Hazard

Worker was exposed to being struck by and run over by a top loader on a marine terminal while working as a clerk and spotter.

Process

The top loader was stacking containers being off-loaded from a vessel to a resting point on the terminal. The top loader operator would pick containers off a semi tractor and chassis and stack the containers as directed by the clerk, at a specific slot in a container stack on the terminal.

Activity at time of incident:

The top loader was backing up after placing a container in a stack as directed by the clerk.

Incident Description

Setting:

The top loader operator and the clerk were working "against a vessel", stacking containers as they were unloaded from the ship to slots in a container yard. The top loader operator was backing out of a container stack after placing a container into a slot as directed by the clerk.

Incident:

[The incident was not observed directly so actions were deduced by investigation.] Halfway through the day shift, the top loader operator was backing out of a container stack after placing a container into a slot as directed, via radio, by the clerk. The clerk, who was fairly new to his position, had his back turned away from the top loader as he recorded information on a clipboard. Unaware that the clerk was standing in the operator's blind spot, the top loader operator struck and backed over the clerk, killing him instantly.

Relevant Factors:

The top loader operator and clerk did not effectively communicate with each other. The lack of communication resulted in the clerk being unaware of the anticipated movements of the operator, and in the operator being unaware of the location of the clerk. The clerk failed to stay out of the path of the top loader and failed to remain in the operator's line of sight. The operator lost sight of the clerk and failed to communicate with the clerk prior to backing out of the container slot.

Applicable Standards and Control Measures

• 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 1910.178(l): Operator Training.

Control Measures

These hazards could have been prevented if the driver:

• Maintaining eye contact between the operator and the clerk.
• Staying out of potential paths of the top loader.
• The operator communicating his anticipated movements to the clerk.
• The operator conducting the backing up maneuver slowly and smoothly.

For more information see Video #1 - Longshore worker killed by top loader (www.nmsa.us)