Fatality Assessment and Control Evaluation (FACE) Program
Youth Farm Worker Dies After Falling Into Operating Feed Grinder/Mixer - Ohio
On August 15, 2002, a 14-year-old male farm worker (the victim) died after falling into an operating cattle feed grinder/mixer. The victim was using a handheld hay hook to drop hay bales into the operating grinder from the top of a stack of hay bales. He apparently lost his footing, slipped, and fell into the grinder. Approximately 20 minutes later, a coworker entered the area and noticed that the grinder was running unattended. He then called out to the victim and received no response. After looking into the mixing/grinding area of the machine he realized that the victim had fallen into the operating grinder and immediately stopped the machine. Emergency Medical Service (EMS) was summoned via 911 and responded within minutes. The coroner pronounced the victim dead on site.
NIOSH investigators concluded that, to help prevent similar occurrences, employers should
On August 15, 2002, a 14-year-old male farm worker (the victim) died after falling into an operating cattle feed grinder/mixer (feed grinder) from above. On August 16, 2002, the U.S. Department of Labor, Wage and Hour Division, notified the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), of the incident. An investigation was initiated by the Chief of the NIOSH Trauma Investigations Section (TIS) on September 17, 2002, with the Federal Wage and Hour investigator via telephone. On September 19 and 20, 2002, the NIOSH TIS Chief met with representatives of the County Sheriff’s Department as well as the Compliance Officer and Assistant Area Director from the U.S. Department of Labor, Occupational Safety and Health Administration (OSHA). The respective investigative case files and findings were reviewed. Photographs of the incident scene taken by these agencies, the coroner’s report, and EMS report were also reviewed. A telephone interview was conducted with the employer involved in the incident on September 23, 2002. On May 9, 2003, a site visit was conducted.
The employer involved in this incident was a co-owned dairy farm that had been in business for over 50 years and operated five farms at various locations at the time of the incident. The employer had 8 employees (including two youth workers – the victim and a 17- year-old male worker) that performed work supporting 126 dairy cows at the time of the incident.
The victim was a part-time summer employee and had been working for the employer for approximately 4 months prior to the incident. The victim worked an average of about 30 hours per week, with work shifts starting typically at 8:00 a.m. The victim’s summer term of employment was to be completed on August 17, 2002. The victim had been formally trained and possessed a certificate of training from 4H, through the Cooperative Extension Service, a service of the Ohio State University, for tractor operation. The employers had retained a copy of this certificate for their records. The certificate identified prohibited occupations in agriculture for children below the age of 16 including “operating or assisting to operate (including starting, stopping, adjusting, feeding, or any other activity involving physical contact associated with the operation) any of the following machines...feed grinder.”
The employer’s safety policies were un-written, however, in addition to the Extension Service training that the youth completed, all new employees were reportedly given hands-on and on-the-job training on how to perform various farm-related duties. Typical duties for the youth employees included feeding and tending the dairy cows, cleanup, operating tractors, and other farm labor duties as assigned.
This was the employer’s first workplace fatality.
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The feed grinder/mixer (feed grinder) involved in this incident was approximately 5 years old and had been purchased from the manufacturer new. The portable feed grinder was hitched to and powered by the power take-off (PTO) of a tractor (Photo 1). The tractor was operated by key, which was left in the ignition (Photo 2). The feed grinder was used on this dairy farm to mix, grind, and blend various feeds, including alfalfa pellets, corn silage, and hay to be fed to the dairy cattle.
The victim had assisted the co-owner and co-workers with the feed grinding operation on previous occasions. According to a co-worker, the victim had been seen on top of the hay stack in the past, and had been told not to stand on top of the hay bales to directly load hay into the feed grinder. Normal procedures were to drop the hay bales from the hay stack down onto a hay wagon. The hay wagon had a working surface approximately 36 inches above ground level (Photo 3) that was positioned near the feed grinder. After the hay bales were dropped down to the hay wagon, employees would get on the hay wagon, hook the bales with a hand-hook, and throw the bales up into the feed grinder. (Note: The loading area of the feed grinder was approximately 7 feet in height, so the workers, while standing on the hay wagon, needed to throw the hay bales approximately 4 feet up and into the feed grinder. The hay bales measured approximately 36"x 18 ½” x 18 ½”, and according to the employer, weigh about 70 pounds when dry). Employees on the farm were reportedly prohibited from performing this operation alone. The victim was permitted only to assist the co-owner or another worker in performing the operation, and only as assigned.
Earlier in the morning of the incident, the victim had reportedly gone to the co-owner asking for job duties. The co-owner stated that he did not have any at the time, and he directed the victim to go to the other co-owner for direction. The owners of the farm both stated that neither of them had assigned grinder loading duties to the victim on the day of the incident. Feeding of the cattle was not scheduled to occur until later in the day. Apparently the victim had not met with the other co-owner, but rather had decided to climb the hay stack and load the operating feed grinder from above. The hay stack was noted to be stacked nine bales high, making the working surface approximately 13 feet above the lower ground level. The victim’s work position was estimated at approximately 6 feet above the point(s) of operation* of the machine. During the process of loading the hay bales into the feed grinder, the victim apparently slipped down into the feed grinder auger area (Photo 4) and was killed instantly.
A co-worker had reported that at approximately 8:45 a.m. he had seen the victim in the area of the tractor and feed grinder and noted that the victim was on top of the hay stack. The coworker was in the process of driving a tractor down the road, away from the farm at the time. When the coworker returned at approximately 9:05 a.m., he attempted to locate the victim. The coworker noticed that the tractor and feed grinder were still operating, and the hay hook that the victim was apparently using was now lying on the ground on the side of the machine. The coworker stated that he looked into the feed grinder and observed the motionless victim. The coworker reportedly immediately shut off the machine and sought help. EMS was called and responded within minutes. On arrival EMS realized that the victim was deceased. The coroner was summoned and pronounced the victim dead at the site.
*According to the Occupational Safety and Health Administration (OSHA), the point of operation on a machine is “the area on a machine where work is actually being performed upon the material being processed”.
Cause of Death
The cause of death listed on the coroner’s report was multiple traumatic injuries.
Recommendations and Discussion
Recommendation #1: Employers should ensure that machinery such as top-loading feed grinders are positioned away from upper level work areas where employees could slip and fall into or onto it, and that the machinery is not operating during manual loading.1
Discussion: Machinery such as top-loading feed grinders and other dangerous equipment should be positioned away from upper levels where employees could slip and fall into or onto it. The operator’s manual for the grinder in this incident includes such guidance: “do not operate mixer if any person is positioned near or over the top of box.”
The manufacturer’s operator’s manual states “do not hand load materials while unit is running.” The co-owner stated that the normal procedure for this operation was to throw the bales of hay down onto a hay wagon with a working surface level approximately 36 inches from the ground and then get on the hay wagon, hook the bales with a hand-hook, and throw the bales up into the operating grinder.