www.cdc.gov/niosh/face

DATE: 

July 3, 2013

TIME: 

9:52 a.m. 

VICTIM:

24-year old oil and gas 

delivery truck driver

INDUSTRY/NAICS CODE:

Oil and Gas/21

EMPLOYER: 

Well servicing company; 

70,000 employees in the 

U.S. 

SAFETY & TRAINING:

Training on caughtbetween, not specific to 

dozer or other large 

equipment

SCENE: 

Access road to a well site

LOCATION:

West Virginia

EVENT TYPE: 

Struck by

___________________________

INCIDENT HIGHLIGHTS

 

 

REPORT#: 2015-01 REPORT DATE: April 18, 2018

Oil and Gas Delivery Driver Crushed Between 

a Dozer and a Semi-truck While Connecting 

Towline—West Virginia

________________________________________________________ 

SUMMARY

On July 3, 2013, a 24-year-old oil and gas delivery truck driver was 

fatally injured when he was crushed between a dozer and the front 

of his semi-truck. The driver was delivering concrete to the job site 

and, due to the hilly terrain, needed a tow to the well site. The 

towing dozer operator backed to the front of the driver’s semi-truck. 

The driver exited his cab to connect to the dozer’s towline... READ 

THE FULL REPORT> (p.3)

________________________________________________________ 

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Lack of safety training or standard operating procedure for 

towing vehicles

• Lack of appropriate safeguards for equipment

• Lack of spotter or designated hookup personnel

• Steep terrain LEARN MORE> (p.9)

______________________________________________________ 

RECOMMENDATIONS

NIOSH investigators concluded that, to help prevent similar 

occurrences, employers should: 

• Ensure employees follow safe operating procedures as written in 

the equipment’s operations manual.

• Implement standard operating procedures for equipment 

operations such as parking and towing. 

• Use a job hazard analysis (JHA) to identify and eliminate towing 

hazards. LEARN MORE> (p.9) 
REPORT#: 2015-01 Page 2

NIOSH • 304-285-5916

1095 Willowdale Road

Morgantown, West Virginia 26505

Fatality Assessment and Control Evaluation (FACE) Program

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and Prevention 

(CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of work-related 

injury and illness. In 1982, NIOSH initiated the Fatality Assessment and Control Evaluation (FACE) Program. FACE examines the 

circumstances of targeted causes of traumatic occupational so that safety professionals, researchers, employers, trainers, and workers 

can learn from these incidents. The primary goal of these investigations is for NIOSH to make recommendations to prevent similar 

occurrences. These NIOSH investigations are intended to reduce or prevent occupational deaths and are completely separate from the 

rule making, enforcement and inspection activities of any other federal or state agency. Under the FACE program, NIOSH investigators 

interview persons with knowledge of the incident and review available records to develop a description of the conditions and 

circumstances leading to the deaths in order to provide a context for the agency’s recommendations. The NIOSH summary of these 

conditions and circumstances in its reports is not intended as a legal statement of facts. This summary, as well as the conclusions and 

recommendations made by NIOSH, should not be used for the purpose of litigation or the adjudication of any claim. For further 

information, visit the program website at www.cdc.gov/niosh/face/ or call toll free at 1-800-CDC-INFO (1-800-232-4636).
REPORT#: 2015-01 Page 3

SUMMARY

On July 3, 2013, a 24-year-old oil and gas delivery truck driver was fatally injured when he was crushed between a dozer 

and the front of his semi-truck. The driver was delivering concrete to the job site and, due to the hilly terrain, needed a 

tow to the well site. The towing dozer operator backed to the front of the driver’s semi-truck. The driver exited his cab 

to connect to the dozer’s towline. The driver was attempting to connect the towline to the front of his truck, but he 

needed a D-ring to complete the connection. The dozer operator got up from his seat and was exiting the dozer to hand 

the driver a D-ring. When exiting the dozer, it is believed his foot hit the parking brake lever and the dozer rolled 

backward, crushing the driver between the two vehicles. Emergency medical services (EMS) was called, and CPR was 

administered by another dozer operator until EMS arrived on-scene. The EMS responders pronounced the delivery truck 

driver dead shortly after their arrival. The medical examiner determined the cause of death was thoracic injuries.

