DATE: 

October 21, 2020

TIME: 

8:30 AM

VICTIM:

52-year-old male mechanic 

employed for six years

INDUSTRY/NAICS CODE:

Other General Government 

Support/921190

EMPLOYER: 

Town highway department

SAFETY & TRAINING:

Some training in general 

Lockout-tagout but not 

specific

SCENE: 

Town highway department 

garage

LOCATION:

New York

EVENT TYPE: 

Compressed by

INCIDENT HIGHLIGHTS

 

REPORT#: 20NY030 REPORT DATE: 6/01/22

Town highway department mechanic 

crushed when truck fell off jack stand —New 

York

SUMMARY

On October 21, 2020, a mechanic for a town highway department 

was fatally injured around 8:30 AM in the morning while he was in 

the process of changing air brake canisters on a truck in the town 

highway department garage. The truck at the time was undergoing 

routine maintenance in preparation for the winter months. The 

decedent had placed a jack under the passenger side rear axle wheel 

hub of the truck after removing the wheel to access the air brake 

canister. The truck transmission was in neutral, and the wheels were 

otherwise not chocked, with no supplemental support or cribbing 

except for a 12-ton jack stand under the passenger side rear wheel 

hub. READ THE FULL REPORT> (p.3) 

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Truck wheels were not chocked

• Truck had been left in neutral, with keys in cab of truck

• No secondary support methods were used besides the 12-ton 

jack stand

LEARN MORE> (p.7)

RECOMMENDATIONS

• New York FACE investigators concluded that, to help prevent 

similar occurrences, employers should: 

• Ensure employees use wheel chocks and cribbing during truck 

maintenance

• LEARN MORE> (p.8)

New York FACE Program
Page 2

The New York State Fatality Assessment and Control Evaluation (NY FACE) is a research program funded by the National Institute for 

Occupational Safety and Health and administered by the New York State Department of Health. NY FACE collects information on workrelated fatalities, investigates the incidents to identify the causes and contributing factors, proposes prevention measures, and shares 

the injury prevention information with employers, workers, and other organizations interested in promoting workplace safety. NY FACE 

does not determine fault or legal liability associated with a fatal incident. Names of employers, victims and/or witnesses are kept 

confidential. Additional information regarding the NY FACE program can be obtained from: 

New York State Department of Health FACE Program

Bureau of Occupational Health and Injury Prevention

Corning Tower, Room 1325

Empire State Plaza

Albany, NY 12237 

866-807-2130

518-402-7900

Email | Twitter | Facebook| Website
REPORT#: 2014-02 Page 3

SUMMARY

On October 21, 2020, a mechanic for a town highway department 

was fatally injured around 8:30 AM in the morning while he was in 

the process of changing air brake canisters on a truck in the town 

highway department garage. The truck at the time was undergoing 

routine maintenance in preparation for the winter months. The 

decedent had placed a jack under the passenger side rear axle 

wheel hub of the truck after removing the wheel to access the air 

brake canister. The truck transmission was in neutral, and the 

wheels were otherwise not chocked, with no supplemental support 

or cribbing except for a 12-ton jack stand under the passenger side 

rear wheel hub. Between approximately 8:25 AM and 8:30 AM in 

the morning, the truck rolled while the decedent was working on it, 

causing the truck to roll off the jack stand, crushing the employee 

with a portion of the truck called a chipper bar that was positioned 

behind the passenger side rear wheel well of the truck. The 

decedent was discovered shortly after the incident by the office 

secretary. 911 was called and emergency responders including 

volunteer firefighters and emergency medical technicians including 

a nearby neighbor responded almost immediately, but the 

employee died at the scene due to mechanical asphyxiation and crushing injuries to the chest.

INTRODUCTION

On October 21, 2020, a mechanic for a town highway department was fatally injured around 8:30 AM while he was in 

the process of changing air brakes on a truck in the town highway department garage (Photo 1). The New York State 

Fatality Assessment and Control Evaluation (NY FACE) staff learned of the incident from news media reports and 

contacted the employer to initiate an investigation. Additionally, NY FACE contacted the Public Employee Safety and 

Health Bureau (PESH) in the New York State Department of Labor (NYSDOL) to request information regarding the 

investigation. PESH is the regulatory body for NYS public employee safety, and initially investigated the case after the 

incident. NY FACE staff discussed the case with PESH to gather specific details of the incident.

