INCIDENT HIGHLIGHTS

DATE:

July 29, 2019

TIME:

11:40 p.m.

WORKER:

45-year-old semi-truck 

driver

INDUSTRY/NAICS CODE:

Specialized Freight(Except 

Used Goods) Trucking, 

NAICS 484230

EMPLOYER:

Interstate trucking, bulk 

transportation

REPORT#: 52-52-2022 REPORT DATE: 4/12/2022

Driver Crushed by Rollaway Woodchip Truck

SUMMARY

Around midnight on July 29, 2019, a 45-year-old semi-truck driver was 

fatally crushed by his woodchip truck when it rolled away. The driver was

at a sawmill in Washington State picking up woodchips for delivery to a 

pulp mill in British Columbia. After loading the chips, he parked his truck on 

a paved road under a fall protection tarping station. The road had a 2% 

downgrade. The driver did not set the truck’s parking brake before exiting 

the cab to access the top of the trailer to prepare his load for tarping.

While the driver was walking on top of his load near the back of his trailer, 

his truck began to roll forward. He ran toward a ladder at the front of the 

trailer that went down to a walkway behind the tractor. While trying to 

descend the ladder, he went over the edge of his trailer and fell to the 

road. The only other driver at the mill left the site without seeing the 

incident. Almost two hours later, another truck driver entered the site and 

found the driver fatally crushed under his tractor’s left front drive wheels.

... READ THE FULL REPORT> (p.5)

SAFETY & TRAINING:

Employer had a written 

Accident Prevention 

Program (APP).

SCENE:

Sawmill, outdoortarping 

station

LOCATION:

Eastern Washington

EVENT TYPE:

Crush - Struck by

CONTRIBUTING FACTORS

Key contributing factorsidentified in thisinvestigation include:

• Uneven road grade at truck tarping station area.

• Parking brake rules in Accident Prevention Program (APP) not followed.

• Inadequate truck parking brake and wheel chocking policy in APP.

• Insufficient safety audits of drivers and customer worksites located 

abroad.

• ...LEARN MORE> (p.18)

RECOMMENDATIONS

Washington FACE investigators concluded that, to help preventsimilar 

occurrences, employers should:

• Install electronic parking brake systems that automatically apply the 

parking brake when the driver has not set it before exiting the cab.

• Develop APP to have a parking brake and wheel chocking policy with 

strict requirements for preventing rollaways and unsafe responses.

• Collaborate with owners of remote customer sites outside of their 

ordinary daily travel range to ensure the sites are safe for their drivers.

• Assist safety supervisors to obtain work visas or hire safety consultants 

abroad to do safety audits at customer sites in other countries.

• ....LEARN MORE> (p.18)
Page 2

DEFINITIONS

APP Accident Prevention Program

BC British Columbia

CDL Commercial Driver’s License

CSHO Compliance Safety and Health Officer

CTPAT Customs Trade Partnership Against Terrorism 

CVIP Commercial Vehicle Inspection Program 

DOSH Division of Occupational Safety and Health 

DRA Driver Risk Analysis

eDVIR Electronic Driver Vehicle Inspection Reports 

ESC Electronic Stability Control

GVWR Gross Vehicle Weight Rating 

JHA Job Hazard Analysis

L&I Washington State Department of Labor & Industries 

NIOSH National Institute for Occupational Safety and Health 

OSHA Occupational Safety and Health Administration

PPE Personal Protective Equipment

SHARP Safety & Health Assessment & Research for Prevention 

TSCBC Trucking Safety Council of British Columbia

USDOT United States Department of Transportation 

WA Washington State
REPORT#: 52-52-2022 Page 3

WASHINGTON STATE FACE PROGRAM INFORMATION

The Washington State Fatality Assessment and Control (WA FACE) program is one of many workplace health and safety 

programs administered by the Washington State Department of Labor & Industries’ Safety & Health Research for Prevention 

(SHARP) program. It is a research program designed to identify and study fatal occupational injuries. Under a cooperative 

agreement with the National Institute for Occupational Safety and Health (NIOSH grant# 5 U60OH008487), WA FACE collects 

information on occupational fatalities in WA State and targets specific types of fatalities for evaluation. WA FACE investigators 

evaluate information from multiple sources. Findings are summarized in narrative reports that include recommendations for 

preventing similar eventsin the future. These recommendations are distributed to employers, workers, and other organizations 

interested in promoting workplace safety. WA FACE does not determine fault or legal liability associated with a fatal incident. 

Names of employers, victims and/or witnesses are not included in written investigative reports or other databases to protect 

the confidentiality of those who voluntarily participate in the program.

Additional information regarding the WA FACE program can be obtained from: 

WA FACE program website

PO Box 44330 Olympia, WA 98504-4330

1-888-667-4277

Email | | Website
REPORT#: 52-52-2022 Page 4

CONTENTS

INTRODUCTION ................................................................................................................................................... 5

EMPLOYER........................................................................................................................................................... 5

WRITTEN SAFETY PROGRAMS and TRAINING..................................................................................................... 5

WORKER INFORMATION ..................................................................................................................................... 6

EQUIPMENT......................................................................................................................................................... 6

INCIDENT SCENE.................................................................................................................................................. 8

WEATHER ...........................................................................................................................................................11

INVESTIGATION ..................................................................................................................................................11

CAUSE OF DEATH................................................................................................................................................18

CONTRIBUTING FACTORS...................................................................................................................................18

RECOMMENDATIONS/DISCUSSION....................................................................................................................18

ADDITIONAL RESOURCES ...................................................................................................................................21

DISCLAIMER........................................................................................................................................................21

REFERENCES .......................................................................................................................................................21

INVESTIGATOR INFORMATION...........................................................................................................................22 

ACKNOWLEDGMENTS ........................................................................................................................................22
REPORT#: 52-52-2022 Page 5

INTRODUCTION

In July of 2019, the Washington State Department of Labor & Industries’ (L&I) Division of Occupational Safety and Health 

(DOSH) notified the Washington State Fatality Assessment and Control Evaluation (WA FACE) Program of the fatality of a 

semi-truck driver who was crushed by his chip truck when it rolled away.