INTRODUCTION

On July 3, 2013, a 24-year-old oil and gas delivery truck driver was fatally injured when he was crushed between a dozer 

and the front of his semi-truck. On January 15, 2015, a safety and occupational health specialist from the NIOSH Division 

of Safety Research, and a guest researcher from the West Virginia University Occupational Medicine Residency Program 

met with the area director of the Charleston Area Office of the Occupational Safety and Health Administration (OSHA) 

and reviewed the circumstances of the incident. Photos from the incident site, witness statements, and the medical 

examiner’s report were provided to NIOSH.

EMPLOYER

The driver was employed by a well servicing company with approximately 70,000 employees in the United States. Well

servicing companies are contracted to provide a wide variety of support activities at oil and gas well sites. In this case, the 

company was hired to deliver material, such as concrete, to the well site; they had 12 employees at the well site on the 

day of the incident. OSHA had not conducted an inspection with the company in the 5 years prior to this incident. 

A second well servicing company employed the dozer operators at the well site. The company was contracted to maintain 

the service roads and tow semi-trucks up to the well site using dozers due to the steep terrain at the jobsite. The company 

had seven employees and provided services in West Virginia, Ohio, and Pennsylvania.

WRITTEN SAFETY PROGRAMS and TRAINING

The truck driver’s employer provided training on caught-between, pinch-point, and struck-by hazards specific to workers 

on foot, hooking up a trailer, and being caught between the truck and another vehicle. This training occurred at least 

yearly, but the training was not specific to dozers or other large equipment. Employees received on-the-job training for 

hooking up to dozers for towing operations. The company used mentors to perform on-the-job training. The experience 

level of the driver’s mentor was unknown. Employees did not receive training on the operations manual specific to their 

vehicle. The driver’s vehicle operations manual included an illustration showing a minimum distance of 6 feet between 

the semi-truck and the towing vehicle as an acceptable distance for vehicle rigging [Kenworth, no date]. Recommended 

towing procedures were not addressed on the Driver Qualification Road Test/Certification or on the company’s drivermentoring checklist. 

The company conducted and documented a job safety analysis (JSA) for jobs performed by concrete delivery/service 

personnel. The task of driving on leased roads was briefly mentioned but did not go into detail about being towed by 
REPORT#: 2015-01 Page 4

other vehicles. A JSA for hooking up bulk or cement trucks addressed spotting the truck with the specific hazard being 

caught between a bulk truck and another object. The JSA also recommended using two spotters when available to 

minimize the possibility of trucks running into each other, equipment, or property and that spotters stand beside the 

equipment, not behind or in front of it, to avoid being caught between the bulk truck and other equipment and/or 

property.

The dozer operator’s employer operated out of the owner’s residence. The employer had a written safety and health 

program. Training records were provided and indicated that 3 months prior to the incident, a toolbox talk had been 

administered that addressed personnel at the worksite and instructed employees to pay attention to their surroundings 

to be aware of any potential hazards. According to interviews conducted by OSHA, the owner said they performed daily 

JSAs covering what they were going to do for the day, potential hazards, and hazard prevention. He also stated that it 

was not recommended practice to keep the blade up when putting the dozer in park and he had previously disciplined 

employees for leaving the blade up while in park. The owner also mentioned that it was common practice for the dozer 

operators to back close to the front of the vehicle being towed due to the length and weight of the tow hook and tail 

chain (Photo 1). The exact weight is unknown; however, according to worker interviews, the hook and tail chain weighed 

30–40 lbs. The dozer operators do not hook up the equipment due to liability reasons. The employer recommended that 

dozer operators remain in the dozer, but they were not prohibited by the employer from exiting during hookup.

Photo 1. Tow hook and tail chain, showing length of towline at time of incident.

(Photo courtesy of WV OSHA.)
REPORT#: 2015-01 Page 5

WORKER INFORMATION

The delivery truck driver was a 24-year-old male who had worked as a driver for the current employer for over 1 year 

before the incident occurred. He had no other previous commercial driving experience and had a commercial driver’s 

license. 

According to an interview with OSHA, the dozer operator had 5 years prior operating experience before working for the 

current employer. He started with the employer in March of 2013, approximately 4 months prior to the incident, and 

had to demonstrate dozer operation before being hired.

INCIDENT SCENE

The incident occurred on an access road to a well site while the delivery truck driver was hooking up his semi-truck to a 

dozer. The section of access road was graded dirt and gravel surface with an approximately 10 percent grade (Photo 2). 

The dozer operator backed his dozer to within 3 feet of the driver’s truck for hookup.

Photo 2. Incident scene, showing terrain and hill accessing the well site.

(Photo courtesy of WV OSHA.)