The employer was contacted by NY FACE staff in March of 2021 and agreed to cooperate with the NY FACE investigation. 

NY FACE staff visited the Town Highway Department garage and interviewed the Town Highway Supervisor, the Deputy 

Town Highway Supervisor, as well as a few employees of the department. NY FACE also inspected the garage bay where 

the incident took place, observed the truck involved in the incident, and reviewed town written safety and health 

programs, worker training records, and equipment maintenance and inspection logs. This report summarizes the 

findings of the NY FACE investigation.

Photo 1: Truck involved in incident with right rear wheel 

missing (photo courtesy of PESH).
REPORT#: 20NY030 Page 4

EMPLOYER

The employer is a municipal town highway department located in a town with a population of approximately 2,800 

people. The department employs six people full-time, with four part-time personnel who are called in for seasonal work. 

The highway department is a union shop. All employees are members of a public employee union except the highway 

supervisor who is the only elected official. The town highway department primarily performs maintenance and 

continuity-of-service functions for 78 miles of town-owned roads and highways, performs tree work along town-owned 

roads and highways, and helps run and maintain a municipal waste transfer facility. The staff truck drivers provide inhouse maintenance and mechanical work on the department’s seven large dump/plow trucks and multiple other pieces 

of equipment including tractors, road graders, small pickup trucks, backhoes, loaders, public transportation vehicles, 

bulldozers, forklifts, rollers, and other types of motorized equipment. Many of the department employees are on or 

were a part of local emergency response services in their community, specifically in the volunteer fire department as 

well as in emergency medical response.

WRITTEN SAFETY PROGRAMS and TRAINING

Employees at the facility had trainings for multiple safety and health facets including lockout-tagout (LOTO), Hazard 

Communication, Right-to-Know, personal protective equipment (PPE), Emergency Response, workplace violence, 

bloodborne pathogens, drivers’ safety, chainsaw and chipper safety, loader and backhoe trailing, aerial equipment 

training, and work zone traffic control. A written LOTO program was available for review and included a lock box, lock 

hasps, locks, and a lockout-tagout log, and a generalized procedure for how to isolate energy systems on trucks owned 

by the highway department. However, no specific LOTO procedures existed for any of the town highway trucks, as well 

as other large pieces of machinery including a backhoe, roller, skid steer, and grading machine. The last department 

wide LOTO training was provided in 2015, five years prior to the incident. The training did not provide equipment 

specific LOTO information and procedure, and no inspections of LOTO procedures were logged on any equipment still in 

service to the highway department. The last time the LOTO log had been used was four years earlier on May 10, 2016.

WORKER INFORMATION

The worker involved in the incident was a 52-year-old white male whose official job title was Equipment Operator 2. He 

had been working at the town highway department since November of 2014 and had a working mechanical background 

before joining the highway department. He was a well-known and well-liked member of the town who had grown up 

there alongside many of his coworkers. The decedent had been the town District Fire Chief and spent several years as a 

member of the Town Volunteer Fire Company.

EQUIPMENT

The machinery involved in the incident was a 2007 Sterling LT9500 tandem wheel dump truck named Truck 22. The 

gross vehicle weight of the truck was 30,200 pounds, which is what the truck weighed at the time of the incident. The 

truck has three axels: one front axle and two rear axles. The front axle has two wheels. The middle and rear axle have 

tandem sets of wheels, or four wheels per axle. In total there are ten wheels on this truck. The decedent was working on 

the passenger side rear air brake canister at the time of the incident, which is positioned behind the passenger rear 

wheel hub of the truck adjacent to the chipper bar. The chipper is a steel bar attachment that is positioned 
REPORT#: 20NY030 Page 5

approximately 12 inches off of the ground. The purpose of the 

chipper bar is to allow a self-propelled chip sealer to attach to the 

truck, allowing the chip sealer to tow the truck along as the truck 

supplies aggregate stone for road surfacing. The chipper bar is held 

to the truck frame with four bolts. Removing the chipper bar 

requires removing the bolts and pulling the bar off the truck frame. 