Washington State FACE investigators reviewed the DOSH compliance safety and health officer’s (CSHO) enforcement 

case file in lieu of interviewing the employer due to their decision not to participate. Documents reviewed during the 

course of this investigation included the DOSH inspection summary report, the worker’s death certificate, co-worker 

interviews, incident scene photos, surveillance camera footage, diagrams, and police report.

EMPLOYER

The employer was a long-haul interstate trucking company that specialized in truckload transportation of bulk wood 

residuals, such as wood chips, sawdust, and shavings, from sawmills to pulp mills. With 31 semi-trucks and 49 truck 

drivers, the almost 60-year-old company was one of the largest cross-border wood residuals haulers serving the Pacific 

Northwest of Canada and the United States. The employer had drivers working in two shifts that began at various times 

during the day and lasted 10 to 13 hours, Monday through Friday. Drivers could also work on Saturdays, if they were in 

compliance with hours of service regulations. The drivers were paid hourly wages. In 2019, the employer’s truck drivers 

traveled a total of 996,894 miles. The employer was a previous recipient of WorkSafeBC and the Trucking Safety Council 

of British Columbia’s (TSCBC) Certificate of Recognition.

The employer was one of five subsidiaries in a conglomerate headed by a privately held, family-owned parent 

corporation based in British Columbia (BC), Canada. The conglomerate provided bulk transportation services in the 

forestry, pulp and paper, petroleum, chemical, mining, and construction industries. The subsidiaries contracted 

additional trucking companies and provided dispatching for a combined fleet of around 350 trucks operated by over 500 

drivers. Trucking operations took place around-the-clock from freight hubs across the Pacific Northwest.

WRITTEN SAFETY PROGRAMS and TRAINING

At the time of the incident, the employer had a formal, written accident prevention program (APP), or safety program, 

designed to comply with national and local workplace and commercial vehicle safety laws in BC and Washington State 

(WA) [SOR 1986; WAC 2001; WSP 2022]. The program was formatted as a worker handbook by the conglomerate’s 

parent company for use by the employer and two other trucking companies in the group. The 80-page handbook 

consisted of four chapters that covered general health and safety policies, job-specific safe work practices, operation 

and maintenance procedures, and safety awareness guidelines for management and workers. Chapter subsections 

specified requirements for safety committee and tool box meetings, personal protective equipment (PPE), new worker 

orientation, safety training, job performance evaluations, disciplinary procedures, and other areas. The APP had a 

vehicle parking and backing out policy that required truck drivers to set their parking brake securely each time they 

exited the cab. The company paid bonuses to drivers as an incentive to encourage safe driving. The program included an 

enforcement policy consisting of progressive coaching and discipline for drivers who demonstrated unsafe driving. Truck 

drivers were instructed to report incidents and injuries to dispatchers who were on duty 24-hours a day.

The employer’s APP required truck drivers to perform daily vehicle pre-trip and post-trip inspections according to 

Schedule 1 of Canada’s National Safety Code Standard 13 and Part 4 of BC’s Motor Vehicle Act [NSC 2009; B.C. Reg.

2021a]. The employer also participated in the U.S. Customs and Border Control’s voluntary Customs - Trade Partnership 

Against Terrorism (CTPAT) program, which required trucks bound for the United States to pass a 17-point safety and 

security inspection [CTPAT 2013]. The inspections checked the condition of major structural, mechanical, and electrical
REPORT#: 52-52-2022 Page 6

vehicle systems, including tractor and trailer air brake systems. Drivers submitted electronic Driver Vehicle Inspection 

Reports (eDVIR) to management after finishing their inspections.

The employer compiled weekly Driver Risk Analysis (DRA) reports to identify, coach, and retrain unsafe drivers. The DRA 

reports collected driving behavior data from electronic stability control (ESC) systems on trucks that recorded unsafe 

driving events, such as excessive speed and hard braking. The employer reviewed driving abstracts anually to identify 

drivers with traffic violations. Safety supervisors conducted in-cab ride alongs and driver performance audits at 

customer sites to observe and evaluate drivers periodically during their employment. The employer provided copies of 

its safety rules to customer sites each year. Whenever possible, bi-monthly safety audits took place at worksites to help 

ensure truck drivers were following APP requirements.

WORKER INFORMATION

The worker who died in the incident was a 45-year-old semi-truck driver. He was an Asian foreign-born worker who lived 

in BC with his wife and child. The employer hired the driver in April 2019, two weeks after he finished a Canadian Class 1 

Commercial Driver’s License (CDL) training program at a professional truck driving school in BC. The program consisted

of 96 hours of classroom instruction, 44 hours of drive time, and 35 hours of observation. The driver’s CDL training 

instructed him in the use of parking brakes, and his CDL had an air brake endorsement.

