Lessons from fatal tyre maintenance incidents

What happened?

Multiple safety incidents related to vehicle

maintenance have been reported. Among these
incidents, some have involved tyre maintenance on
vehicles. Below are two examples that illustrate the
importance of vigilance in vehicle upkeep:

1. —A contracted tyre technician was struck

and killed by a tyre rim after a sudden failure.
—The heavy vehicle tyre was previously
inflated inside a safety cage and mounted on
a one-piece rim.

—The technician noticed air leaking from the

tyre while it was resting outside the safety
cage.
—While the technician was
inspecting/troubleshooting the tyre, the wheel
suddenly parted, causing the rim to eject and
hit the technician on the head.

—The fatal outcome was a result of the

unexpected release of the tyre rim and the
impact on the technician.

2. —An employee was fatally struck by a heavy

vehicle tyre rim during maintenance.
—The heavy vehicle wheel involved had
been reported defective by a previous shift
driver.

—The driver was loosening the lug nuts of

the defective wheel with the intention of
replacing it with a spare.

—During this process, the rim

catastrophically failed and cracked in two,
releasing the tyre and part of the rim with
explosive force.

—The driver was projected several metres

away from the vehicle due to the force of the
release. Unfortunately, the driver sustained
fatal injuries as a result of this incident.
Why did it happen?

Both incidents occurred during routine activities in

controlled logistics environments, suggesting that
even seemingly standard procedures can carry
risks.

Following the incidents, prior damage was noted

on the tire rims in both cases. This may have
occurred either through wear and tear during rough
terrain driving or potentially through driving with a
partially deflated tire.

In both incidents, workers were in the line of fire

from a pressure hazard and had not recognised
this as a risk.

In both incidents, the tires were not deflated prior

to the troubleshooting task commencing.

In one incident, substandard practice was noted, in

that the wheel was removed from its cage without
an inspection of the rim seat area.

In both incidents, tire rim damage had been

sustained and not recognised. Subsequent
inspection of other vehicles found cases of cracks
and damage.

In the first incident, original equipment

manufacturer (OEM) recommendations for tire rim
inspection had not been followed.

In the second incident, learnings from the first

incident had been insufficiently embedded.
What did they learn?

The catastrophic failure of the tyre rims resulted in

fatal accidents, highlighting the importance of
proper inspection and maintenance procedures.

Perform tyre and tyre rim inspections across the

fleet of vehicles and verify inclusion of both tyres
and tyre rims in vehicle inspection programs.

Raise awareness of the need to deflate tyres

before removal from the vehicle.

Raise awareness of the general risk of pressure

release from tyres and different modalities where
such release can occur.

Reinforce line of fire awareness with all personnel

and the importance of avoiding body positioning in
the line of fire.

Procure and raise awareness of tools and methods

that enable humans to perform any activities
related to tyres, such as inflation and deflation,
away from the line of fire.

Reinforce the hazard of tyres and tyre rim damage

through reflective learning or similar activities.

Attain a deeper understanding of tyre rim

construction, types, and inspection requirements
as per OEM recommendations.

Reinforce the requirement to monitor for weak

signals with respect to tyre and tyre rim
construction during driving. Stop the job in case
anomalies are noted.

Reinforce the availability of learnings from previous

incidents.
Ask yourself or your crew

How can something like this happen here (e.g. on

our site)?

What safety measures (i.e. procedures,

controls/barriers) do we have in place to mitigate
the risk?

How do we know the risk controls/barriers are

working?

What improvements or changes should we make

to the procedures, controls/barriers, or the way we
work?

Multiple safety incidents related to vehicle maintenance have been reported. Among these incidents,
some have involved tyre maintenance on vehicles, highlighting the importance of proper inspection
and maintenance procedures.

Original content courtesy of IOGP