The truck drivers at the highway department were responsible for 

maintaining and servicing the department trucks. The decedent was 

very familiar with the vehicle and had years of experience working 

on it, including changing air brake canisters. The truck operator 

manual and maintenance manual did not have specific procedures 

for servicing or maintaining the air-brake canisters. The truck 

maintenance manual and Highway Department LOTO procedures 

did not mention of lowering the dump box, removing the chipper 

bars, or use of cribbing and chocks as steps for controlling potential 

hazards. 

 

INVESTIGATION

For five days before the day of the incident, the decedent and his 

colleagues had been working on Truck 22 and preparing it for the 

upcoming winter in the town highway department in garage bay 1. 

Truck 22 was considered the decedent’s responsibility as he was the 

primary driver of the truck throughout the year for highway department 

work activities. The decedent had worked on the transmission of the truck, the tires of the truck, the brake lines of the 

truck, the salt spreader (sander) on the truck, the bed chain of the truck, and other air brake canisters on the truck with 

help from his colleagues at times. For maintenance tasks that required going under the truck, a 22-ton pneumatic floor 

jack (Photo 4) was placed under the rear tandem axels of the truck, and wheel hubs were supported by a 12-ton jack 

stand. This was considered common practice but was not included in a written procedure. Both jack stands could 

support the weight of the elevated truck, which weighed 30,200 pounds, or 15.1 tons, while unloaded. There weren’t 

written procedures on how to work on trucks safely. Maintenance activities and safeguards were left to the best 

judgement of the highway department mechanics and management staff. Eyewitness interviews noted that in the days 

before the incident, both the 22-ton pneumatic floor jack and the 12-ton jack stand were used during Truck 22 

maintenance. Interviews do not mention the use of wheel chocks, blocks, cribbing, or other devices used to prevent 

Truck 22 from rolling or falling off the 12-ton jack stand in the days before the incident. 

Photo 2: Chipper bar behind right rear tires of truck
REPORT#: 20NY030 Page 6

The day of the incident, the decedent was working on changing out the passenger 

side rear axle air brake canister on Truck 22 in Bay 1 (Photo 3). The passenger side 

dual rear axial wheels had been removed from the wheel hub to better access the 

air brake system. The wheel hub was supported by the 12-ton jack stand seen in 

photo 7. According to eyewitness statements and PESH investigation, the 22-ton 

pneumatic jack was not being used in conjunction with the 12-ton jack stand on the 

day of the incident. Additionally, there was no cribbing under the truck, no wheel 

chocks were being used, the keys to the truck had been left in the truck’s ignition, 

and the truck had been left in neutral. The truck’s braking system, including the 

parking brake, was not operable because the maintenance activity the decedent was 

performing required releasing air from the truck’s systems, which included the 

parking brake. The box of the truck, which was elevated and held up by its support 

arm, was not cribbed on the day of the incident. The box of the truck being elevated 

may have affected the truck’s center of gravity, placing more weight on its rear 

wheels and the 12-ton floor jack. The floor of Bay 1 where the decedent had been 

working had a floor gradient of approximately 3-4 degrees sloping towards a central 

floor drain, which was an approximate slope angle based on the photo 6, supplied 

by PESH for this investigation.

The decedent was performing the work lying on his back on a mechanics creeper 

under the truck. The mechanics creeper is a low-lying rolling dolly meant to be laid 

down on by mechanics for servicing the underside of vehicles without needing the 

mechanic to lie directly on the ground (Photo 5). To work on the air brake canisters, 

the decedent was required to position his body underneath the chipper bar behind 

the right rear wheel hub (Photo 2). The creeper’s height off the ground was 

approximately 3 inches, and the chipper bar was positioned about 12 inches off the 

ground, which allowed for approximately 9 inches of clearance between the chipper 

bar and the mechanics creeper for the decedent to fit between in order to work on 

the passenger side rear axle air brake canister.

