|NIOSH In-house FACE Report 2004-01
May 14, 2004
On October 18, 2003, a 23-year-old Hispanic laborer (the victim) leaned outside
a skid steer loader’s operator compartment and was crushed between the frame
of the skid steer loader and a scraper attachment. The victim and three other
Hispanic coworkers were assigned to routine cleanup at a rendering plant. The
victim was operating a skid steer loader equipped with a metal/rubber scraper
attached to the loader lift arms. After completing his cleaning task, the victim
drove the skid steer loader behind the plant. Approximately 10 minutes later,
the plant manager went to look for him and discovered the victim crushed between
the frame of the skid steer loader and the scraper attachment. The plant manager
used the controls to release the victim, and he and a coworker carried the victim
to the parking lot where they placed him on the ground. Meanwhile, another coworker
called emergency medical services (EMS) from a telephone in the company’s
lunch room. EMS responded within 7 minutes. They examined the victim and determined
that he had sustained fatal head injuries. They contacted the county coroner who
pronounced the victim dead at the scene.
NIOSH investigators concluded that, to help prevent similar occurrences, employers
- ensure, through periodic inspections and reminders, that equipment
operators use seat belts provided on equipment they are assigned to
- develop, implement, and enforce a comprehensive written safety program
which includes training in hazard recognition and the avoidance of unsafe
conditions. A written training program should require training for all
equipment operators that includes a requirement that they follow the
equipment manufacturers’ recommendations for safe equipment operation.
- ensure that equipment is inspected daily before work begins and that
equipment with defective safety features, for example, a seat bar that
fails to prevent movement of controls when lifted, is removed from service
until needed repairs have been made
- purchase the manufacturer’s operator manuals and safety decals
in the primary languages used by their workforce
- ensure that the nearest area office of the Occupational Safety and
Health Administration is notified within 8 hours of a fatality or in-patient
hospitalizations of three or more workers as a result of a work-related
incident at their company.
On October 18, 2003, a 23-year-old Hispanic laborer (the victim) leaned
outside a skid steer loader’s operator compartment after lifting
the seat bar and was crushed between the frame of the skid steer loader
and the scraper attachment. The county sheriff’s department notified
officials of the Occupational Safety and Health Administration (OSHA)
of the fatal incident several days after the incident. The company had
not notified OSHA. On October 28, 2003, OSHA notified the National Institute
for Occupational Safety and Health (NIOSH), Division of Safety Research
(DSR) of the incident. On November 19, 2003, a DSR safety and occupational
health specialist interviewed the company’s general manager and
observed as one of the company’s mechanics demonstrated the operation
of the skid steer loader. The plant manager, who was the victim’s
brother, had not returned to work after the incident and was not available
for interview. The DSR investigator met with a county sheriff’s
department officer assigned to the case. Official reports and photographs
from the county sheriff’s department and the county coroner’s
office were reviewed. The DSR investigator spoke with the OSHA compliance
officer who had investigated the case and reviewed OSHA findings. A distributor
for the manufacturer of the skid steer loader was interviewed by telephone
and a copy of the manufacturer’s operator’s manual for the
equipment was reviewed.
Employer: The victim’s employer was a rendering company
that had been in operation for 59 years and employed 43 full-time employees.
Six of the 43 employees were Hispanic. Four Hispanic employees, including
the victim, worked as laborers and performed cleanup functions and other
Victim: The victim worked for the company as a laborer for three
months and spoke primarily Spanish. He had emigrated to the United States
from Honduras approximately 5 months before the incident.
Training: The employer had no written safety program. According
to the company’s general manager, verbal hazard communication and
lock out tag out training was provided to employees in English and Spanish.
The bilingual plant manager communicated safety-related information verbally
to the Hispanic workers. The only training provided to the victim, including
skid steer loader operator training, was given on-the-job by the victim’s
brother, the bilingual plant manager. According to the company manager,
the bilingual plant manager showed other Hispanic workers how to do their
jobs by providing on-the-job training. The company had no documentation
of employee training.
Equipment: The skid steer skid loader had been purchased new by
the owner and was approximately 2 years old. It had a gasoline powered
engine and was operated completely through the use of hand controls. It
was equipped with a rollover protective structure, side screens, a seat
belt, a seat bar (control interlock), hand rails, and lift arm support
struts (Figure 1). According to the operator’s
manual, when the seat bar is functioning correctly and is in the “up”
position, it prevents forward/rearward movement of the machine and also
prevents movement of the loader arms and bucket.
