Colorado FACE Investigation 90CO058
A Colorado Farm Wife was Killed in a Tractor Run-over Incident
The 60 year-old wife of a farmer in Colorado was assisting her husband doing farm chores for a neighbor. The victim was attempting to connect a feed grinder to the draw bar of the tractor as her husband backed up the neighbor's tractor. She apparently slipped. Her husband was unable to stop the tractor in time due to lack of familiarity with the controls and faulty brakes on the tractor. The Colorado Department of Health investigator concluded that, to prevent future similar occurrences, employers should:
On November 11, 1990 a privately-owned farm was the site of a fatal tractor run-over injury.
A report by the county sheriff to the Colorado Department of Health (CDH) of a work-related fatality prompted the investigation of this fatal injury. The farm owners were contacted and reports were obtained from the local sheriffs department, ambulance service, and the county coroner. Photographs were taken at the site of the incident.
The victim was attempting to connect a feed grinder to the draw bar of a 1964 Case Model 940 tractor. This tractor was equipped with a rear-mounted fuel tank behind the operator's seat. This tank obstructed the driver's view of the draw bar. The tractor was an older model that has a hand clutch that operates in reverse of that of newer models. The brakes on the tractor were defective and this was known by the operator. The operator had instructed his wife to guide him back to the feed grinder and to insert the draw pin. As the tractor proceeded backward with a jerking motion, the victim's foot either slipped or was caught under the rear tire. As she fell down, the tractor travelled over the length of her body.
CAUSE OF DEATH:
The cause of death was determined by the coroner to be massive traumatic abdominal and chest injuries.
Recommendation #1: Maintain equipment in a high state of repair.
Discussion: The failure to repair the faulty brakes contributed to the possibility of a hazardous event taking place. The inability to quickly stop the tractor permitted the vehicle to travel an unnecessary distance and significantly contributed to the injuries of the victim.
Recommendation #2: Employers should conduct a job site survey on a regular basis to identify potential hazards, implement appropriate control measures, and provide subsequent training to employees that specifically addresses all identified site hazards.
Discussion: The different operational features of the clutch on this specific model of tractor and the operator's lack of experience with this piece of equipment enhanced the probability of a hazardous event taking place.
Recommendation #3: Location flags should be positioned on both the draw bar and the hitch point of equipment to be connected. These location flags should be of sufficient height to be visible from the operator's position.
Discussion: The fuel tank size and location obscured the vision of the operator and made the process of connecting equipment to the draw bar difficult. The use of flags would allow equipment to be aligned by the operator without the assistance of another individual.
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