At 8:15 AM the day of the incident, the Highway Superintendent called to inform the 

decedent that he was to take care of a tree down on a local road. After the decedent 

finished speaking with the Highway Superintendent, he informed the Deputy 

Highway Superintendent. who was in the highway department office, of the call and asked if a coworker could be 

dispatched to respond to the downed tree so that the decedent could continue working on his truck. The Deputy 

Highway Superintendent gave the decedent permission to continue working on his truck, and the decedent’s coworker 

was sent out to deal with the tree. The Deputy Highway Superintendent then left the premises to take a vehicle to get 

inspected at a nearby town garage. The decedent then continued to work on the air brake canisters while lying on the 

mechanic creeper underneath the chipper bar of Truck 22.

Photo 3: Air brake canisters or 'air 

cans' involved in routine 

maintenance of truck braking 

system

Photo 4: 22-ton pneumatic jack 

typically used to support truck 

during air brake maintenance 

(photo courtesy of PESH)
REPORT#: 20NY030 Page 7

Security cameras existed at the time of the incident at the town highway department garage, which provided the 

following information around the timing of the incident. However, no security camera caught the incident itself. Around 

8:26 AM, the coworker left the garage to respond to the fallen tree. At 8:29 AM, the highway department secretary 

arrived at the highway department and went into the garage to say hello at which time she heard sounds coming from 

Bay 1. When she approached the truck, she saw the decedent lying on the ground under the truck, pinned by the 

chipper bar behind the right rear wheel hub of Truck 22. The decedent was lying on the mechanics creeper when the 

truck came down on him. The truck came down with enough force on the decedent that a wheel from the creeper was 

broken off. The truck then rolled approximately 1.5 feet downgradient with the decedent trapped under the chipper 

bar. Upon discovery the secretary immediately called 911 and went across the street to the home of a firefighter/EMS 

member to get assistance. 

The firefighter/EMS neighbor responded immediately and began assessing the decedent. As he did that the Town Fire 

Department District Chief responded to the site and began working on getting the decedent out from under the truck by 

placing a 2.5-ton hydraulic jack under the right rear axle and began to jack the truck up off the decedent. Once the truck 

was raised approximately one inch off the decedent, the emergency responders pulled the decedent out from under the 

truck by his ankles. The decedent had no pulse and was not breathing. CPR was initiated immediately, but the victim 

died as a result of his injuries.

 

CAUSE OF DEATH

According to the medical examiner, the decedent died of mechanical asphyxia as a result of compression of chest.

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. New York FACE investigators identified the following 

unrecognized hazards as key contributing factors in this incident:

• Truck wheels were not chocked

Photo 5: Mechanics Creeper 

used by decedent for 

maintenance under Truck 22

Photo 6: Floor gradient at Bay 1 central drain over 10-foot 

span (phot courtesy of PESH)

Photo 7: Floor jack stand 

involved in incident
REPORT#: 20NY030 Page 8

• Truck had been left in neutral, with keys in the cab of the truck

• No secondary support methods were used besides the 12-ton jack stand (cribbing, wood blocks, other backup 

support)

• Truck was parked on garage floor with slight incline towards floor grate in center of floor

• The chipper bar attached to the truck had remained attached to the truck, instead of being removed to allow for 

greater clearance and access to the air brake canister.

• Decedent was not adequately trained in controlling hazardous energy through LOTO regarding Truck 22.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should ensure employees use wheel chocks and cribbing during truck maintenance. 

Discussion: During the PESH investigation, it was determined that the decedent did not use any wheel chocks or 

additional cribbing under the vehicle to prevent truck movement or the potential failure of the 12-ton jack stand. 

Employers should ensure that employees use wheel chocks and cribbing to prevent truck rolling or falling. Using chocks 

and cribbing in addition to the 12-ton jack stand would have prevented the truck from rolling, which is ultimately what 

caused the incident. Wheel chocks and cribbing use should be included in an Employer’s LOTO procedure for 

maintenance items that require personnel to work under trucks.

Recommendation #2: Employers should develop LOTO procedures for specific maintenance items on equipment.

Discussion: Equipment listed on an employer’s inventory list should have multiple LOTO procedures for the maintenance 

tasks required to service and upkeep equipment. One piece of machinery may only have a few maintenance items 

where hazardous energies can be controlled in the same way each time, but other pieces of equipment may have many 

different maintenance tasks that will require different energy controls for each task. 