The employer required the novice driver to complete a four-week new driver mentoring and training program before 

allowing him to drive alone. The one-on-one, on-the-road training was led by two credentialed trainers who rotated 

instructional duties during the training period. The training covered tractor and trailer operation, fall protection, and 

loading and unloading procedures at mills. It also included several mill site orientations in BC and WA. The driver was 

trained to operate a Western Star semi-tractor with a TYCROP high-cube, quad axle, Super B-train chip trailer.

The truck driver worked Monday through Friday. His daily shifts began at 4:30 p.m. and ended 10 to 13 hours later. He 

operated a semi-trailer truck to load and deliver woodchips from a sawmill in northeastern WA to a pulp mill in 

southcentral BC. The employer did not own the mills but was contracted by a Canadian private limited company to haul 

the chips. In addition to maintaining commercial driving requirements, the driver’s duties included loading, leveling, 

tarping, and unloading freight with the truck he drove during the employer’s new driver training. He typically made two 

daily five-hour round-trip deliveries that involved traveling nearly 336 miles over secondary highways between the mills. 

He met the required medical qualifications to safely perform his job.

EQUIPMENT

The chip truck in the rollaway incident was a BC-registered 2016 Western Star semi-tractor with a 2004 TYCROP highcube, quad-axle, possum belly Super B-train chip trailer (Photo 1). The Gross Vehicle Weight Rating (GVWR) of the 

tractor and trailer was 105,500 lbs. At the time of the incident, the loaded truck had a total weight of 66,225 lbs. spread 

over four axles on the tractor and four on the trailer. The vehicle was 70 feet long from the tractor’s front axle to the 

trailer’s rear axle. The tractor was an airbag equipped day cab model with an automatic transmission. Its odometer 

reading was 388,739 kilometers (241,551 miles) when the rollaway occurred. The trailer had an open top aluminum 

body, side roll tarp, top hinge tailgate with ladder at the rear, and a fall protection work platform with ladder mounted
REPORT#: 52-52-2022 Page 7

at the front. Driving hazards included the risk of collisions and rollovers, while performing job tasks on and around the 

truck entailed the risk of struck by incidents, crushing, strains and sprains, and slips, trips, and falls.

Photo 1: The fatally injured driver operated this 2016 Western Star semi-tractor with a 2004 TYCROP highcube, quad-axle, possum belly Super B-train chip trailer.

The chip truck had a dual air brake system consisting of primary and secondary circuits for the drive and steer axles, 

respectively. The system used an engine-mounted compressor that pumped pressurized air into a series of hoses, valves, 

storage tanks, and couplings to brake chambers at each wheel. The driver contolled the tractor and trailer service brakes 

with a foot pedal located next to the accelerator on the driver’s side floor of the tractor cab. The service brakes were 

applied and released with a foot pedal located next to the accelerator on the driver’s side floor of the tractor cab. The 

tractor parking brake was released and applied by manually pushing and pulling a yellow air brake valve control knob on 

the driver’s instrument panel in the cab (Photo 2). Pulling the yellow knob would set the tractor parking brake and the 

trailer emergency brake at the same time. Pulling the red trailer air supply knob would only set the trailer emergency 

brake, which was not intended as a parking brake but to protect the tractor's air supply if the trailer broke away and air 

pressure dropped. Safe air pressure range in the system was from 100 to 120 psi and was indicated by a gauge on the 

driver’s instrument panel. The air compressor would automatically recharge the system when the pressure dropped 

about 20 psi below safe operating range. Low air pressure between 20 and 45 psi would make the control knobs pop out 

and activate the parking brake. A warning light and buzzer on the instrument panel would activate when air pressure 

dropped below 60 psi. The driver’s pre-trip inspection included a test that checked the air brake system’s mechanical 

performance and warning features. The instrument panel had transmission shift and parking brake indicators. Also, an

in-cab alert system emitted an audible alarm signal when a driver left theirseat without setting the parking brake.
REPORT#: 52-52-2022 Page 8

Photo 2: Industry standard push-pull air brake valve control knobs that are installed on semi-truck cab 

dashboards.

In addition to driver training, vehicle safety was achieved with safety technology and software, preventive maintenance 

checks and services, and commercial motor vehicle inspection requirements. Trucks in the employer’s fleet had 

mandatory electronic stability control (ESC) systems to help prevent skidding and rollovers due to sudden braking, 

slippery roads, and loss of steering control. The computer-controlled system used sensors to monitor wheel-speed, 

lateral acceleration, and steering angle to determine the correct braking forces for individual wheels. The system’s 

monitoring capabilities provided vehicle performance data that management used to create weekly DRA reports to 

identify unsafe drivers. Any equipment deficiencies had to be reported to the employer’s maintenance staff for repairs. 

Unsafe trucks would not be dispatched until repairs were completed. The employer required lease operators’ trucks in 

its fleet to maintain the same safety standards as its own trucks.