EQUIPMENT

The delivery driver was driving a Kenworth model 660 semi-truck and bulk cement trailer. He was struck by a Komatsu 

dozer that rolled backward and made contact with the Kenworth truck. The truck was equipped with a pin-type tow 

hitch on the front bumper that required the use of a D-ring to connect the hitch pin with the dozer’s winch line hook 

(Photos 3 and 4). The truck did not have a D-ring (Photo 4) connected to the hitch prior to the truck pulling onto the 

access road. However, D-rings were kept on the dozers for trucks that came on-site without them.
REPORT#: 2015-01 Page 6

Photo 3. Pin-type tow hitch on front of the truck involved in this incident. 

(Photo courtesy of WV OSHA.)

Photo 4. D-ring needed for connection between hook and hitch pin. 

(Photo courtesy of WV OHSA.) 
REPORT#: 2015-01 Page 7

The Komatsu dozer model D65PX-15 weighed approximately 47,000 lbs (Photo 5). The dozer was equipped with a winch 

for towing. Specifications on the winch are unknown. Two levers lock different parts of the machine. The safety lock 

lever is a device that locks the work equipment, such as the blade, from being used. The parking lever stops the tram 

control from being used and the machine from moving. In this incident, it is believed that the operator inadvertently 

kicked the parking brake lever while exiting the machine, releasing it and causing the dozer to roll backward (Photo 6).

Photo 5. Dozer involved in the incident. 

Note: The tow hook and tail chain have been removed.
REPORT#: 2015-01 Page 8

Photo 6. Safety lock lever (1) and parking lever (2).

(Illustration adapted from Komatsu [2004].)

WEATHER

The incident occurred at 9:52 in the morning. The temperature was 74 degrees Fahrenheit; the visibility was 10 miles, 

with a wind speed of 2 mph SSW [Weather Underground 2013]. Weather is not believed to have been a factor in this

incident.

INVESTIGATION

On July 3, at approximately 9:52 a.m., the delivery truck driver arrived at the well site access road. Due to the hilly 

terrain, the truck needed to be towed up hill to the worksite. The towing dozer operator backed his Komatsu dozer to 

within 3 feet from the front of the Kenworth semi-truck. According to OSHA interviews, the owner of the dozer company 

said that this distance was common practice for their dozer operators. The driver exited his truck and was attempting to 

connect the winch line to the hitch on the front of his truck, but was unable to because a D-ring was not attached to the 

hitch. A second dozer operator was operating his dozer nearby and noticed that the driver was having difficulty and 

radioed the towing dozer operator to give the driver a D-ring. The towing dozer operator engaged the parking lever and 

lowered the blade to approximately 6 inches above the ground. He then got up from his seat and turned to exit the 

dozer. As he did so, it is believed that the back of his heel caught the parking lever, releasing the parking brake. This 

allowed the dozer to roll backward, pinning the driver between the dozer and the semi-truck. The dozer operator drove 

the dozer forward, and the delivery driver fell to the ground. Emergency medical services (EMS) was called. Both dozer 

operators checked on the delivery truck driver and found he had a pulse but was not responsive. When he lost a pulse, 

CPR was initiated by the second dozer operator and continued until EMS arrived. EMS personnel arrived on-scene and 

pronounced the delivery truck driver deceased; he was transported to the state medical examiner’s office.
REPORT#: 2015-01 Page 9

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. NIOSH investigators identified the following 

unrecognized hazards as key contributing factors in this incident:

• Lack of safety training or standard operating procedure for towing vehicles

• Lack of appropriate safeguards for equipment

• Lack of spotter or designated hookup personnel

• Steep terrain

• Short length of chain being used; winch cable and chain not spooled out

• Truck not properly equipped ahead of time for towing (i.e., no D-ring pre-mounted on hitch pin)

CAUSE OF DEATH

The medical examiner listed the cause of death as thoracic injuries.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should ensure employees follow safe operating procedures as written in the 

equipment’s operations manual.

In this incident, the towing dozer operator was operating a Komatsu dozer model D65PX-15. The following procedures 

were listed in the manufacturer’s operations manual.

• Always apply the lock when leaving the operator’s seat (Figure 1). Before standing up from the operator's seat (such 

as when adjusting the operator's seat), lower the work equipment completely to the ground, set the safety lock 

lever (1) and parking lever (2) securely to the LOCK position, then stop the engine. If you accidentally touch the 

levers when they are not locked, the machine may suddenly move and cause serious injury or property damage

[Komatsu 2004].