In this case, the decedent was working on replacing air canisters under the truck, which is a part of the braking system of 

the truck. Although the truck was off, and the air in the system had been released, the truck’s transmission had been left 

in neutral instead of in gear, and the wheels had not been chocked, creating not only the potential energy of an elevated 

truck on a jack stand, but also the potential energy of the truck’s ability to roll freely, which eventually led to the death. 

To ensure worker safety and prevent fatal injuries, cribbing or other alternatives should be utilized under the truck to 

provide support and additional protection against a truck falling from elevation. Devices such as chocks should be 

utilized under truck wheels to prevent the vehicle from rolling, and the truck should be left in gear which could help stop 

the wheels from rolling freely.

Since equipment maintenance items can vary in many ways even in the same piece of equipment, employers should 

develop individual LOTO procedures and list the steps to controlling hazardous energies for each maintenance item. 

Manufacturer maintenance manuals should be used as reference to create LOTO procedures where possible. If 

equipment does not have a maintenance manual, or maintenance tasks are not listed in a maintenance manual, 

employers should consult equipment manufacturers to determine best safety practices and LOTO requirements.
REPORT#: 20NY030 Page 9

Recommendation #3: Employers should ensure employees are using all required safety devices when performing 

maintenance tasks on equipment.

Discussion: During the PESH investigation, it was determined that the decedent had not used safety devices to properly 

secure the truck he was working on, including LOTO devices such as locks and tags for the key to the truck as well as the 

truck steering wheel. The key to the truck had been left in the cab of the vehicle, opening the possibility of unauthorized 

use of the truck while it was being worked on, which is contrary to the employer’s LOTO program. Supervisors should 

ensure that all employees routinely use all methods available to secure equipment being worked on from unauthorized 

use, such as locking keys to vehicles being maintained in a lockbox, and ensuring that wheel chocks, cribbing, and other 

hazardous energy controlling devices are deployed while working around or under machinery that can fall and 

potentially injure employees in accordance with a comprehensive LOTO program.

Recommendation #4: Employers should train employees in LOTO procedures on specific pieces of equipment.

Discussion: During the PESH investigation, it was determined that employees had some general LOTO training but were 

not trained in controlling hazardous energies for various maintenance tasks regarding their vehicles and other pieces of 

equipment at the highway department. The most recent LOTO training on record was five years earlier in 2015 and did 

not address the specific employer’s LOTO program or the equipment that is part of the employer’s LOTO program. 

The Occupational Safety and Health Administration (OSHA) training parameters require employers to ensure that 

employees are trained in how to correctly perform LOTO activities in line with an employer’s LOTO program. If 

maintenance activities performed by employees deviate from an employer’s LOTO program, retraining would be 

required. Retraining would also be required if an employee does not demonstrate knowledge in how to effectively 

perform LOTO according to the employer’s LOTO program. All training is required to establish or reestablish employee 

proficiency and if necessary, address new or updated LOTO procedures. Over time, training efficacy in employees 

diminishes, and at the same time, employees come and go, and old equipment may be swapped out for new equipment. 

Frequent trainings and re-trainings ensure affected employees are competent in LOTO requirements for all relevant 

pieces of equipment on an employer’s site.

Recommendation #5: Employers should conduct Job Hazard Analyses (JHAs) for specific tasks related to maintaining 

equipment.

Discussion: JHAs help employers highlight the potential dangers of specific maintenance tasks on equipment. Where 

LOTO procedures instruct employees on where to isolate hazardous energies on pieces of equipment, JHAs help 

determine the potential hazards of job activities, like equipment maintenance, to ensure that employees are aware of all 

potential hazards while offering solutions to help mitigate the potential hazard. In this case, the decedent had only used 

one jack stand under the passenger side rear axle wheel hub on Truck 22, and the floor of the garage bay where the 

decedent was working had a gradient that allowed the truck to roll. The chipper bar had also remained attached to the 

truck. A JHA would have discussed how to access the air brake canisters and what truck components should be removed

to safely and easily access the part requiring maintenance. The dump box was in the raised position during the incident, 

which may have affected the center of gravity on the truck contributing to the truck rolling unexpectedly. While a LOTO 

procedure might direct an employee to address the hazardous potential energy of the truck falling off the stands by 

adding cribbing or other support, a JHA goes over the potential risks of elevated equipment and the surrounding 
REPORT#: 20NY030 Page 10

environment where the work will take place. A JHA would address the floor gradient as a safety risk and discuss the 

potential severity of injury, the likelihood of injury, and suggest methods to help mitigate the risk. 

