Description of Event:
On Monday, December 14, 2021, a hydro operator employee traveled eastbound on HWY 222 at 3 22 am. He lost traction and slid into a nearby guardrail in his personal vehicle, a 4 Wheel Drive (WD) truck. The employee left for the Powerhouse (PH), taking an alternate route for his 12-hour shift. Based on interviews, the employee was well-rested and ready for his drive after an unexpected day off Monday, December 13, 2021 due to a road closure on highway.
Per the lead hydro operator, he had spoken with the employee on Monday the 13th around the long drive on HWY 222. He stated that with inclement weather conditions arriving “on time” was not the priority and that being well-rested and making the drive at a safer time was to be prioritized. The supervisor did not recall if a driving Job Safety Analysis (JSA) was mentioned.
The morning of the drive was snowing, dark, with low visibility, reportingly 4 inches of snow on the ground. Before leaving the house, the employee called the switching center to let the night shift operator know he was on his way and would be an hour late and verified that chains were not required using the state transportation website. He also checked the weather, and the only snow reported was in an area closer to the powerhouse.
The employee was thirty minutes into his drive, approximately 20.7 miles from home at an elevation of around 3,589 feet. The driver typically uses a 2 WD passenger vehicle as a commute car, but he anticipated snow at a higher height of 4,534 feet, so he took his 4WD truck. As he was approaching a slight curve going 40 miles per hour (MHP) he felt his tires start to slide. When he recognized his tires had lost traction, he pressed the brakes as a natural reaction. Since chains were not required for the local area, the employee operated in 2WD instead of 4WD while heading to the powerhouse. After impact, the driver got out to look at the damage to the front and side of his truck and roughly 20 feet of damage to the guardrail when he saw ice under the snow.
Actions Taken:
The employee safely moved the vehicle out of the roadway and contacted the switching center using a handheld company radio. The switching center contacted the supervisor, the state highway police, and towing service.
Method & Findings:
Human Factors:
Omitted Action – The employee did not perform the driving JSA as required by the Job Safety Analysis and Pre-job Brief company procedure.
Improper technique – The employee was driving 40 MPH during snowy icy conditions. The state highway police report recommended speed limit at that time was 25 MPH. Also, the employee was driving a 4 WD vehicle in 2 WD.
Inadequate situation assessment – Failure to recognize changing weather conditions. It was approximately 3:30 am with low visibility, about ¼ of a mile, snowy icy conditions.
Inadequate action/response – The employee was driving 40 MPH during snowy icy conditions. The state highway police report recommended speed limit at that time was 25 MPH. Also, the employee was driving a 4 WD vehicle in 2 WD.
Suboptimal ambient environment – The employee started his drive at 3:00 a.m. during freezing temperatures, in the dark, with low visibility.
Inadequate planning – The employee did not complete driving JSA to assess all driving hazards.
Failure to provide adequate training – Employee wasn’t given the opportunity to take 4WD training.
Policies/Procedure- There is no clear understanding on when a driving JSA is required to be completed. Legal state the utility carries no responsibility over traveling to and from work and the intent of the guidance is a JSA is performed when traveling from site to site. However, based on discussion with hydro operations leadership, employees are required to complete the driving JSA before leaving their residence. Leadership is under the impression that employee is identifying hazards before driving when they aren’t being assess until they arrive at the powerhouse.
Supporting Materials:
Corrective Actions:
A-1- Driver participated in the Fleet Response Driver Training Course: Driving in Adverse Weather Conditions.
CA-2- Tail boarded incident to Supervisor group
CA-3- Tailboard safety stand down at the team meeting.
CA-4- Provide additional training to driver in weather requirements.
Sequence & Completion Dates for Actions Listed:
Lessons Learned:
Recommendations: