| Case Name |
A case of failure occurred when a victim jumped into a fuel truck which had begun to move |
| Pictograph |
|
| Date |
October 13, 1997 |
| Place |
Toyohashi City, Aichi Prefecture |
| Location |
A construction site at Toyohashi municipal junior high school |
| Overview |
The victim arrived in a fuel truck from a local gas station to fill up the heavy construction equipment with gas. When the victim prepared to fill up the equipment, the truck suddenly began to move. The victim tried to jump into the truck to stop it. (He could just hold on to a door) However, the truck sped up, went out of control, fell on its side and unfortunately the victim was crushed under the weight of the truck. The ground where the victim stopped the truck for filling up had a slope of 3.2%. The victim may not have pulled up an emergency brake completely, and forgot to set the car lock. |
| Incident |
In the afternoon, on August 10th, 1997, when the victim prepared to fill up a hydraulic shovel (0.7m3) with gas, the fuel truck suddenly began to move. |
| Sequence |
* When the victim prepared to fill the hydraulic shovel (0.7m3) up with gas, the fuel truck suddenly began to move. The victim may have forgotten to pull up an emergency brake, or not have pulled it up completely. The biggest mistake was the fact that the victim forgot to set the car lock.
* Before starting to fill up, the victim left the truck with the engine turned on to ask an operator of the hydraulic shovel to give him a key, and the truck suddenly began to move. (A slope of 3.2%)
* When the victim noticed that the truck began to move, he was on the other side from the driver's seat. He crossed in front of the truck and tried to stop it by holding on to the driver's door. (At the beginning, the speed of the truck was not so high)
* Then, the slope became steep (see a sketch). The truck sped up along the slope of 3.2%-3.9%-7.5%. Finally, the truck bounced off an earthwork, so the victim was thrown off the truck and unfortunately was crushed under the weight of the truck. The victim had worked with the fuel truck for 13 years. |
| Cause |
* The victim did not pull up the emergency brake completely and forgot to set the car lock.
* The main contractor and the subcontractor gave the victim instructions in safety during feeding, but they did not instruct the victim to set the car lock.
* They entrusted a fuel supplier (the third contractor) with the safety control.
* Since the ground on which the victim stopped the truck to fill up had a slope of 3.2%, it is possible for the truck to begin to move.
* The victim had filled up at the same place almost every day so the victim was not careful. |
| Response |
* The fire department's view- this accident was not caused by the gas.
* The police view- A kind of traffic accident. |
| Countermeasures |
Preventive step 1
* To specify the filling up on the flat ground with a sign.
* To set stop equipment like emergency brake and a car lock when a driver leaves the driving seat.
* To provide thorough instructions in safety control to the fuel supplier.
Preventive step 2
* To make a visitor card which is same size as a driving license and require the fuel supplier to take the card around with him. |
| Knowledge Comment |
* Men want to save their precious things.
* The car has a possibility to begin to move by itself.
* It is difficult for men to distinguish flat ground from slight slope. |
| Background |
* Since the victim had done same operation almost every day, he was not careful.
* The operator entrusted a fuel supplier to the safety control because he did not feel a sense of responsibility on filling up.
* An on-site manager, the prime contractor and the subcontractor did not pay attention to the outer fuel supplier.
* The victim did not pull up the emergency brake completely.
* Regrettably, the victim forgot to set a car lock.
* It is necessary to leave the engine running when one tries to filling up with gas with a pump on the truck. |
| Scenario |
| Primary Scenario
|
Carelessness, Insufficient Precaution, Ignorance of Procedure, Disregard of Procedure, Ignorance of Procedure, Disregard of Procedure, Malfunction, Poor System, Non-Regular Operation, Emergency Operation, Malfunction, Poor System, Bodily Harm, Death
|
|
| Number of Deaths |
1 |
| Physical Damage |
The damage of fuel truck |
| Consequences |
Newspapers and television programs reported about this accident. |
| Field |
Civil Engineering
|
| Author |
KAWAMOTO, Masayuki (Japan Earth Moving Constructors Association)
KUNISHIMA, Masahiko (The University of Tokyo)
|