This was the company’s first workplace fatality.
Back to Top
The rendering company involved in this incident operated 24 hours per
day 6 days per week. The company rendered (cooked) animal parts and sold
animal by-products, grease and protein, to companies that manufacture
pet and domestic animal food. On Saturdays, the rendering plant was shut
down for cleaning. The victim and three other Hispanic coworkers worked
as laborers and were cleaning the plant on the day of the incident. A
plant manager, maintenance worker, and a truck driver also worked that
day performing other duties. The shift started at 8:00 a.m. and ended
at approximately 2:00 p.m.
According to information obtained from the general manager, the victim
and three Hispanic coworkers had spent the day of the incident cleaning
the cookers and the floor of the plant. After stopping for lunch at around
noon, coworkers used hoses to spray the plant floor with water while the
victim operated a skid steer loader with a metal and rubber scraper attachment
to scrape water and animal debris into a pit for disposal.
At approximately 1:45 p.m., the victim spoke with the plant manager who
reminded him that it was time to go to the shower room to get cleaned
up before ending the shift. The victim told the plant manager that he
had one more thing he wanted to do and drove the skid steer loader behind
the plant. At approximately 2:00 p.m., the plant manager went to look
for him and found the victim still partially in the skid steer loader
with his upper body leaning forward and his head crushed between the frame
of the skid steer loader and the scraper attachment (Photos
1 and 2). Coworkers had seen the skid steer
loader with the scraper attachment raised and engine running minutes before
the incident, but did not witness the fatal incident. The plant manager
reached into the operator’s compartment and used hand controls to
lift the attachment up and off of the victim’s head. He later reported
to the general manager that the victim was not wearing a seat belt, that
he lifted the seat bar and pushed the victim, who was leaning forward,
back toward the operator’s seat so that he could grasp his body
and pull him out of the machine. He and a coworker carried the victim
to a parking lot near the lunch room where they placed him on the ground.
Meanwhile, one of the other coworkers called emergency medical services
(EMS) from a telephone in the company’s lunch room. EMS responded
within 7 minutes and examined the victim. They determined that he had
sustained fatal head injuries and contacted the county coroner. The county
coroner pronounced the victim dead at the scene.
County sheriff’s department officers requested a demonstration of
the skid steer loader. They noted that when the seat bar was lifted, the
loader lift arms dropped rapidly without any movement of the hand controls.
According to the police findings, it appeared that the victim’s
head was pinned between the cross member of the scraper attached to the
loader arms and the frame on the right entry-exit area of the skid steer
loader. They surmised that the victim lifted the seat bar while sitting
in the operator’s seat and leaned over and/or attempted to exit
the vehicle and was fatally injured when the lift arms holding the scraper
attachment dropped. The report indicated that the results of the tests
they conducted were contrary to a coworker statement about the safety
bar being down on the operator when he was found.
The OSHA inspection revealed that the seat bar on the skid steer loader
was not functioning properly and that bulbs were missing in the head and
tail lamps. There were no maintenance records for the skid steer loader.
Following the incident, the company mechanic examined the seat bar on
the skid steer loader used by the victim and determined that it was not
adjusted properly. The company manager removed it from service until repairs
Cause of Death
The coroners report indicated that the cause of death was severe head
Back to Top
Recommendation #1: Employers should ensure, through periodic inspections
and reminders, that equipment operators use seat belts provided on equipment
they are assigned to operate.
Discussion: The skid steer loader used in this incident was equipped
with a seat belt. When used correctly, the seat belt can help ensure the
safety of the operator by holding the operator in place in the operator’s
seat. Operators should not take their seat belt off until after the equipment
has been properly shut down. Proper shut down would include lowering lift
arms to the ground before stopping the engine. The plant manager reported
to the general manager that he found the victim without his seat belt
secured, in an extreme forward leaning position with his head beyond the
operator compartment and with the skid steer loader’s engine running.
Recommendation #2: Employers should develop, implement, and enforce a
comprehensive written safety program which includes training in hazard
recognition and the avoidance of unsafe conditions. A written training
program should require training for all equipment operators that includes
a requirement that they follow the equipment manufacturers’ recommendations
for safe equipment operation.
Discussion: A comprehensive safety program should be developed that includes
training in hazard recognition and the avoidance of unsafe conditions.
