Norfolk report faults safety lapses in worker's death

NORFOLK

Managers and employees in the city's waste management department had a poor understanding of safety and made "unacceptable risk decisions" that contributed to the death of a sanitation worker, according to an internal review.

In addition, two critical safety systems failed to work when Jerry Holton died in the back of a city trash truck. Holton had pressed a button that should have shut off the truck's hydraulic system, but it didn't work, according to the report.

Norfolk never inspected the truck's two safety systems prior to Holton's death, the report says.

The latest details about Holton's death and the city's waste management department were revealed in the report, which The Virginian-Pilot obtained under the Freedom of Information Act. It was written by city safety officer Craig Watkins, who, while critical of the waste management department, also said that Holton, 51, failed to follow certain safety rules, too.

The lack of safety training was a "contributing factor" in Holton's death, according to Watkins' findings, and the waste management department failed to participate in training required by the federal and state government.

Since Holton's death, City Manager Marcus Jones has replaced senior management in the waste management department, and safety training has improved, Watkins said.

Holton, a Navy veteran who had worked for the city for 21 years, died Feb. 3 in the back of a city truck. He had climbed into the "hopper" section to clear debris that blocked the system from crushing trash. The system engaged while he was in the hopper, and he was crushed.

The truck was one of nine the city purchased from the Southeastern Public Service Authority, the regional trash agency, in May 2010. Many were beyond their expected useful life of six years and subsequently needed repairs. One had to be towed to Norfolk from Chesapeake. The city spent $200,000 in repairs on the trucks in their first year of use, according to city documents.

After Holton's death, a state investigation cited the city for 19 serious violations of state laws and regulations, including eight directly related to the incident.

Watkins and other city leaders told The Pilot last month that one safety system had failed that might have saved Holton's life. They acknowledged then that two of the former SPSA trucks had been rewired to bypass a mechanism designed to shut down the hydraulic system when a hopper door is opened.

In his report, Watkins wrote that another safety system, the truck's "power takeoff" switch, also failed. When depressed, it was supposed to shut down the truck's hydraulic system. When the truck was rewired to bypass the hopper door safety system, the power takeoff switch became inoperative, Watkins said.

Holton appears to have depressed the button to turn off the hydraulic system, Watkins wrote.

The fact that Holton was not trained to drive the Heil truck he used that day was also a factor in his death, Watkins wrote. He did so because the one he usually drove was broken, Watkins said. It was Holton's second time driving the vehicle he died in, Watkins said.

The compaction systems, which use hydraulic power to crush trash, are different in the Heil truck and the one that Holton typically used. The system in the truck he usually drove has a "continuous motion" system that always moves when it operates. That allowed Holton to see, when he depressed the power takeoff switch, that the system had shut down.

The compaction system in the Heil truck was not in continuous motion, Watkins said, so there was no way for Holton to know whether the system was still engaged when he pressed the button.

Whether SPSA, the city or a private vendor rewired the truck has not been determined. When contacted last week, Watkins and SPSA Executive Director Rowland "Bucky" Taylor denied rewiring the truck.

Any work the city required on the wiring services of trucks likely would have been contracted out to Mid-Atlantic Waste Systems of Chesapeake, Watkins said, adding that he couldn't find a request from the city to re-wire the truck Holton drove.

Rich Weinstein, general manager of the Easton, Md., company, said Mid-Atlantic last worked on that truck in 2007, when it was owned by SPSA.

"We looked at our records, and we never worked on the electrical system," Weinstein said last week. "And we would never bypass a safety system."

Watkins said the city is continuing to investigate how the rewiring occurred.

"It's important that we find out," he said.

The city has not received maintenance records from SPSA on the trucks they purchased even though Norfolk has requested them, Watkins said. SPSA officials said they gave Norfolk officials the opportunity to take the maintenance records before and after the trucks were sold.

Taylor said in an email Friday that the records were discarded five months after Norfolk purchased the trucks.

In the report, Watkins wrote that Holton put his own life in jeopardy by failing to turn the truck off and take the keys out of the ignition, an industry standard. Holton also ignored warning placards on the access door to the back of the truck that said keys must be removed from the ignition prior to entering.

Watkins said other sanitation truck drivers he interviewed admitted that they also had entered the backs of trucks without taking the keys out of the ignition. They did so, he said, because it often takes minutes to bring a truck's hydraulic system up to full operation after shutting off the vehicle.

"You tell a worker he has to follow certain procedures," Watkins said. "But if I'm a driver, I can save time by not following that procedure. If I do this procedure 40 times a week, it can pay off."

At the time, city policy was to allow a driver to enter the back of a truck after taking the keys out of the ignition. A mechanic must now be present whenever a driver enters the back of a truck.

Jessica Holton Hendricks, Jerry Holton's daughter, said, "My father would not have gotten into the back of the truck without taking the keys out of the ignition unless others were doing the same thing. He was a careful man."

Watkins said he believes the city's decision to purchase the SPSA trucks complicated the safety training by introducing new types of vehicles to a fleet that had too many makes and models. The city needs to standardize its sanitation trucks so training can be universal, he said.

When asked whether drivers in Norfolk are safe now, Watkins said: "I think we're safer. I don't think we're as safe as we can be. That's my honest opinion.

"It's going to be an evolving process."

Harry Minium, (757) 446-2371, harry.minium@pilotonline.com