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MIFACE Investigation Report #14MI122

Subject: Truck Driver Struck by Rear Tractor Tires When Semi Tractor 

Driven Forward

Summary

In late fall 2014, a truck driver in his 50s died when he was struck 

and run over by the passenger side tires of a 2011 International 

semi-tractor while positioned in a blind spot on the passenger side 

of the cab. The incident occurred at night. The incident occurred in 

a staging area lit by four lights attached to the building. Several of 

the decedent’s coworkers were on site, working together to quickly 

move trucks and associated tankers in and out of a designated 

staging area at a dairy due to a procedural change imposed on the 

company by the dairy. One of the decedent’s coworkers (Coworker 

1) was assisting the 2011 International truck driver. Coworker 1 

was positioned on the driver’s side of the tractor cab unhooking the

trailer. He also acted as a spotter during both the backing and

forward movement of the tractor-tanker unit. The decedent was 

positioned on the passenger side of the semi-tractor and was 

lowering the landing gear down while the Coworker 1 unhooked the hoses, electrical and other 

connections from the tractor and tanker. When the trailer was unhooked and landing gear 

lowered, Coworker 1 saw the decedent standing away from the tractor and signaled the semitractor driver to back the tractor to disconnect from the tanker. The driver backed the tractor and 

felt the tanker shift and come off the truck. Coworker 1 did not see the decedent prior to 

signaling the tractor driver to drive forward. The semi-tractor driver checked his mirrors and 

looked out his windows. He drove forward to disengage the trailer. As the driver drove forward, 

the Coworker 1 walked around to the rear of the tractor and saw the decedent lying on the 

ground. Subsequent investigation showed that the decedent was standing between the passenger 

side cab, behind the muffler unit and in front of the rear dual tires. As the driver moved forward 

to disengage the tractor from the tanker, the decedent was struck and run over by the passenger 

side rear tires.

MIFACE identified the following key and possibly contributing factors:

 Unexpected change of tanker delivery and tanker holding schedule at dairy site

 More than one individual unhooking a trailer

 Insufficient communication between workers

 Decedent wearing dark clothing

 Working at night

Photo 1. Rear view, passenger 

side of similar truck
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RECOMMENDATIONS

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

pedestrian, including pedestrians acting as a spotter. As a driver, emphasis should be 

placed on the need to determine pedestrian location for both forward and backward 

movement and as a pedestrian, the need to be seen and acknowledged by the truck driver.

 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. 

 Ensure designated individual required to communicate important information to 

coworkers has the time to communicate the information

 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.

BACKGROUND

In late fall 2014, a truck driver in his 50s died when he was struck and run over while positioned 

in a blind spot on the passenger side of a 2011 International semi-tractor cab. MIFACE learned 

of this incident from the MIOSHA 24-hour ASAP reporting system. MIFACE contacted the 

company owner who agreed to speak with the MIFACE investigator about the incident. During 

the writing of this report, the death certificate, police and medical examiner reports, and the 

MIOSHA compliance file were reviewed. The pictures used in this report are courtesy of the 

MIOSHA compliance file. MIFACE removed identifying information from the pictures for use 

in this report. 

A dairy processing plant had contracted the decedent’s employer, a trucking company, to haul 

milk from dairy farms in Michigan and nearby states. The trucking firm had been in business for 

eight years. The company owner indicated the company employed 23 individuals at the time of 

the incident, 21 of whom were truck drivers. The decedent worked full time. The company set 

the driver’s pickup and delivery schedules; all drivers had a variable schedule depending upon 

the number of drivers available for the day and dairy farm scheduling. The decedent had been 

employed with the company for approximately one month. Drivers were paid by the load. For at 

least 10 years prior to his employment with this employer, the decedent had had been a long haul 

truck driver for another company. 

The firm did not have specific written safety procedures for working with others to unhook 

tractor/trailers. Routinely, the semi driver was responsible for hooking/unhooking his trailer. The 

company owner was designated safety person. Safety meetings were held as necessary prior to 

incident. The decedent had attended the meetings. Company-sponsored safety training was less 

than 8 hours annually; the firm relied on CDL training received. 
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The trucking firm had a week-long “new driver” training program. For all newly hired drivers, 

the firm assigned an experienced driver to accompany the new driver on his/her route, 

introducing the driver to the farm owner and the farm’s pickup location and procedures as well 

as the required work procedures at the dairy plant. This training activity was oriented toward 

food safety requirements rather than safe work practices. The length of this training was for one 

week.