The training plan should address the proper use of equipment and ensure
that the equipment manufacturers’ safety recommendations are incorporated
into the training. The training should reinforce the requirement that
the operator’s manual be kept on the machine at all times to serve
as a ready resource for safety questions. The content of the training
program and the names of those completing the training should be documented
and retained with other company safety records. Training workers using
the operator’s manual for the specific piece of equipment assigned
helps workers identify safety recommendations and features unique to the
machine in use.
Employers should ensure that the trainer who provides training is qualified
through education or experience to conduct training and ensure that the
trainer has been provided with training materials that are at a literacy
level and in a language that workers can comprehend. Employers should
document the trainer’s experience and training, and all training
provided to other workers.
The Manufacturer’s Operator’s Manual1
for the skid steer loader used in the incident provided many instructions
for safe operation of the equipment. Among warnings relevant to this incident,
- “Warning: When you operate, always keep all
parts of your body inside the operator compartment. Then, before you
leave the operators seat, always lower the loader bucket or attachment
to the ground and stop the engine. You can be injured or killed if you
do not follow these instructions.” Leaning outside the safety
of the operator compartment was a likely contributor to this fatal incident.
- “Warning: Raised equipment on the machine without
an operator can cause injury or death. Before you leave the operators
compartment, always support or lower the equipment (backhoe, blade,
boom, bucket, etc.) to the ground and stop the engine.”
The Operator’s Manual also includes warnings regarding parking:
- “When you park the machine and before you leave the operator’s
seat, check the seat bar for correct operation (the seat bar, when raised,
engages the parking latch and locks the loader controls). Lower the
lift arms and stop the engine.
- If the loader lift arms are raised, always install the support strut
before you service the machine.
- Always face the machine and use the hand rails and steps when getting
off. Do not rush and do not jump from the machine.”
The operator’s manual includes a copy of safety warning labels
on the machine (Figure 2), including the label which
is placed on the skid steer loader next to handrails designed for use
during exit and entry.
Training should reinforce the importance of testing safety features.
Training should also remind workers that safety features can fail and
that they must heed the manufacturer’s warning “when you operate,
always keep all parts of your body inside the operator’s compartment.
The manufacturer’s safety instructions include the following: “Most
accidents involving machine operation and maintenance can be avoided by
following basic rules and precautions. Read and understand all the safety
messages in this manual and the safety signs on the machine before you
operate or service the machine. See your dealer if you have any questions.”
Additional information useful for training workers about skid steer loader
safety can be found in a NIOSH Alert: Preventing Injuries and Deaths
from Skid Steer Loaders 2 available
through the NIOSH web site at http://www.cdc.gov/niosh
or by calling 1-800-356-4674. The Alert is available in both English and
(Link Updated 3/14/2013) The Alert contains a tear-out sheet (reprinted in English and Spanish
in the Appendix) that summarizes safety precautions
for operators of skid steer loaders. Posting this tear-out sheet at the
worksite may serve as an additional means of communicating safe work procedures
OSHA has developed a standard for performance based training for powered
industrial truck operators. In addition to using equipment specific operator’s
manuals for training, employers are encouraged to use this standard as
a model for operator training for other types of equipment, such as skid
steer loaders, which are not covered by the standard. The requirements
applicable to powered industrial truck operator training are available
at https://www.osha.gov/ and are located
in 29 CFR 1910.178(l)(1).3
Recommendations #3: Employers should ensure that equipment is inspected
daily before work begins and that equipment with defective safety features,
for example, a seat bar that fails to prevent movement of controls when
lifted, is removed from service until needed repairs have been made.
Discussion: Employers should designate a supervisor to be responsible
for daily pre-shift equipment checks and for verifying that any problems
are corrected. Although equipment may also be inspected by other workers,
for example, an equipment operator, the supervisor must be responsible
for ensuring that inspections are performed daily by a qualified person,
that necessary repairs have been made, that scheduled maintenance is performed,
and that records of all inspections are maintained.
The inspection should include testing the function of all safety equipment
installed on the equipment. When an inspection reveals, for example, that
the seat bar is not operating correctly, equipment should be removed from
service until repairs are made. When operating and used correctly, the
seat bar protects workers from injury by locking controls. The controls
that move the lift arms and that move the equipment back and forth are
locked in place when the seat bar is lifted.