• When leaving the machine, always lower the work equipment completely to the ground, set the safety lock lever (1) 

and parking lever (2) securely to the LOCK position, then stop the engine. Use the key to lock all the equipment. Always 

remove the key, take it with you, and keep it in a specified place [Komatsu 2004].

Figure 1. Safety lock lever (1) and parking lever (2).

(Adapted from Komatsu [2004].)
REPORT#: 2015-01 Page 10

• Park the machine on firm, level ground. Select a place where there is no hazard of falling rocks or landslides, or of 

flooding if the land is low. Lower the work equipment completely to the ground. When leaving the machine, set the 

steering, directional, and gearshift levers in the NEUTRAL position and set the blade lever in the HOLD position; then 

apply the safety lock lever (1) and the parking lever (2) and stop the engine. Always close the operator's cab door 

and use the key to lock all the equipment in order to prevent any unauthorized person from moving the machine. 

Always remove the key, take it with you, and leave it in a specified place (Figure 2) [Komatsu 2004]. 

Recommendation #2: Employers should implement standard operating procedures for equipment operations such as 

parking and towing.

OSHA regulations require employers to train workers to recognize and avoid unsafe conditions that may be present in 

their work environments and to provide training on the regulations applicable to their work [Safety and health 

regulations for construction, 1998]. 

Employers should ensure that drivers and equipment operators receive adequate safety training. In this case, 

consideration should be made for special hazards present during towline connection and disconnection, particularly 

when performed on a slope. 

Employees need a set of standard procedures that they will always follow. Operators of tow vehicles should place the 

transmission in neutral, provide at least 6 feet of distance between the equipment, lower the blade, engage the parking 

brake and any brake system backups, and ensure that the vehicle is stable and secure before exiting or signaling for 

another individual to enter the hazard zone between the vehicles. Some procedures for consideration during connection

or disconnection may include the following: 

• Make towing connections on level ground, such as a designated hookup location. If level ground isn’t available, offset 

or stagger the machine from the unit being pulled so that even if the machine rolls, it will not roll into the unit.

• Identify hazardous zones and functions between or near vehicles that could result in crushing injuries during the 

connection process. 

• During the connection process, the dozer operator remains in the equipment operator’s seat. 

Figure 2. Warning label from the Komatsu operations manual. 

(Adapted from Komatsu [2004].)
REPORT#: 2015-01 Page 11

• The worker connecting the tow cable/chain makes confirmed visual contact with the vehicle operator(s) prior to 

entering the area between the two vehicles.

• The worker connecting the tow cable/chain maintains visual contact with the towing vehicle during the connection 

process.

• After the towing vehicle is connected, the operator makes positive eye contact with the individual connecting the 

towing vehicle to ensure the person is clear of crushing hazards or other identified hazards, such as being struck by 

the towing chain or cable, prior to disengaging the braking system.

• Use a spotter [Montgomery and Krieger 1997].

Recommendation #3: Employers should use a job hazard analysis (JHA) to identify and eliminate towing hazards. 

Conducting a job hazard analysis alerts the employers and workers to the hazards associated with towing. A JHA looks at 

job tasks in order to identify their associated hazards and develop control strategies and techniques before injuries 

occur. In this case, the JHA might have identified the hazard of being crushed between the dozer and the semi-truck and 

prompted the development of a safe vehicle-towing procedure. Employers should always include workers in the JHA 

process to encourage workers to implement the identified control strategies [OSHA 2010]. 

Additionally, a JHA policy or program specifically related to tasks involving more than one contractor should be in place. 

Each company may have their own form of JHA or towing/hauling policies; an agreement on which to follow should be 

reached before work commences.

Recommendation #4: Ensure vehicles are properly equipped for towing prior to initiating the towing connection 

procedures (either have a D-ring pre-mounted on the truck’s hitch pin or have a D-ring in the truck).

In this case, the dozer operator was exiting the dozer to give the truck driver a D-ring for connection. Vehicles 

being towed should be properly equipped for towing with all necessary hookup equipment prior to engaging 

in the hookup procedures. For example, the D-ring can either be equipped on the truck or placed on the truck 

before preparing to be towed. This is especially true where towing connection is an ongoing activity at the job 

site. 

Recommendation #5: When possible, ensure a designated area is flat prior to making towing connections.