The firm had a 2009 edition employee handbook at the time of the incident. Example topics 

included dairy plant procedures, farm milk sample procedures, company policies and procedures 

(e.g. drug and alcohol testing, attendance, vacations, reporting absences, etc.), pre-trip vehicle 

inspection, defensive and night driving, W-4 information, MIOSHA Health and Safety 

Protection on the Job poster, and Michigan Whistleblower’s Protection Act. 

Company Remediation 

The firm made procedural changes to minimize a recurrence of a similar incident:

 Requirement that reflective vests must be worn at all times. Vests are kept at work and 

drivers retrieve them when they arrive. This change in procedure was instituted the day 

after the incident.

 The firm holds mandatory quarterly safety meetings for all personnel at the company’s 

main office.

 Revised employee handbook to include “Get Out And Look (GOAL)”, a program 

pertaining primarily to backing a vehicle. One of the main tenants of the program is “if 

you are not 100% certain of your surroundings, then take an extra minute and Get Out 

And Look. (See Appendix A)

 Developed and implemented a policy where all employees have to be visibly accounted 

for before moving vehicles including blind spot training.

 Instituted a pre-employment safety briefing discussing truck movement (GOAL) and 

safety vest requirement,

MIOSHA General Industry Safety Division issued a Safety and Health Recommendation to the 

company at the conclusion of its investigation: 

 It is recommended that the firm develop, document, and train employees on a procedure 

for truck operation where all employees are accounted for before truck movement occurs.

INVESTIGATION

By end of business on Friday of each week, the decedent’s employer determined the driver’s 

weekend schedule for milk pickup from farms and delivery of the full tankers to the dairy 

processing plant. The decedent’s employer had communicated the driver’s schedule via e-mail, 

the firm’s usual communication method. 
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The dairy plant notified the decedent’s employer of a change of procedure - the trucking firm 

could only have three tankers on site at all times. The dairy plant notification occurred after the

employer’s business hours on Friday. The decedent’s employer had already notified its drivers of 

their driving schedules. The reason for the dairy procedural change was unknown. Previously, 

the decedent’s employer had as many trucks and trailers on site as needed. 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. The firm determined 

that the extra trailers were to be hauled out of the plant property to a drop yard approximately 1⁄2 

mile away.

The trucking firm had one individual referred to as a “shagger” at the dairy processing facility. 

The shagger drove a semi-tractor that hooked up to a dropped full tank and transported the tank 

to the scale to be weighed and then moved the tank to the appropriate area of the dairy for 

emptying. The shagger also transported clean, empty tanks to the staging area where an incoming 

driver could hook up and take the empty tank to a farm for filling. 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 (from six tanks on the property to the three tanks limited 

by the new procedure) on the dairy plant property. 

After receiving the email from the dairy processing plant, the firm sent 

another email to the drivers with their new schedules. The firm emailed 

the shagger, informing him that as drivers came into the plant, the 

shagger should inform them of the changes for the next day’s 

deliveries. The firm owner also went to the diary processing 

facility and spoke to the shagger about the new procedures. A 

follow-up email was sent to the drivers asking them to speak 

with the shagger when they arrived at the plant to determine

their next steps. The owner was not present at the dairy; he 

relied on the shagger to share the information with the 

incoming procedural changes. 

The change in procedure by the dairy directly related to why 

several of the trucking firm’s drivers were on location at the 

same time. There were four employees on site at the time of the incident. The drivers were acting 

as “shagger” by moving vehicles in and out and dropping trailers to remove empties and replace 

full tankers where they were not normally to be parked. 

The decedent reported to the company office, determined which semi-tractor he would use, and 

drove directly to the dairy. 

Drawing 1. Layout of incident 

scene. Not to Scale
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The shagger was bringing an empty tank to the staging area and three drivers wanted this tank. 

Because the drivers had not yet read/received the emails, several drivers 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. (See 

Drawing 1) The firm’s owner stated that it was not a normal operation to have numerous 

employees performing hooking and unhooking of units. Normally drivers do all aspects 

themselves.

Since only three of the firm’s tankers were now permitted on the property, the arrival of a 2001 

International semi-tractor with a tanker full of milk at the staging area to be processed took 

precedence. 