INCIDENT SCENE

The incident scene was an outdoor fall protection tarping station at a sawmill in rural northeastern WA. The employer 

did not own the mill but was contracted to deliver woodchips from it to a pulp mill in BC. The sawmill owner was in 

charge of the area. The tarping station was a steel fixed scaffold structure at the north end of a pair of approximately 47- 

foot-high steel bulk storage bins where trucks loaded the chips (Photo 3). The bins and tarping station had an 

approximately 15-foot clearance height that allowed trucks to drive and park under them. The loading procedure began 

when a single tractor and trailer unit arriving from BC would drive slowly on the paved road under the bins from their 

south entrance and position the trailer below them (Photo 4). The bins had overhead, hydraulically operated, clam-shell 

type bottom gates that opened to release dried chips into the trailer. Hardhat and eye protection requirement signs 

were posted on the bins. After setting the parking brake, the driver would exit the cab, walk to an approximately 15-foot 

ladder, and climb it to a platform on the left side of the bin where hydraulic levers were located that controlled the 

bottom gates. Pit-style scales in the road under the bins weighed the truck as it loaded. The truck’s engine was left
REPORT#: 52-52-2022 Page 9

running the whole time. The driver would then return to his truck and move it slightly back and forth to use the inertia 

of the woodchips to slide, spread, and level them in the trailer. The procedure would then be repated once again to 

finish loading. When the trailer load reached capacity, the driver would fill out a bill of lading and leave copies for the 

mill in a box next to the bins. The entire loading process would take from eight to fifteen minutes.

Photos 3 and 4: The left photo shows the fall protection tarping station extending north from the bulk woodchip 

storage bins. Arrow shows the path of chip truck travel on paved road under the bin entrance and loading area 

to the tarping station exit in foreground. Right photo shows entrance to bin loading area. Red arrow shows the 

bin’s clamshell gates that released woodchips into trailers. Blue arrow shows PPE requirement signage.

After loading was completed , the truck would pull forward and park under the ad joining tarping station, which 

extended approximately 50 feet from the bin loading area exit (Photo 5). The road under the tarping station had a 2% 

downgrade toward the station’s exit. Drivers were required to set their parking brake, shut off the engine, and put the 

ignition key in their pocket when exiting the cab to tarp the trailer. An approximately 16-foot caged ladder mounted to 

the station allowed truck drivers to access a platform equipped with fall protection guardrails above the right rear of the 

trailer (Photo 6). A second platform at the north end of the station could be accessed from the ladder and platform on 

the front of the trailer (Photo 7). Guardrails extended from the platforms around the entire tarping station. The 

guardrails allowed the driver to walk from the platforms onto their load to level and tarp it with a reduced risk of falling 

off the trailer. When tarping was finished, the driver climbed down from the tarping station, returned to the truck cab, 

started the engine, dropped the trailer’s rear tag axle, released the parking brake, and drove out to their delivery 

destination. Leveling and tarping would typically take five to ten minutes to complete.
REPORT#: 52

-52-2022 Page 10

Photos 5 and 6: Top left photo shows 

tarping station extending north from 

binstoward exit. Red arrow showsrear 

of incident truck’s trailer. Blue arrow 

shows bin hydraulic control platform 

with ladder. Top right photo shows 

caged ladder and first tarping platform 

that drivers used to access top rear of 

trailer.

Photo 7: Arrow in bottom left photo 

shows second tarping platform and 

entrance that drivers accessed by 

climbing their front trailer ladders. 

Yellow guardrails around tarping 

station provided fall protection for 

truck drivers tarping on top of trailers.
REPORT#: 52-52-2022 Page 11

Chip truck loading operations continued around the clock. Spotlights illuminated the area during hours of darkness. The 

employer’s PPE requirements in the area consisted of work boots, hardhats, safety glasses, and high-visibility vests. The 

entire loading area was fenced and had a speed limit of 10 mph, which was posted at the entry gate. Vehicles inside the 

fenced area were subject to inspection at any time.

WEATHER

The incident happened around 11:40 p.m. The weather was clear with no wind and temperature of 58 degrees [Weather

Spark 2019]. The sun set at 8:34 p.m. The weather was not a factor in this incident.

INVESTIGATION

On Monday, July 29, 2019, the chip truck driver started his usual night shift at 4:30 p.m. He was performing his regular 

job of loading and hauling woodchips from a sawmill in northeastern WA to a pulp mill in southcentral BC. His employer 

did not own the mills but was contracted by a Canadian private limited company to haul the chips. The driver was 

operating a 2016 Western Star semi-tractor with a 2004 TYCROP high-cube, quad-axle, possum belly Super B-train 

woodchip trailer (Photo 1). He arrived at the sawmill in WA at 11:18 p.m., completing the first half of his second and 

final 160-mile, five-hour trip between the mills. He had been to the sawmill at least 30 times before without incident.

The truck entered the woodchip loading area after entering the sawmill southward through a fenced security gate near 

the property’s northern boundary (Photo 8). Both sides of the gate had red plastic reflectors and private property, no 

smoking, and 10 mph speed limit signs posted. The paved road into the area was bordered by freight railroad tracks on 

the left and a small stand of pine trees on the right. Woodchip debris were scattered on the road surface. The fall 

protection tarping station and elevated bulk storage bins were situated about 110 feet from the entrance on the left 

side of the road. The road and loading areas were lit by truck headlights and spotlights mounted on various structures. 

The truck’s tractor and trailer lights were on at all times. A security camera located south of the area monitored and 

recorded truck traffic.