JHAs are meant to be discussed between employers and employees prior to taking on potentially dangerous tasks. Using 

and discussing JHAs help remind employees of the potential consequences of performing maintenance tasks and can 

help augment safety trainings by ensuring employees are thinking about the ways to perform a task safely before the 

work begins. 

Recommendation #6: Employers should routinely inspect LOTO procedures to ensure methods for controlling 

hazardous energies are accounted for and updated.

Discussion: During the PESH investigation, it was determined that although the employer had a LOTO program and some 

LOTO procedures for various pieces of equipment, many newer pieces of equipment did not have LOTO procedures, and 

equipment that did have LOTO procedures had not been inspected or updated as required. Employers should ensure 

that all equipment requiring maintenance has associated LOTO procedures for each maintenance task, that LOTO 

procedures are checked and updated routinely to ensure all equipment has an existing procedure for each maintenance 

task, and that all equipment is accounted for in a LOTO program. 

Recommendation #7: First responders should ensure proper equipment is used for extrication.

Discussion: During the PESH investigation, it was determined that first responders at the scene used a 2.5-ton floor jack 

to lift the truck enough in order to extract the decedent. The 2.5-ton floor jack was not suited to lift the weight of the 

truck from the decedent but was probably the closest nearby floor jack to the emergency responders, which is why it 

was used. The 2.5-ton jack was capable of lifting the truck enough to extract the decedent, but if it had failed before the 

victim could be removed, emergency responders would have not only lost time getting the victim out, but may have 

caused more damage to the victim, or created an unsafe scenario where the truck moved further, potentially injuring 

first responders in addition to the decedent.

DISCLAIMER

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

Occupational Safety and Health (NIOSH). In addition, citations to websites external to New York FACE and NIOSH do not 

constitute New York FACE and NIOSH endorsement of the sponsoring organizations or their programs or products. 

Furthermore, New York 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

New York Fatality Assessment and Control Evaluation Program. “Flatbed Truck Starts on Its Own, Crushing Auto Body 

Shop Worker.” Retrieved September 16, 2021 from https://www.cdc.gov/niosh/face/pdfs/14NY013.pdf

Iowa Fatality Assessment and Control Evaluation Program. “Truck driver entangled in drive train while freeing seized 

brakes.” Retrieved September 16, 2021 from https://www.cdc.gov/niosh/face/pdfs/05IA086.pdf
REPORT#: 20NY030 Page 11

Massachusetts Fatality Assessment Control and Evaluation Program. “Mechanic Dies while Changing Tire Mounted on a 

Multi-piece Split Rim Wheel.” Retrieved September 16, 2021 from 

https://www.cdc.gov/niosh/face/stateface/ma/07MA058.html

OSHA. The Control of Hazardous Energy (Lockout/Tagout). 29 CFR 1910.147. Retrieved September 16, 2021 from 

https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.147

OSHA. Control of Hazardous Energy Lockout/Tagout OSHA 3120 2002 (revised). Retrieved September 16, 2021 from 

https://www.osha.gov/sites/default/files/publications/osha3120.pdf

OSHA. Archived Standard Interpretations, Hazardous energy control lockout/tagout (LOTO) program documentation and 

certification requirements.” Retrieved September 16, 2021 from https://www.osha.gov/lawsregs/standardinterpretations/2005-05-10

INVESTIGATOR INFORMATION

This investigation was conducted by NY FACE, Bureau of Occupational Health and Injury Prevention, Center for 

Environmental Health, New York State Department of Health.

ACKNOWLEDGEMEMENT

The NY FACE Program would like to acknowledge the PESH Albany Area Office for providing assistance and information 

for this investigation.