Ministry Of Labour, Training And Skills Development Prevention Root .

Ministry of Labour, Training and Skills Development Prevention Root-Cause Analysis Report GENERAL FREIGHT (TRUCKING): DRIVER FATIGUE February 2020

Ministry of Labour, Training and Skills Development Prevention Table of Contents 1. Risk Assessment: The Swiss Cheese Model of Accident Causation 2. Background: Revisiting the 2019 Risk Assessment Workshop Results 3. Root-Cause Analysis: Risk Statement 4. Workshop: A Tripartite and Collective Process 5. Workshop Participants: Industry, Research and System Partners 6. “Fishbone” Diagram: Primary Causal Factors 7. Top 10 Primary Causal Factors: Prioritized List of Factors 8. “Fishbone Diagram”: Lower Level Causal Factors 9. Next Steps: Focus on Systemic Weaknesses Immediately! 10. Appendix A: Risk Assessment Methods/Standards 11. Appendix B: Workshop Contacts 2

Risk Assessment: The Swiss Cheese Model of Accident Causation Examples that could lead to increased risk Failure/absence of risk controls ACTIVE FAILURE LATENT FAILURE LATENT FAILURE LATENT FAILURE LATENT FAILURE Unsafe act Fatigue Training material not current Shortage of key skillset 3 Simultaneous failure/absence of risk controls could cause a “catastrophic event” Design issues Adapted 2013 Industrial Safety Integration

Ministry of Labour, Training and Skills Development Prevention Revisiting 2019 Risk Assessment Results: Top 10 Risk Events Risk Rank Category Event (Situation or Condition) that could result in Injury or Illness OR “What could keep you up at night?” 1 Environmental Distracted driving 2 Fatigue Driver fatigue 3 Awareness Careless drivers on the road (other truck drivers, other motorists) 4 Awareness Lack of truck awareness training for average everyday car drivers sharing the roads with the trucking industry 5 Environmental Driving conditions 6 Slips/Trips/Falls Slips, trips and falls 7 Psychosocial Stress 8 Training Inadequate or insufficient training/skills/qualifications 9 Occupational Illness Illness resulting from the lifestyle of a long-distance truck driver Slips/Trips/Falls Working at heights (tarping loads) 10 Risk

Ministry of Labour, Training and Skills Development Prevention Root-Cause Analysis: Risk Statement Based on the results of the General Freight Risk Assessment, “Driver Fatigue” was selected by the Infrastructure Health & Safety Association’s (IHSA) Transportation Advisory Council for a Root-Cause Analysis using the “Fishbone” approach: Driver Fatigue can have serious unintended adverse “ effects on the safety and well-being of the driver, carrier, fellow workers and the community.” 5

Ministry of Labour, Training and Skills Development Prevention Workshop: A Tripartite and Collective Process Workshop participants were peer-recognized industry/system experts Workshop process was open, transparent and collaborative Workshop was face-to-face. No teleconferencing Ranking/prioritization of causal factors was done using Employer and Worker votes only (Government & IHSA do not vote) 6

Ministry of Labour, Training and Skills Development Prevention Subject Matter Experts: Industry, Research & System Partners Consulted # Company/Representation # Company/Representation 1 Teamsters (Cooney Bulk Sales) * 11 ESDC Labour Program 2 Teamsters (Loblaws) * 12 University Health Network (UHN) 3 Owner-Operator (ConTrans) * 13 MTO: Enforcement & Carrier Branch 4 Non-Union (APPS Transport) * 14 Infrastructure Health & Safety Association 5 AMJ Campbell* 15 MLTSD: Operations Division 6 ERB Transportation* 16 MLTSD: Prevention Division 7 JBT Transport* 8 Midland Transport* ESDC: Employment & Social Development Government of Canada MTO: Ministry of Transportation MLTSD: Ministry of Labour, Training & Skills Development 9 Northbridge Insurance 10 Unifor (Penske Logistics) * Voting Participant 7 February 29, 2020 Workshop facilitated by MLTSD

Ministry of Labour, Training and Skills Development Prevention “Fishbone” Diagram: Primary Causal Factors People Health conditions & unhealthy lifestyle Processes Inexperienced drivers Facility delays Tools & Machines Inability to detect fatigue Vehicle maintenance Substance use Work-life balance Regulation & policy Licensing Age Distractions Attitudes Cross docking Nature of product Driver Fatigue Time Electronic Logging Devices (ELDs) Under-reporting Noise Political will Measures Number of truck/rest stops Rushing to get job done Lights Number of truck/rest stops Media Inexperienced drivers Traffic conditions Weather Security of load Regulation & policy Equipment Rest in truck Seats Business environment Fatigue management systems Vehicle/Cab design Procurement Scheduling Education & training to recognize driver fatigue Delivery zones Failure of IRS Electronic devices Line of sight Long commute home to & from work Education & training to recognize driver fatigue Hours of Service (HOS) recording device Cell phones Community Mental health Electronic Logging Device (ELD) Lights Air quality Vehicle/Cab design Roads Hypnotic effects during periods of drowsiness Environment Stress Work-life balance Classification of skill Profit margin Company culture Driver shortage Education & training to recognize driver fatigue Societal attitudes Enforcement Media Intolerance towards safety Electronic Logging Device (ELD) Culture