Photo 8: View looking south at road through sawmill entrance’s security gate. Incident truck is parked on left with the 

fall protection tarping station and bulk woodchip storage bins behind it
REPORT#: 52-52-2022 Page 12

The truck passed the tarping station and bulk storage bins on its left and made a wide left U-turn to align itself with the 

south end entrance to the bins (Photo 4). The truck stopped for 20 seconds until the only other truck in the area, which 

was parked at the end of the tarping station road ahead, exited the property. The driver was now alone in the area. He 

drove his truck slowly under the bins and parked it when the back half of its trailer was below the second bin at the far 

end. It is not known if he had set his parking brake under the bins. He then exited the cab, walked to the bin control 

platform ladder, and climbed up to use the hydraulic levers for the bottom gates that released woodchips into his trailer 

(Photo 9). After the back of his trailer was loaded, the driver returned to his truck and reversed it to level the load and 

position the front half of the trailer under the first bin behind him. The driver parked the truck and went back to the bin 

controls to finish loading the trailer.

Photo 9: Bin control platform with ladder that 

truck drivers used to access hydraulic leversfor 

bottom gates that released woodchips into the 

trailer. Arrows point to the gates.

As he was loading, another chip truck from the same employer pulled into the site at 11:27 p.m. and parked 

approximately 20 feet behind his trailer. The second driver exited his cab to check the bins and wait for the first driver to 

finish loading. As he waited, he saw the first driver on the bin control platform and asked him for a flashlight to get a 

better look at the bins. The first driver returned again to his truck and maneuvered it under the bins for the last time. He 

also brought a flashlight to the second driver, and both drivers determined the bin had sufficient woodchips to load the 

second driver. The first driver then climbed back to the control platform to finish loading his trailer. The second driver 

walked to his truck to open his tarp in preparation for loading. When the first driver finished loading his trailer, he
REPORT#: 52-52-2022 Page 13

returned to his truck, drove it forward until the trailer was under the adjoining fall protection tarping station, and parked 

on the station’s paved road, which had a 2% downgrade toward the exit. The second truck then pulled forward and 

parked the front of its trailer under the first bin. This left approximately 30 feet of space between the front of the

second truck and back of the first truck now parked at the tarping station (Photo 10).

Photo 10: Red arrow shows where the back of the fatally injured driver’s trailer 

waslaligned under the back of the tarping station above. Green arrowsshow the 

ladder and platform that allowed the driver to access the rear top of his trailer. 

Yellow arrow shows where the front of the second truck’s tractor was located 

under the bins when the incident occurred. Approximately 30 feet of space 

separated the trucks. The paved road under the tarping station had a 2% 

downgrade toward the exit in the foreground.
REPORT#: 52-52-2022 Page 14

As the second driver began loading his trailer, the first driver exited his cab to drop off a sawmill copy of his bill of lading 

in a box near the bins. Around the same time, he submitted load information to his dispatcher using an onboard fleet 

tracking system. The driver then walked to the tarping station, climbed the ladder to the guardrailed platform, and 

stepped onto his load at the top rear of his trailer to level it for tarping. The second driver returned to his cab, reversed 

his truck under the bins, and made several brake applications to slide and level the load in his trailer. As he drove 

forward again, the first truck started to roll ahead at approximately 1.2 mph under the tarping station with the driver 

still on the trailer. Security camera footage showed that as the truck rolled away, the driver ran on his load from the 

back of the trailer toward the front trailer ladder before going over the edge and out of view (Photo 11). The truck rolled 

approximately 30 feet down the road. When it stopped, the rear of the trailer was almost aligned with the tarping 

station exit (Photo 12 and Diagram). During interviews by investigators, the second driver said he saw the first truck 

move at the tarping station but was not paying attention to see if the driver was on the load. He did not percieve the 

movement as a roll away, but assumed the first driver had finished tarping and pulled forward to take a rest break or fill

out paperwork. Thinking he saw nothing unusual, the second driver parked his truck under the bins again and resumed 

loading his trailer. When he finished loading, he saw the first truck still stopped at the tarping station exit. Unable to pull 

his trailer fully under the tarping station, he backed out from the bins and drove forward on their west side until he was 

parallel with the first truck. He parked next to the truck for seven minutes but never left his cab or saw the fatally

injured driver before departing the mill at 11:51 p.m.

Photos 11 and 12: Red arrows in left photo show front trailer fall protection platform and ladder that driver ran 

toward while on top of the load at the back of the trailer when rollaway ocurred. Yellow arrow shows the trailer’s 

air and electrical supply lines suspended between the tractor to the trailer. Right photo shows truck’s approximate 

stop location after it rolled away down the paved road’s 2% grade.
REPORT#: 52-52-2022 Page 15

Diagram of incident scene. A) sawmill entrance gate, B) 

paved road, C) chip bin loading area where second truck 

parked, D) tarping station where first truck rolled away, E) 

location where rollaway truck crushed driver and stopped. 

Arrows show travel path of chip truck from sawmill 

entrance gate to chip bin and tarping station areas. Image 

courtesy of Google Maps.
REPORT#: 52-52-2022 Page 16

A third truck from the same employer arrived at the sawmill at 1:51 a.m., nearly two hours after the rollaway occurred. 

As the truck entered the area, the driver saw the rollaway truck still parked with its lights on at the tarping station exit. 

The truck’s engine was not running because an idle shutdown system stopped it after idling in neutral for several 

minutes. The third driver’s attention seized on the rollaway truck’s partially levelled load and what appeared to be a 

chock block laying nearby. He reversed his truck and from his cab window saw the first driver on the ground partially 

crushed under the tractor’s left front drive wheels. The third driver parked his truck, exited the cab, and saw that the

first driver was deceased. He called his dispatcher and 911 to report the incident. After police arrived, an area manager 

and safety supervisor for the employer came to the scene and found the rollaway truck’s parking brake released. A body 

recovery team asked the area manager to back the truck off the driver’s body. He reversed the truck four feet to free the 

body.