The company’s general manager told the DSR investigator that the
seat bar was tested and adjusted to ensure proper function, and that missing
bulbs were replaced in both head and tail lamps following the incident
before the skid steer loader was returned to service. The operator’s
manual provides the following instructions regarding testing the seat
bar: “After each work day and after servicing the seat bar, test
the seat bar and loader controls for correct operation.” Page 128
of the operator’s manual goes through steps for checking the seat
bar for effectiveness in locking the loader controls and locking against
To ensure safe operation, these adjustments should be made by a mechanic
who is qualified through experience and training, or equipment should be
taken to an equipment dealer for adjustment and repair.
Recommendations #4: Employers should purchase the manufacturer’s
operator manuals and safety decals in the primary languages used by their
Discussion: Employers should purchase the manufacturer’s operator
manuals and safety decals in the primary languages used by their workforce.
The distributor for the skid steer loader informed the DSR investigator
that the operator manuals and safety decals for the skid steer loader
used in the incident are produced in several languages, including Spanish.
An operator manual and hazard warning decals written in English are provided
with the equipment when it is delivered from the manufacturer. There is
a charge for these items when written in other languages.
Operator manuals, hazard warnings, and illustrations written by manufacturers
for safe use of their products should be available in the primary languages
spoken by workers in the workplace. In this incident, six employees were
Hispanic and spoke primarily Spanish, but the hazard warnings and operator
manual provided with the skid steer loader were written in English. Many
employers employ Hispanic workers and their understanding of English may
be limited. The Bureau of Labor Statistics estimated 15.4 million employed
Hispanics in 2000, making up 10.9% of the U.S. workforce. The Hispanic
workforce increased 43% between 1990 and 2000, and is expected to increase
another 36% by 2010 to nearly 21 million employed Hispanic workers.4
When employers purchase and ensure the use of written information about
safe equipment use in the primary languages used by their employees, they
increase the likelihood that workers will be able to comprehend the safe
procedures they are to follow when operating equipment.
Recommendation #5: Employers should ensure that the nearest area office
of the Occupational Safety and Health Administration is notified within
8 hours of a fatality or in-patient hospitalizations of three or more
workers as a result of a work-related incident at their company.
Discussion: Within eight hours after the death of any employee from a
work-related incident or the in-patient hospitalization of three or more
employees as a result of a work-related incident, employers must report
the fatality/multiple hospitalizations by telephone or in person to the
area office of the Occupational Health and Safety Administration (OSHA),
U.S. Department of Labor, that is nearest to the site of the incident.
Employers may also use the OSHA toll free central telephone number, 1-800-321-OSHA
(1-800-321-6742) [29 CFR 1904.39(a)].5
This early reporting allows OSHA investigators to accurately assess the
hazards present and to remove other workers from potential hazardous situations.
In this incident, the employer was unaware of this reporting requirement.
- Case Corporation (1999). Operators Manual for 1840 Uni-Loader P.I.N.
JAF0223014 and After. Racine WI: Case Corporation.
- NIOSH . Alert: Preventing Injuries and Deaths from Skid Steer
Loaders. Cincinnati, OH: U.S. Department of Health and Human Services,
Public Health Service, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health , DHHS (NIOSH) Publication
- Code of Federal Regulations . 29 CFR 1910.178(l)(1). Powered
industrial truck operator training. Washington, DC: U.S. Government
Printing Office, Office of the Federal Register.
- BLS . BLS Releases 2000-2010 Employment Projections. [ftp://ftp.bls.gov/pub/news.release/History/ecopro.12032001.news].
Date accessed: March 26.
- Code of Federal Regulations . 29 CFR 1904.39(a). Reporting
fatalities and multiple hospitalization incidents to OSHA. Washington,
DC: U.S. Government Printing Office, Office of the Federal Register.
This investigation was conducted by Doloris N. Higgins, Safety and Occupational
Health Specialist, Fatality Investigations Team, Surveillance and Field
Investigations Branch, Division of Safety Research.
Figure and Photographs
Figure 1. Safety features on
the loader [used with permission of manufacturer]
Photo 1. This photo illustrates
the skid steer loader used on the day of the incident. An “X”
marks the approximate location on the horizontal bar of the scraper
attachment which came down and crushed the victim’s head between
it and the frame of the skid steer loader marked with a “Y”
on photo 2. Photograph courtesy of the County Sheriff’s
Photo 2. This photo illustrates
the skid steer loader used on the day of the incident. A “Y”
marks the area on the frame where the head injury occurred. A “Z
marks the seat bar. Photograph courtesy of the County
|Figure 2. Safety
warning labels on the skid steer loader, including the label next
to the hand holds regarding exiting the machine [used
with permission of manufacturer].