Towing connections should be conducted on level ground where possible. In this incident, an attempt to hook up was 

performed on a slope of approximately 10 degrees. Steep terrain increases the chance of machinery moving

unintentionally during operations. Designating a level area for hookup operations may reduce the risk of involuntary 

movement. If level ground isn’t available, the machines should be staggered/offset so that if the potential to roll 

backward exists, the machine would not roll into the unit being towed.

Training and standard operating procedures should be developed to ensure employees understand the hazards of 

towing on inclined terrain. During training, the truck drivers and dozer operators should be informed of designated 

towing hookup areas. 

Recommendation #6: Dozer equipment manufacturers should consider providing an engineering control, such as an 

interlock or other safe guards, to prevent parking brake levers from disengaging. 
REPORT#: 2015-01 Page 12

Control guards are safety features designed to prevent the inadvertent operation of equipment. Larger controls, such as 

levers, may require bars or specifically designed guards to limit access to the levers. Alternatively, mechanical stops, 

such as removable pins or blocks, can be used to limit movement of the lever until the operator is ready to safely 

activate the control. 

In this incident, the victim was pinned between the dozer and semi-truck. It is believed that the dozer operator bumped 

the parking brake lever while dismounting the dozer, which disengaged the parking brake and caused the dozer to roll 

back and onto the victim. 

An interlock device prevents a vehicle from shifting into motion on its own. Many companies have developed several 

different types of interlock variations, including a brake transmission interlock, a brake shift interlock, and a starter 

ignition interlock.

A brake transmission interlock works by applying the brakes automatically if no one is in the operator's seat. If the safety 

restraints are not being used, the brakes are also automatically applied. A brake shift interlock does not allow the gear

shift to move unless the brake is applied. A starter ignition interlock requires a key and the brake to be applied for a 

vehicle to start. 

In this case, the dozer operator left the cab to give the delivery driver a D-ring, and the parking brake lever was 

inadvertently disengaged, which caused the dozer to roll back. A separate safety lock lever on the right side of the seat 

controls the work equipment attachments, such as the blade, from moving up and down. It is believed that this safety 

lock lever may not have been engaged. The operator’s manual warns that if the control lever (parking brake lever) is 

touched by accident, the machine may suddenly move and cause serious personal injury.

The manual states: “When leaving the machine, always lower the work equipment to the ground, set work equipment 

lock lever and parking brake lever to lock position, and stop the engine. Always lock all parts, take the key with you, and 

leave the key in the specified place” [Komatsu 2004].

DISCLAIMER

Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety 

and Health (NIOSH). In addition, citations to websites external to NIOSH do not constitute NIOSH endorsement of the 

sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these 

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

REFERENCES

Kenworth [no date]. Operating instructions and preventive maintenance manual. Kirkland, WA: Kenworth, 

KW1466J7/04.

Komatsu [2004]. Komatsu D65PX-15 operation and maintenance manual. Rolling Meadows, IL: Komatsu America Corp. 

Montgomery JF, Krieger GR, eds. [1997]. Power shovels, cranes, and similar equipment. In: Accident prevention manual 

for business and industry: engineering and technology. 11th edition. Itasca, IL: National Safety Council. 

OSHA [2010]. OSHA 3071: Job hazard analysis. Rev. Washington, DC: Occupational Safety and Health Administration, 

http://www.osha.gov/publications/osha3071.pdf.
REPORT#: 2015-01 Page 13

Safety and health regulations for construction. General safety and health provisions. Safety training and education. 29 

CFR 1926.21 [1998]. 

Weather Underground [2013]. Weather history for Bridgeport, WV, July 3, 2013. Atlanta, GA: The Weather Channel 

Interactive, Inc., 

http://www.wunderground.com/history/airport/KCKB/2013/7/3/DailyHistory.html?req_city=Jacksonburg&req_state=W

V&req_statename=&reqdb.zip=26377&reqdb.magic=1&reqdb.wmo=99999.

INVESTIGATOR INFORMATION

This investigation was conducted by Nancy Romano, Safety and Occupational Health Specialist. The report was coauthored by Melanie Moore, Safety and Occupational Health Specialist, Fatality Investigations Team, Surveillance and 

Field Investigations Branch, Division of Safety Research, and Yusef Sayeed, MD, MPH, MEng, CPH, Guest Researcher, 

West Virginia University Occupational Medicine Residency Program.

ACKNOWLEDGEMEMENT

The NIOSH FACE Program and the safety and occupational health specialists would like to acknowledge the compliance 

officer and staff of the West Virginia Department of Labor, Occupational Safety and Health Division for their assiantance 

with this investigation.