Investigators concluded the truck rolled away because when the driver exited his cab to use the fall protection tarping 

station, he left the truck’s engine running with the transmission in neutral and parking brake released while parked on 

the road with the 2% downgrade (Photos 13-15). As is typical for semi-tractors, the truck’s automatic transmission did 

not have a park position, which made it absolutely necessary to set the brake. The employer conducted a post-incident 

inspection that found no faults with the truck’s air brake system. The driver’s pre-trip vehicle inspection report from the

day of the incident also indicated the truck was in safe operating order. Maintenance records showed that three months 

earlier, the incident truck passed a mandatory semi-annual safety inspection per requirements of BC’s Commercial 

Vehicle Inspection Program (CVIP) [B.C. Reg. 2021b]. Around the same time, the brake pads and drums on the tractor’s 

rear drive axle were replaced by a commercial truck maintenance shop in BC. An air brake system regulator was also 

replaced about two weeks before the incident.

An area manager, safety supervisor, and driver trainer for the employer stated during interviews by the CSHO that they 

instructed drivers to follow the employer’s APP requirement to set their parking brake each time they left the cab, and 

that drivers were required to shut the truck off and put the ignition key in their pocket if they were going to enter the 

trailer. They also stated having knowledge of the tarping station road’s downgrade but had no way of checking if drivers 

were regularly using their parking brakes at the location. A driver told the CSHO that he also knew about the downgrade, 

and that it would immediately cause a truck to roll if the parking brake was not set. Another driver said he believed most 

drivers disarmed their in-cab alert systems that activated audible alarm signals when a driver left their seat without 

setting the parking brake. No one knew why the deceased driver failed to set his truck’s parking brake, if he was aware

of the downgrade, and if his truck had a disarmed parking brake alert system. A safety supervisor also told the CSHO that 

fewer worksite safety audits took place in the Unites States because not all safety supervisors had work visas to legally 

travel for work across the border from Canada. Employer records showed that only four audits were made at the 

incident sawmill in the three month periods before and after the incident date. Out of nine instances where the 

employer disciplined unsafe drivers in the year leading up to the incident, only one occurred in WA. The fatally injured 

driver was never audited or evaluated when he worked at the mill.
REPORT#: 52-52-2022 Page 17

Photo 13: Red arrow in top left photo shows 

approximately where the driver’s body was found 

crushed under the chip truck’sleft front drive wheels. 

Yellow arrows show base of front trailer ladder and 

walkway between cab and trailer that the driver 

attempted to access as his truck rolled.

Photos 14 and 15: Bottom left photo shows chip truck’s 

transmission shifter set to “N” neutral after the crushed 

driver was found. The transmission did not have a “P” 

park position. Bottom right photo shows dashboard 

instrument panel indicator showing that the truck’s 

transmission shifter wasin “N” neutral and parking brake 

disengaged when the incident occurred.
REPORT#: 52-52-2022 Page 18

CAUSE OF DEATH

According to the coroner’s report, the chip truck driver died of crush injuries of the head, neck, and torso.

CONTRIBUTING FACTORS

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger 

sequence of events that ultimately result in the injury or fatality. Washington FACE investigators identified the following 

unrecognized hazards as key contributing factors in this incident:

• Uneven road grade at truck tarping station area.

• Parking brake rules in Accident Prevention Program (APP) not followed.

• Inadequate truck parking brake and wheel chocking policy in APP.

• Insufficient safety audits of drivers and customer worksites located abroad.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should install electronic parking brake systemsthat automatically apply the parking 

brake when the driver has not set it before exiting the cab.

Discussion: An employer’s best efforts to establish safe parking brake practices through APP policies and safety training 

may not guarantee a truck driver will always set their parking brake as required. When this happens it can end in severe 

or fatal injuries and costly property damage. One of the surest ways to prevent this from happening is to install 

commercially available electronic parking brake systems. These safety technology systems automatically apply the 

truck’s parking brake when the driver has not set it or has mistakenly released it before exiting the cab. Current system 

designs replace the truck’s parking and trailer brake control valve knobs with ergonomic electronic switches that are 

wired to servos inside the dashboard that set or release the brakes. Electronic interlocks automatically set the parking 

brake when sensors detect a driver has left their seat or opened the door before applying the brake. The switches 

feature built-in LED indicator lights that show the status of the brake in applied or released positions. The technology 

can be integrated with existing fleet telematics systems to notify managers when a rollaway occurred or almost 

happened so they can respond appropriately. Drivers should be trained to understand that the automatic parking brake 

technology is a driver assistance system that does not replace the need to maintain safe driving and parking practices. 

Drivers should also be trained not to modify or disable any such systems.

Recommendation #2: Employers should develop APP to have a parking brake and wheel chocking policy with strict 

requirements for preventing rollaways and unsafe rollaway responses.