Source: NIOSH . Alert: Preventing Injuries and Deaths from
Skid Steer Loaders. Cincinnati, OH: U.S. Department of Heath and Human
Services, Public Health Service, Centers for Disease Control and Prevention,
National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication
Preventing Injuries and Deaths from
Skid Steer Loaders
Workers who operate or work near skid-steer loaders may be crushed
or caught by the machine or its parts.
If you operate or work near skid steer loaders, take these steps
to protect yourself.
- Follow safe operating procedures:
· Operate the loader from the operator’s compartment—never
from the outside.
· Stay seated when operating the loader controls.
· Work with the seat belt fastened and the restraint bar in place.
· Keep your arms, legs, and head inside the cab while operating
· Load, unload, and turn on level ground when possible.
· Travel and turn with the bucket in the lowest position possible.
· Operate on stable surfaces only.
· Do not travel across slopes. Travel straight up or down, with
the heavy end of the machine pointed uphill.
· Keep bystanders away from the work area.
· Never disable safety devices.
- Enter and exit from the loader safely:
· Enter the loader only when the bucket is flat on the ground—or
when the lift arm supports are in place.
· When entering the loader, face the seat and keep a three point
contact with handholds and steps.
· Never use foot or hand controls for steps or handholds.
· Keep all walking and working surfaces clean and clear.
· Before leaving the operator’s seat,
—lower the bucket flat to the ground,
—set the parking brake, and
—turn off the engine.
- Maintain the machine in safe operating condition:
· Follow the manufacturer’s instructions.
· Keep the foot controls free of mud, ice, snow, and debris.
· Regularly inspect and maintain
—Rollover protective structures (ROPS)
· NEVER modify or bypass safety devices.
· If you must perform service under a raised bucket, use the
lift arm supports.
Please tear out and post.
Prevención de lesiones
y muertes causadas por
Los trabajadores que operan o trabajan cerca de minicargadores pueden
ser aplastados o quedar atrapados por la máquina o sus piezas.
Si usted opera o trabaja cerca de minicargadores, siga los pasos
siguientes para protegerse.
- Observe procedimientos de seguridad al operar la máquina:
· Haga funcionar el cargador desde el compartimiento del operador,
nunca desde fuera.
· Esté sentado cuando haga funcionar los controles del
· Trabaje con el cinturón de seguridad puesto y la barra
de sujeción en la posición correcta.
· Mantenga los brazos, piernas y cabeza dentro de la cabina mientras
esté operando el cargador.
· Cuando sea posible, cargue, descargue y gire en terrenos llanos.
· Haga el recorrido y gire con el cucharón en la posición
más baja posible.
· Opere la máquina únicamente en superficies estables.
· No atraviese terrenos inclinados. Vaya derecho hacia arriba
o hacia abajo con la parte pesada de la máquina apuntando hacia
la parte elevada del terreno.
· Mantenga a los espectadores alejados del área de trabajo.
· Nunca desactive los dispositivos de seguridad.
- Entre y salga del cargador de manera segura:
· Entre al cargador únicamente cuando el cucharón
descanse sobre el suelo o cuando se encuentren en posición los
soportes de los brazos de elevación.
· A entrar al cargador, hágalo mirando de frente el asiento
y utilice asideros y peldaños para mantener tres puntos de contacto.
· Nunca utilice los controles de mano o de pie como asideros
· Mantenga todas las superficies de trabajo y para caminar limpias
· Antes de abandonar el asiento del operador,
—haga descender el cucharón hasta que descanse en el suelo,
—accione el freno de estacionamiento, y
—apague el motor.
- Mantenga la máquina en condiciones de funcionamiento
· Observe las instrucciones del fabricante.
· Mantenga los controles de pie libres de lodo, hielo, nieve
· Inspeccione y dé mantenimiento con regularidad
—Cinturones de seguridad
—Barras de sujeción
—Estructuras de protección contra volcamientos (ROPS)
· NUNCA modifique o pase por alto los
dispositivos de seguridad.
· Si se debe realizar servicio de reparaciones debajo de un cucharón
alzado, utilice los soportes de los brazos de elevación.