 16, 2016 Director Date Page 6 of 6