Ministry of Labour, Training and Skills Development Prevention Ministry of Labour, Training and Skills Development Prevention Top (Priority) Primary Causal Factors: Driver Fatigue Priority Category Primary Causal Factor 1 Environment Traffic conditions 2 People Health conditions & unhealthy lifestyle People, Culture Work-life balance Culture Culture, Processes, Measures Stress Mental health Hypnotic effects during periods of drowsiness Number of truck/rest stops Education & training to recognize driver fatigue Processes Licensing Culture Rushing to get job done Political will Inexperienced drivers Company culture Classification of skill Societal attitudes Vehicle maintenance Seats Rest in truck Electronic Logging Device (ELD) Substance use 3 People Environment 4 5 6 7 8 Environment Measures Environment, People Culture Culture Culture Tools & Machines 9 Tools & Machines Tools & Machines 10 Tools & Machines, Culture People

Ministry of Labour, Training and Skills Development Prevention Top Primary Root-Cause Primary Root-Cause Second level Root-Cause Third level Root-Cause Fourth level Root-Cause “Fishbone” Diagram: Tools & Machines Seats Procurement Suspension Reduces downtime Cost/budget Lower priced truck Changes risk levels Quality of sleeper berths Increases manufacturers market share Margins ( ) Screen time Road Procurement Automatic vs. standard transmission Change attitude of drivers Inexperience Visibility Design Vehicle/cab Design Mattress Quality Windshield Multitasking Vibration Procurement Mirrors Bluetooth Ergonomics Rest In Truck Line Of Sight Cell Phones Standards Universal standards Cost Repetitious White noise ELD Internal lights Flashing lights Company set up Cognitive load Repetitious Head lights Stress Electronic Logging Device (ELD) Electronic Devices Distribution Attention News overload Delays Downtime Lack of equipment Age Radios Lights Load type (E.g. Refrigeration noise) Dashboard Lights built-in Beepers Tools & Machines E.g. Owner/operator Company size Cost Lack of understanding of use Equipment Emission control Outdated equipment Vehicle Maintenance

Ministry of Labour, Training and Skills Development Prevention Top Primary Root-Cause Primary Root-Cause Second level Root-Cause Third level Root-Cause Fourth level Root-Cause “Fishbone” Diagram: Culture (Part 1) Driver Shortage Classification Of Skill Quality compromised Quality Deregulation Intolerance Towards Safety Overwork Government not doing their homework Attitudes evolved over the years Hours of service There is no real driver shortage Deregulation Rushing To Get Job Done Pay structure Inadequate training Hours Driver Inc. Shortage of skilled/trained drivers Pay structure Employment relationship Just-in-time Company culture Culture Customer pressure Just-in-time Under stress Skilled vs. unskilled labour Crossdocking Operations vs. safety pressure Pay structure Hours of service Deregulation Communication False sense of security Compromising safety Underestimated/ underappreciated Conflict between personal vs. company culture Not taking breaks Advanced technology Discipline Stress Public sees the truck not the driver Behaviour around a truck Dispatchers Awareness Company Culture Part 1 Anybody can be a driver More a lifestyle choice than a career choice Public awareness Societal Attitudes

Ministry of Labour, Training and Skills Development Prevention Top Primary Root-Cause Primary Root-Cause Second level Root-Cause Third level Root-Cause Fourth level Root-Cause “Fishbone” Diagram: Culture (Part 2) Electronic Logging Device (ELD) Education & Training To Recognize Fatigue Number Of Truck/ Rest Stops No advocating for truck/ rest stops Lack of standards Stress Company set up Acceptable Improper/ inadequate Getting on the road quick Cost prohibitive Lack of rest stops Infrastructure Big brother oversight Culture Part 2 Rest cycle Driver Inc. Stress Shift Financial Time management Crisis Reprisal Driver shortage Lack of spot checks Inability to refuse unsafe work Pressure on drivers Blame the driver No freight rates regulation Driver shortage Pressure on dispatch Federal vs. provincial regulations Client looking for cost reduction Family obligations Work-life Balance Awareness Enforcement Media Profit Margin

Ministry of Labour, Training and Skills Development Prevention Top Primary Root-Cause Primary Root-Cause Second level Root-Cause Third level Root-Cause Fourth level Root-Cause “Fishbone” Diagram: Processes Licensing Facility Delays Cross Docking Scheduling Time zone change Road test in 25 languages Competing warehouse priorities Road signs only in 2 New immigrants not acclimatized in road rules/laws Resources Just in time Inaccurate information Dispatchers Pressure to keep going Scheduling System failing the driver Management by dispatchers/drivers Trip planning Slip seating Processes Different region to region Different Hours of Service Knowledge & training Compliance vs. education Enforcement exposures Lack of relevant & meaningful policy Devices Fit for duty Regulation & Policy Shift work Shipper Lack of government support Speed limiters Log book improperly maintained Perception of Risk of Load e.g. flammable Inability To Detect Fatigue Nature Of Product Driver Consistency Lack of apprenticeship Dispatch Quality Behaviour Understanding diverse groups Variety Messaging & delivery Education & Training To Recognize Fatigue

Ministry of Labour, Training and Skills Development Prevention Top Primary Root-Cause Primary Root-Cause Second level Root-Cause Third level Root-Cause Fourth level Root-Cause “Fishbone” Diagram: Environment (Part 1) Electronic Logging Device (ELD) Time Inexperienced Drivers Long Commute Home To & From Work Accidents Task Pay structure Stress Muscle fatigue Training/Skills Multitasking Repetition Over work hours Company set up Time zones Licensing Lack of rest time Driver Inc. Environment Part 1 Awareness Bells Blame the driver Temperature Quality of rest Snow ploughs Customer locations Having more than one employer Cost cutting competitiveness Customer locations Emergency detour routes Congestion Speed limiters Dangerous drivers (public) Road closures Scheduling Delays Train Noise Weather Media Business Environment Traffic Conditions