Date of incident: February 2021
Notice of incident number: 2021112850004
Employers: Ski hill

Incident summary

At a ski resort, two workers travelled up the ski hill in a snow grooming machine, snowcat 1, to conduct repairs on a second, broken-down snow groomer, snowcat 2. They parked near snowcat 2, and one of the workers (the operator of snowcat 1) started troubleshooting a mechanical problem with snowcat 1 that he had noticed. The other worker exited the cab and stood on the machine’s passenger-side track. The operator, not realizing that the other worker had exited snowcat 1, spun in his seat to obtain a better view of the rear of the machine, which caused his left elbow to contact the machine’s forward track controls. The machine lunged forward, and the other worker was thrown under its track. He sustained fatal injuries.

Investigation conclusions

Cause

• Snowcat ran over worker after unintended activation of controls. While the operator was occupied with trying to solve snowcat 1’s tiller problem, the other worker exited the operator’s cab and stood on snowcat 1’s passenger-side track. The operator, who had not noticed the other worker leave the cab, spun in his seat to look over his right shoulder out the rear window of snowcat 1 at the tiller. His left elbow inadvertently contacted the track controls by the left armrest, causing snowcat 1 to move forward. The worker on the track was propelled forward and then under the snowcat.
• Parking brake not applied. When snowcat 1 arrived at the incident scene, the operator stopped the machine, did not apply the parking brake, and sat stationary for about 30 seconds while trying to diagnose the tiller malfunction as the other worker sat in the passenger seat. The operator’s manual for snowcat 1 and the employer’s third-party slope grooming manual stated that when the snow grooming machine is stopped, entered, or exited, the parking brake must be set. Unlike other types of snow grooming machines, snowcat 1 was not equipped with a door interlock that would automatically apply the parking brake if a door on the operator’s cab was opened.

Contributing factors

• Equipment malfunction. Because snowcat 1’s tiller (on the back of the machine) was not lifting correctly, backing up the machine to get it off the fallen worker was not a viable option. If snowcat 1 was put in reverse without its tiller lifted, the tiller would get caught on the snow and prevent the machine from moving backward. Also, with the tiller not lifting, the lift-and-reverse feature on snowcat 1 (which caused the tiller to lift automatically when snowcat 1 was put in reverse) would not have been operational. Because the tiller would not lift, the operator planned to drive snowcat 1 forward so that the fallen worker would end up behind the body of snowcat 1 but in front of its tiller.
• Lack of experience with snowcat 1. Unlike snowcat 1, snowcat 3 had a door interlock safety system that would set the machine’s parking brake automatically if a door of the operator’s cab was opened. Experience with snowcats like snowcat 3 may have factored into the operator not setting the parking brake in snowcat 1.
• Lack of adequate training. The worker who was fatally injured was a new worker according to the Occupational Health and Safety Regulation, but no record of new worker orientation or other required training existed. The investigation found no evidence that the employer provided workers with training to operate and troubleshoot the snow grooming equipment at the resort.
• Inadequate supervision. The operator’s manual for snowcat 1 stated that towing was an operation that required extensive safety measures, and advised workers to consult the manufacturer’s service support centre before towing. A hazard identification or risk assessment for the activities planned (which included trying to tow snowcat 2 with snowcat 1 if necessary) had not been completed. As well, no direct supervisor input had been provided on the repairs being attempted the day of the incident.
• Inadequate health and safety program. The employer’s health and safety program lacked the critical components of hazard identification and risk assessment, as well as safe work procedures (SWPs) for troubleshooting mechanical problems with the snow grooming machines. Managers and supervisors did not identify these gaps in the program and rectify them. These failings contributed to the development of unsafe working conditions on the day of the incident.

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