Discussion: Every trucking company should have an APP or safety program with a clearly written parking brake and 

wheel chocking policy that has strict rollaway prevention requirements. The policy can be included in an APP chapter 

that covers hazard prevention and control. It should be based on Job Hazard Anlaysis (JHA) results and information from 

vehicle manufacturer’s instructions and commercial motor vehicle safety research and regulations. At a minimum, a 

parking brake policy should require all vehicle operators to set the parking brake any time they park. This is safer than 

only requiring the driver to set the brake when they leave the cab because they may park their truck and stay in the cab 

to fill out paperwork, make a phone call, take a rest break, or use the sleeper berth. It is more likely in such situations for 

distraction and loss of situational awareness to occur that can lead a driver to forget to set their parking brake if they 

subsequently decide to leave their cab, especially if they are fatigued or rushing. If this happens while a truck is parked 

on a grade, as with the chip truck involved in the incident, then the risk of a rollaway greatly increases.
REPORT#: 52-52-2022 Page 19

The parking brake and wheel chocking policy should also require drivers who leave their truck unattended to put their 

foot on the service brake, place the transmission in neutral, set the parking brake, stop the engine, lock the ignition, and 

remove the key and place it in their pocket. If parked on any grade, drivers must turn the truck’s front wheels to the

curb or side of the road and chock at least one tractor drive wheel on each side. This is also a safer practice because an 

unattended truck parked on a very slight grade with its parking brake disengaged can easily roll away if it is bumped by 

another vehicle or mobile equipment. As a form of hazardous energy control similar to Lockout/Tagout (LOTO), such 

procedures are required by state safety rules for workplaces and public roads to control the sudden hazardous release

of a vehicle’s mechanical energy caused by unexpected vehicle movement [B.C. Reg. 2021c; RCW 1980; WAC 2005; WAC

2017]. Drivers should also be required to check their dashboard parking brake indicator, if equipped with one, before 

exiting their cab. The policy should plainly state the employer will periodically check the operation of the parking brake 

alert system or other warning indicators installed on trucks and discipline drivers who disarm or ignore them. Drivers 

should be trained and evaluated in their knowledge and performance of the parking brake and wheel chocking 

procedure requirements.

The parking brake and wheel chocking policy should also provide guidance on how to respond if a rollaway occurs. A 

driver who sees or feels their truck begin to roll while they are outside of their cab may respond in various instinctive 

ways to try to stop it. However, such responses may be more likely to end in serious injury or death than in safely 

stopping the truck. Attempting to jump off or onto a truck as it is rolling can end in serious injury or death caused by 

falling hard on the ground or being struck or crushed by the moving vehicle. If a driver is on top of a rollaway tractor or 

trailer, and the truck’s movement does not present a risk of major injury or death to themselves or bystanders, then

they should not attempt to climb down or jump off as doing so may increase the risk of serious injury or death and not 

allow them to stop the truck anyway. If the driver is outside of or away from the rolling truck, then they should not try to 

jump into the cab as it would be a serious injury or death risk and unlikely for them to establish three points of contact

to enter it safely.

Recommendation #3: Employers should collaborate with owners of remote customer sites outside of their ordinary 

daily travel range to ensure the sites are safe for their drivers.

Discussion: As lone mobile workers, truck drivers at remote customer sites should have a level of hazard protection that 

equals the standard maintained at their employer’s own facilities. While drivers have the right to refuse working at 

hazardous job sites on reasonable grounds, a better approach to ensuring safety is active collaboration between the 

driver’s employer and the customer site owner. The goal of collaboration or working together is achieving the most 

effective methods of hazard prevention that will keep truck drivers safe and business relationships and operations 

stable. Collaboration involves partnering with customers in developing site hazard identification, assessment, and 

control methods. Such methods can include designing jobsite hazard analysis forms and checklists for customers to 

identify unsafe conditions in loading and tarping areas, such as uneven roads, lack of signage, dim lighting, dangerous 

walking surfaces, erratic traffic patterns, loud noise, and chemical exposure risks. The customer can also be asked to 

assess job tasks drivers will be completing and equipment they may be using, such as loading from bulk storage bins, 

climbing ladders to work platforms, and working on fall protection tarping stations.

Employers can request written hazard descriptions, measurements, diagrams, maps, photos, and video to help them 

assist the customer in assessing the risks that identified hazards present to drivers. This is especially vital at outdoor

work areas where continuous exposure to truck traffic and erosive natural forces emphasize the need for frequent site 

safety audits to identify and address changes in physical workplace conditions that may be diminishing the effectiveness 

of previously implemented hazard controls at the site. The employer should ask to review the customer’s hazard findings 

and participate in designing corrective action plans and solutions to eliminate or control hazards, such as repaving
REPORT#: 52-52-2022 Page 20

deteriorated or uneven roads and parking areas and installing signs that remind drivers to set their parking brakes and 

report hazards. The employer and customer can periodically reevaluate their collaborative methods to identify ways to 

improve them. Employers can describe their approach to collaboration in an APP chapter dedicated to customer site 

safety, which can also be developed with customer input.

Recommendation #4: Employers should assist their safety supervisors to obtain work visas or hire safety consultants 

abroad to do safety audits at customer sites in other countries.

Discussion: If feasible, trucking companies that are international carriers should assist their safety supervisors who 

perform driver evaluations and worksite safety audits to obtain work visas that will permit them to travel to customer 

sites in other countries. The ability to travel abroad can also allow employers to perform worksite Job Hazard Analyses 

(JHA) with shippers and customers to jointly ensure safe work conditions for truck drivers working at pick up or delivery 

sites outside of the employer’s home country. Employers can contact the destination country’s nearest embassy or 

consulate to inquire about specific international business travel requirements [Embassy Finder 2022].

