Final Incident Communication Incident Date: 10/21/11 Officers and Directors: This is the final communication following our investigation into the motor vehicle incident, where Utility Worker Jeremy Kirk was seriously injured when his company vehicle went off the road on State Route (SR) 108 east of Sonora. Our investigation into this incident is complete and we want to share our conclusions, along with the steps that will be taken to help prevent an accident like this from happening again. Please share this information with your employees. Incident Summary: Jeremy Kirk, a Utility Worker with four years of company service, sustained serious injuries after his Company vehicle went off the road and into the embankment off of Highway 108. The incident occurred 6 miles east of Leland Creek at approximately 5:15 p.m. on Friday, October 21, 2011. This was a single-vehicle incident and the employee was driving alone. What Happened: Jeremy Kirk was part of a larger Power Generation GC Hydro Construction crew working on the Relief Dam project at Kennedy Meadows. At the end of the work day, Jeremy was driving a PG&E Ford F250 4X4 ¾ -ton regular cab long bed pickup truck to return to the work crew s assembly point when the incident occurred. On the day of the incident, weather conditions were clear and SR 108 was dry and in good condition. As the vehicle traveled westbound on SR-108, it drifted to the right off the paved road and onto the gravel shoulder. In an effort to bring the vehicle back onto the road, the driver forcefully turned the steering wheel to the left. This turning movement sent the vehicle into an uncontrollable counter-clockwise yaw across both lanes of SR-108, striking a granite boulder embedded in the opposing embankment. The vehicle ricocheted off the opposing granite boulder causing the vehicle to land back across both lanes of SR-108 and onto the westbound lane s dirt shoulder. When PG&E crew members came upon the scene soon after the incident, they found Jeremy outside of his vehicle and lying on the dirt shoulder of the westbound lane with serious injuries. The crew members immediately contacted Emergency Medical Services, secured the incident scene, ensured that the area was safe, performed traffic control and administered first aid to Jeremy. As a result of their exceptional efforts, the rescue crew has been nominated to receive a Britton award. Investigation Key Findings: 1. Both PG&E and California Highway Patrol (CHP) investigations concluded that the PG&E vehicle lost control when it drifted off the road and the right-side tires dropped 1 to 2 inches onto the gravel shoulder. In an effort to bring the vehicle back onto the road, the driver forcefully turned the steering wheel to the left, causing the vehicle to enter into an uncontrollable yaw across the west and eastbound travel lanes, where it struck a granite boulder embedded in the cut bank along the south side of the roadway. The vehicle struck the opposing granite boulder with force great enough to cause the vehicle to ricochet off the granite boulder and land back across both lanes of SR-108 onto the dirt shoulder of the westbound lane. 1 of 6
2. According to the vehicle's Powertrain Control Module and investigation findings, the vehicle was traveling approximately 67 mph at the time of the incident, which is the above the posted speed limit of 55 mph. 3. The CHP's and PG&E's investigative findings revealed that the employee did not wear his seatbelt at the time of the incident. As a result of not wearing his seatbelt, the employee was forcefully thrown around in the cab of the vehicle after hitting the granite boulder, causing the employee to sustain serious injuries. 4. Based on the investigation findings, the employee s injuries were significantly more severe as a result of the increased speed of the vehicle and his failure to wear a seatbelt. 5. Based on the employee and crew-member interviews, fatigue was not a factor to the incident. 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 breaks. 6. The vehicle was placed in service on 8/17/2006 and was in normal operating condition prior to the incident. There were no modifications made to this vehicle, no manufacturer recalls were in effect, nor were there any documented complaints by drivers of this vehicle. The weight of the vehicle was not a factor in this incident, as the vehicle's weight was within the manufacturer's specifications and the vehicle was not overloaded with tools and materials. 7. 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. (figure 1) Vehicle Damage - 2006 F250 4x4 3/4-ton regular cab long bed pickup 2 of 6
(figure 2) State Route 108 Westbound Note: This depicts the view entering the left curve where the vehicle drifted off the right shoulder. (figure 3) State Route 108 Westbound Right Shoulder Note: This depicts where the vehicle drifted off the right shoulder. 3 of 6
(figure 4) State Route 108 Westbound Opposite Embankment Note: This depicts the vehicle travel path to opposite embankment. (figure 5) State Route 108 Westbound Opposite Embankment Note: This depicts where the vehicle contacted opposite embankment. 4 of 6
(figure 6) State Route 108 Westbound Opposite Embankment Note: This depicts vehicle travel during incident. Corrective Actions: 1. Create a safety video on how to safely re-enter a roadway. Owner: Myron Ko Due Date: April 1, 2012 2. Identify high-exposure work groups to complete one of the two classes provided by PG&E Academy via My Learning: EQIP-0012 Defensive Driving Passenger vehicle Including the Skid-car EQIP-0121 Defensive Driving Truck Including the Skid-truck Owner: Randy Livingston Due Date: April 1, 2012 3. Discuss incident and lessons learned at First Quarter Safety Conference. Share tailboard for General Defensive Driving Maneuver for Controlling Vehicle When Your Tires Go Off the Road." Owner: Randy Livingston/Scott Roesener Due Date: April 1, 2012 Reminders: While the investigation was unable to determine why the vehicle initially drifted off the road, it is important to remember the hazards of driving and steps to stay safe behind the wheel. Driving is considered to be one of the most dangerous activities we do each day. In fact, 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 No. 1 work-related event that results in fatalities in the last 20 5 of 6
years. Given that statistic, our No. 1 focus needs to be on driving. When driving, always focus on maintaining a safe speed for the condition of the road and maintaining our situational awareness. By taking your eyes off the road for 5 seconds while traveling 60 mph, your vehicle will travel approximately the length of the football field. Avoid any activities that will remove your focus from driving. All of us want to return home safely. Our family and loved ones are depending upon us. Our ability to maintain awareness of our environment and associated hazards is essential not only to our safety, but also to the safety of our coworkers and the general public. All employees should continually reinforce Situational Awareness and utilize the Human Performance Tools (e.g. Two Minute Rule, Self-Checking/STAR and Questioning Attitude) as referenced in the Safety and Performance Fundamentals Handbook. Please share this important information with employees in your organization. Randy Livingston Vice President - Power Generation Maria Henderson Sr. Director (Interim) - SE&HS The PG&E investigation team is as follows: Lyndon Jesmin Lead Investigator - Safety Engineer, SE&HS Al Bolen Sr. Safety Program Consultant, SE&HS Suzanne Lightstone - Principal, Utility Performance Improvement Ken Lee Attorney, Law Department Jim Powell Manager, Fleet Services Bert Friel - Supervisor, Fleet Services Larry Parks - Supervisor, PG&E Academy David Forester Supervisor, Power Generation Jason Phillips Miscellaneous Equipment Operator, Power Generation Odorado Lopez-Yanez - Fleet Engineer, Transportation Services 6 of 6