Posted: February 16, 2012
PG&E’s final report on Miles, Weiss fatal accident
Note: The narrow edge of the roadway with the drop-off to the dirt shoulder and the skid marks
The following report was recently prepared and distributed by PG&E management.
This is the final communication following our investigation into the serious motor vehicle incident, where Linemen Ryan Miles and Aaron Weiss tragically lost their lives when their 4-door F-550 service body truck went off the road and into the Rock Creek Reservoir off of State Route (SR) 70 in the Feather River Canyon, east of Chico. Our investigation into this serious incident is complete and we want to share our conclusions, along with the steps that will be taken to help prevent a terrible accident like this from happening again. Please share this information with your employees.
On Thursday, October 13, 2011, at approximately 4:30 p.m., two Electric General Construction (GC) employees from the Chico Service Center were fatally injured in a motor vehicle incident. Linemen Ryan Miles and Aaron Weiss tragically lost their lives when their vehicle went off the road and into the Rock Creek Reservoir off of SR-70 in the Feather River Canyon, east of Chico. Two other employees in the truck were able to escape the submerged vehicle and survive the incident with minor injuries.
(Figure 2) Skid marks leading to the reservoir
Four employees were returning from their work location to their temporary headquarters when the incident occurred. They were part of a larger GC crew working on the Caribou #2 60KV capital improvement project, which was approximately a one-hour drive from their reporting location. The crew's work assignment for the day was to frame six-to-eight poles at various locations in the area.
Weather conditions were clear and SR-70 was dry and in good condition. The PG&E vehicle was witnessed by a California Highway Patrol (CHP) officer roughly seven minutes prior to the incident. The officer stated that the vehicle appeared to be driving at a safe rate of speed with the headlights on and all seatbelts fastened.
The speed limit on this section of SR-70 is 55 miles per hour. According to the CHP report and the vehicle’s Restraint Control Module (aka Black Box) data, the vehicle was not traveling in excess of this speed.
As the vehicle traveled westbound on SR-70, it drifted to the right and onto the unpaved gravel shoulder. In an effort to bring the vehicle back on the road, the driver turned the steering to the left. This turning movement sent the vehicle into an uncontrollable counter-clockwise yaw across both lanes of SR-70 and into the Rock Creek Reservoir.
The two employees seated in the rear of the vehicle were able to escape through their respective doors. Both Ryan Miles and Aaron Weiss who were seated in the front of the vehicle were unable to escape.
(Figure 3) Incident Reconstruction
Investigation Key Findings:
1. Based on CHP interviews with the surviving spouses, both Ryan and Aaron got about 6 to 7 hours of sleep the night prior to the incident. Ryan had taken the prior three-day weekend off and worked two 10-hour days prior to the incident. The crew met at 6:00 a.m. at Paradise Service Center and later arrived at Roger’s Flat at approximately 6:45 a.m. None of the employees on the crew complained of being tired at any time throughout the day. The crew had a normal lunch and took regular morning breaks. The work for the day was relatively light and consisted of framing six-to-eight poles at Roger’s Flat and on Caribou road, in addition to staging material for the next day. Ryan was current in all required motor vehicle related courses including the Smith Driving System.
2. The vehicle was new (placed in service on 8/18/2011) and in normal operating condition prior to the incident. Moreover, there were no manufacturer recalls in effect nor were there any documented complaints by drivers of this vehicle. The side-curtain air bags and driver’s-side seat air bags deployed. When tested, all four doors were functional and the deployed air bags did not appear to obstruct access to the door handles. The vehicle’s weight was within the manufacturer’s specifications, and the vehicle was not overloaded with tools and material, therefore the weight of the truck was not a factor in this incident.
3. Both PG&E and California Highway Patrol (CHP) investigations concluded that the PG&E vehicle lost control when the right-side tires went off the pavement and dropped three-to- four inches onto the dirt shoulder. Based on the CHP report, the driver turned the steering wheel to the left in an attempt to bring the vehicle back onto the roadway. This turning movement sent the vehicle into an uncontrollable counterclockwise yaw across both lanes of SR-70 and into the Rock Creek Reservoir. The driver-side rear door window was broken upon impact, which likely resulted in water rapidly entering the vehicle.
4. While we may never know why the vehicle initially drifted off the roadway, this incident is a clear reminder that there are no routine activities – including driving – and we must always strive to maintain focus and situational awareness of the task at hand.
Note: The vehicle skidded across the roadway after the driver turned the steering wheel in an effort to bring the vehicle back on the road.
As a corrective action, we plan to create an instructional video on how to safely re-enter a roadway and share it with our employees.
While the investigation was unable to determine why the vehicle drifted off the road, it is important that we be reminded of the hazards of driving and some steps that we can all take to keep us safe when behind the wheel. Driving is considered to be one of the most dangerous activities we do each day. In fact according to the Smith System Driver Improvement Institute, a recognized leader in safe driving techniques, the Occupational Safety and Health Administration (OSHA) and the National Highway Traffic Safety Administration (NHTSA) consider driving the number one work-related event that results in fatalities in the last 20 years. We need to focus on driving, maintaining a safe speed for the condition of the road, staying in control of our vehicle, and maintaining our situational awareness.
By taking your eyes off the road for 5 seconds while traveling 60 m.p.h., your vehicle will travel approximately the length of the football field. Avoid any activities that will remove your focus from driving.
SMITH Driving gives us 5 principles for safe driving practice:
- A 15 second eye lead time provides advanced warning of dangerous situations
- Good decisions cannot be made without adequate time to evaluate your driving environment
- Maintain a minimum of 4 seconds following distance
- Position your vehicle to maximize visibility
- Scan at least one of your mirrors every 5 to 8 seconds
- Avoid focusing on any object for more than 2 seconds
- Active eyes enable you to get and keep your big picture
- Surround yourself with space
- Your safest position in traffic is where the fewest potential conflicts exist
- Seek eye contact
- Use your warning devices at the proper time
All of us want to return home safely. Our family and love ones are depending on us.
Our ability to maintain awareness of our environment and associated hazards is essential to our safety, as well as our co-workers and the general public. All employees should continually reinforce Situational Awareness and utilize the Human Performance Tools as referenced in the Safety and Performance Fundamentals Handbook.
Please share this important information with employees in your organization.
|Gregg Lemler||Maria Henderson||Mike Swanson||Ron Van Hoosear|
|Sr. Director, Electric M&C||Sr. Director (Interim), SE&HS||Director, Restoration & Control||Director, Distribution Operations Field Safety|