The semi-tractor driver had clocked in at the office at 11:00 a.m. on the day of the incident and 

had been on the job for longer than 10 hours. When he arrived at the dairy, after his tanker was 

unhooked, he was instructed to use the tractor to connect to another tanker and transport it to the 

off-site storage 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. The 

decedent was wearing a black coat, black sweatshirt and 

black baseball cap, and blue pants.

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. At this time, his view 

was blocked from seeing the decedent. 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 (See Photo 2). 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. Emergency 

response was called and the decedent was pronounced 

dead at the scene. 

Photo 2. Location of decedent when 

truck driver drove forward

Photo 3. View from driver’s seat in 

truck cab
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The MIFACE researcher sat in the driver’s seat of a similar unit at the firm’s headquarters. The 

researcher observed that while in the driver’s seat there was a large blind spot created by the 

large muffler system, which was mounted on the right (passenger) side of the truck tractor and 

blocked view of this area. Figure 3 is a picture taken by the MIOSHA compliance officer seated 

in the cab of the incident tractor and shows the driver’s view out of the back window and the 

blind spot created by both the height of the cab above the ground and the muffler unit. 

KEY WORDS: Struck By, Blind Spot, Semi-Tractor, Transportation & Warehousing 

RECOMMENDATIONS/DISCUSSION

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

pedestrian, including pedestrians acting as a spotter. As a driver, emphasis should be 

placed on the need to determine pedestrian location for both forward and backward 

movement and as a pedestrian, the need to be seen and acknowledged by the truck driver.

Although under normal circumstances, the firm’s truck driver hooked/unhooked his own vehicle 

blind spot training would still be applicable because the drivers worked moved trailers at farms 

and the dairy where workers on foot might be present. A blind spot is the area around a vehicle 

or piece of equipment that is not visible to operators, either by direct line-of-sight or indirectly 

by use of internal and external mirrors. After the incident, the firm adopted a Get Out and Look 

(GOAL) program, which addresses hazards associated with the backing of a truck but does not 

directly address the hazards associated with pulling a truck forward. Although the firm now 

requires that everyone be in eyesight before moving, it is unclear whether within eyesight 

includes an acknowledgement from the driver and/or spotter that the pedestrian is seen by both

the driver and/or spotter. 

Workers who are pedestrians, including spotters, near the trucks should be instructed that the 

area directly in front, behind or to the side of the truck is a prohibited zone unless the worker on 

foot receives a verbal and visual approval confirmation from the driver that it is safe to enter the 

area. 

MIFACE recommends that both vehicle drivers, spotters, and pedestrian workers receive 

training to ensure a safe driving and/or backing activity. Training for truck operators should 

include, but not be limited to: 

 Window rolled down. 

 Radio off. 

 No cell phone or similar distraction while backing. 

 Foot on brake. 

 If you lose sight of the spotter or pedestrian in your mirror, STOP. 

 If any individual on foot is not acknowledged and eye contact is not made, the driver 

should not move the truck until visual contact is re-established.
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During backing operations, a spotter should be used to assist the driver when there are other 

workers in the area. Training for the "spotter" should include, but not be limited to: 

 Always wear a high visibility reflective vest. 

 Inspect the backing area and all other sides of the vehicle checking for hazards before

allowing the vehicle to move - be sure to also check overhead clearance. 

 Communicate any observed hazards to the driver. 

 Stand alone, do not allow anyone to congregate around you. 

 Spotter position: eight to ten feet away from and on the driver side of the vehicle. Stay 

out of the direct path of the moving/backing vehicle's movement. 

 Keep clear of both the vehicle and any fixed objects. Make sure pathway is clear f 

tripping hazards. Watch for pinch points behind you such as other vehicles, utility poles, 

trees, etc. 

 If you cannot see the driver’s face in the driver’s side rear view mirror, have him/her 

STOP until you do. 

 Give clear, understandable, and consistent hand signals. Coordinate with driver/operator 

of what signals are used 

 Walk along the side of the backing vehicle and do not walk backwards while directing

the vehicle. 

 Always have an escape route. 

 Never turn your back on the moving equipment. 

 Stop the driver if any hazards are observed or if you are uncertain of the direction that the 

driver is maneuvering.

 Always wear a high visibility vest/clothing when a pedestrian around moving vehicles, 

especially at night and/or in dimly lit areas.

The firm now mandates the use of high-visibility vests that comply with industry standards for 

their employees. For safety, the truck drivers should don and doff the vest in the corporate office. 