If unable to travel abroad, employers can also consider hiring the services of occupational safety and health consultants 

based in other countries where their drivers routinely work. Consultants provide many services to help manage APPs 

and can assist employers in determining how to keep their drivers safe where they are working abroad. Before hiring a 

consultant, it is important to verify their credentials, experience, and qualifications by interviewing them and checking 

their professional references. Employers should keep records of the consultant’s work to satisfy any legal obligations 

they may have to show that the consultant is qualified or competent to act on their behalf. Consultants can be found by 

contacting industry associations, health and safety associations, credentialing organizations, and searching the internet 

[CCOHS 2021].
REPORT#: 52-52-2022 Page 21

ADDITIONAL RESOURCES

CA/FACE [1994]. Delivery Truck Driver Dies after being Crushed by a Truck while Making a Delivery to a Local Market.

Sacramento, CA: California State Fatality Assessment and Control Evaluation Program.

KY FACE [2021]. Truck Driver Killed After Vehicle Rollaway. Lexington, KY: Kentucky Fatality Assessment and Control 

Evaluation Program.

OSHA [2002]. Job Hazard Analysis. Washington D.C.: Occupational Safety and Health Administration.

OSHA [2016]. Recommended Practices for Safety and Health Programs. Washington D.C.: Occupational Safety and 

Health Administration.

TIRES [2019]. It Really Happened: Rollaways Crush Lives. Olympia, WA: Trucking Injury Prevention through Surveillance 

Emphasis Project.

WA FACE [2013]. Fatality Investigation: Truck Driver Dies after being Run Over by Propane Transport Rolling Backward at

Bulk Plant. Olympia, WA: Washington State Fatality Assessment and Control Evaluation Program.

WA FACE [2019]. Trucking Fatality Narrative: Truck Driver Crushed Between Two Trailers. Olympia, WA: Washington 

State Fatality Assessment and Control Evaluation Program.

WA FACE [2022]. Trucking Fatality Narrative: Mechanic Crushed When Rollaway Semi-Truck Hits Trailer. Olympia, WA: 

Washington State Fatality Assessment and Control Evaluation Program.

DISCLAIMER

Mention of any company or product does not constitute endorsement by Washington FACE and the National Institute 

for Occupational Safety and Health (NIOSH). In addition, citations to websites external to Washington FACE and NIOSH 

do not constitute Washington FACE and NIOSH endorsement of the sponsoring organizations or their programs or 

products. Furthermore, Washington FACE and NIOSH are not responsible for the content of these websites. All web 

addresses referenced in this document were accessible as of the publication date.

REFERENCES

B.C. Reg. [2021a]. B.C. Reg. 26/58 Motor Vehicle Act Regulations. Victoria, BC: Queen’s Printer.

B.C. Reg. [2021b]. B.C. Reg. 26/58 Division 25 - Vehicle Inspection and Maintenance, Part 1 - Inspection. Victoria, BC: 

Queen’s Printer.

B.C. Reg. [2021c]. B.C. Reg. 26/58 Division 6 - Brake Regulations Respecting Buses, Trucks, Truck Tractors and

Commercial Trailers. Victoria, BC: Queen’s Printer.

CCOHS [2021]. Selecting and Hiring an OH&S Consultant. Hamilton, Ontario: Canadian Centre for Occupational Health & 

Safety.

CTPAT [2013]. CTPAT 17- Point Truck and Trailer Inspection. Washington D.C.: United States Customs and Border 

Protection.

Embassy Finder [2022]. World embassy page: Embassies around the world. Embassy-Finder.com.

NSC [2009]. NSC Standard 13: Trip Inspections. Ottawa, ON: Transport Canada, Government of Canada.
REPORT#: 52-52-2022 Page 22

RCW [1980]. RCW 46.61.600: Unattended motor vehicle. Olympia, WA: Washington State Legislature.

SOR [1986]. SOR/86-304 Part XIX: Hazard Prevention Program. Canada Occupational Health and Safety Regulations. 

Government of Canada.

WAC [2001]. WAC 296-800-140: Accident prevention program. Olympia, WA: Washington State Legislature. 

WAC [2005]. WAC 296-865-30015: Semitruck brakes. Olympia, WA: Washington State Legislature.

WAC [2017]. WAC 296-803-20005: Establish a written energy control program. Olympia, WA: Washington State 

Legislature.

WSP [2022]. Commercial Vehicle Laws & Regulations. Olympia, WA: Washington State Patrol.

Weather Spark [2019]. July 29, 2019 Weather History in Kettle Falls Washington, United States. Excelsior, MN: Cedar 

Lake Ventures, Inc.

INVESTIGATOR INFORMATION

Todd Schoonover has a PhD in Industrial Hygiene from the University of Illinois at Chicago. He is a Certified Industrial 

Hygienist (CIH) and Certified Safety Professional (CSP). Todd is currently the Principle Investigator for the WA FACE 

Program.

Paul Karolczyk has a PhD from Louisiana State University. He is a Safety and Health Specialist with the WA FACE Program. 

Randy Clark has a BA from the Evergreen State College. He is a Safety and Health Specialist with the WA FACE Program.

ACKNOWLEDGMENTS

This report was reviewed by stakeholders from labor and business communities and various Washington State and 

Federal worker safety agencies. Though we are unable to acknowledge specific individuals for their contributions to this 

report, we would like to recognize the following for their help and support of the FACE mission and objectives:

• Washington State Division of Occupational Safety and Health (DOSH)

• Federal FACE Program management (NIOSH)

• Occupational Safety and Health Administration (OSHA)

• Safety & Health Assessment & Research for Prevention (SHARP)