The vest should worn and kept closed in front and on sides be worn at all times to ensure 

visibility. 

 Management should develop a procedure to document firm-wide communication has 

received and employees have acknowledged the receipt of the communication. 

The firm routinely used email for communicating with drivers, but did not require a response 

from the drivers indicating that the email was opened and read. Ensure if utilizing email or other 

social media for firm-wide communication, management should ensure that it is required that 

employees acknowledge the email/text. In this incident, the email system used by the employer 

for communication could have been used to inform employees of all changes to procedure. 
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 Ensure designated individual required to communicate important information to 

coworkers has the time to communicate the information

If one individual is selected to communicate information to employees, the individual must be 

given time to do so. In this incident, the shagger had other responsibilities at the site and could 

not stay at the entrance of the facility to inform his coworkers of the plans made by the employer 

to accommodate the number of trucks staged at the facility. Because the shagger was also 

required to move trailers carrying milk into the facility and transport empty trailers from the 

facility, the shagger was unable to carry out the employer-designated communication 

responsibilities. Employees who arrived while the shagger was moving trailers within the site 

could not receive the necessary information; this led to two unusual situations for the decedent 

and his coworkers. The first situation was that more employees were present than would 

normally be present waiting for trucks, hooking/unhooking tractors from trailers in an effort to 

move the trucks and trailers more quickly. Secondly, the employees on site normally did not 

work together to unhook trailers from the tractor; no signals or communication methods between 

the workers on the ground and the driver had been established. 

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

The firm identified the need to develop a checklist for which agencies to call when there is a 

problem, regardless of whether or not it is an emergency. The firm owner stated he received 

contradictory information depending upon which agency he called... DOT, MIOSHA, Law 

Enforcement, Food and Drug Administration, etc. MIFACE recommends the firm develop a 

checklist of agencies, which require a call based on a broad type of issue. For example, issues 

could be a vehicle crash, worker injury, contaminated milk, etc. 

 When a change in a firm’s procedure affects suppliers, the firm should allow suppliers 

adequate time to institute and communicate changed procedures.

A factor in this incident was the sudden change of a long-standing practice. When possible, when 

a procedure or practice change that would affect suppliers is being considered, the firm should 

notify suppliers, if applicable, of its plans to change. In this incident, the decedent’s employer 

did not have sufficient planning time for this unexpected procedure change and coupled with 

other communication issues, the incident occurred. 

KEY WORDS: Struck by, run over, semi-tractor/trailer, working at night, high visibility vest, 

blind spot, transportation

REFERENCES

 OSHA Blind Spot Activity: https://www.osha.gov/dte/grant_materials/fy11/sh-22285-

11/Handouts.pdf
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RESOURCES

 MIFACE Investigation Report #04MI107: Engineering Technician Dies When Backed 

Over by Cement Mixer. https://oem.msu.edu/images/MiFACE/04MI107v1.pdf

 MIFACE Investigation Report #08MI040: Municipal Truck Driver Dies After Being 

Backed Over by Dump Truck https://oem.msu.edu/images/MiFACE/08MI040.pdf

MIFACE (Michigan Fatality Assessment and Control Evaluation), Michigan State University 

(MSU) Occupational & Environmental Medicine, 909 Fee Road, 117 West Fee Hall, East 

Lansing, Michigan 48824-1315; http://www.oem.msu.edu. This information is for educational 

purposes only. This MIFACE report becomes public property upon publication and may be 

printed verbatim with credit to MSU. Reprinting cannot be used to endorse or advertise a 

commercial product or company. All rights reserved. MSU is an affirmative-action, equal 

opportunity employer. 

April 25, 2018
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Appendix A

GOAL (Get Out and Look) 

States the following:

99% for all accidents caused by trucks backing up is preventable

If you are not 100% sure of your surroundings then take a minute to Get Out and Look

You will save yourself and the company a lot of time, hassle and money

Why? Because it is never safe to back a truck up

Backing a truck into a dock for unloading is a reality of driving

But it is not safe and 40 tons at 5MPH can do a lot of damage

Only you can prevent this accident

And you can only prevent it with the knowledge of your surroundings

It takes constant care and caution to have a great driving record

It takes seconds to ruin your record or your carrier

So take care and be 100% aware of your surroundings

And if you are not 100% certain of your surroundings

Then take an extra minute and Get Out and Look