Colorado FACE Investigation 95CO082


A Colorado Farmhand is Killed when a Tractor Rolls over Him


SUMMARY:

The 50-year-old farmhand was killed while attempting to jump-start a Case model 1270 tractor. The victim was standing between the front and rear wheels of the tractor while he used the handle of a pair of pliers to short-circuit the terminals on the tractors starter. The tractor was in gear when the engine was started. The vehicle lurched forward, knocking the victim to the ground. The rear wheels rolled over his left leg knocking him to the ground. The tractor had a wheat drill (planter) attached to the tow bar. The wheat drill was pulled over the victim's lower extremities, abdominal region and thoracic region. The farm owner noticed the driverless tractor turning in circles in the field. When he investigated, he discovered the victim. A local ambulance was called and the victim was transported to the local hospital where he expired in the emergency room.

The Colorado Department of Public Health and Environment (CDPHE) investigator concluded that to prevent future similar occurrences, employers should:

 

INVESTIGATIVE AUTHORITY:

CDPHE performs investigations of occupational fatalities under the authority of the Colorado Revised Statutes and Board of Health Regulations. CDPHE is authorized to establish and operate a program to monitor and investigate those conditions which affect public health and are preventable. The goal of the workplace investigation is to prevent work-related injuries in the future by study of the working environment, the worker, the task the worker was performing, the tools the worker was using, and the role of management in controlling how these factors interact.

This report is generated and distributed to fulfill the Department's duty to provide relevant education to the community on methods to prevent severe occupational injuries.

 

INVESTIGATION:

On September 30, 1995 a Colorado wheat field was the site of a fatal tractor run-over incident. The investigation of this work-related fatality was prompted by a report of the incident to CDPHE by the County Coroner. The farm owner and the coroner were interviewed. Reports were obtained from the ambulance service and the county coroner. Photographs were taken at the site of the incident.

The employer is a wheat farmer that employed one hired hand. The employer did not have specific written safety rules that covered this type of incident, although the vehicle manufacturer's equipment manual addressed the issue and warning labels were visible on the equipment. Employee training is on-the-job.

 

CAUSE OF DEATH:

The cause of death was determined by the coroner to be massive traumatic abdominal, pelvic, and chest injuries.

 

RECOMMENDATIONS/DISCUSSION:

Recommendation #1: Ensure that employees are familiar with all safety features on equipment that they will operate.

Discussion: This model of tractor owned was equipped with a safety switch that prevented the engine from starting while in gear. However according to the manufacturer's manual and warning labels located on the starter, this switch is by-passed when the terminals on the starter are short-circuited.

 

Recommendation #2: Bi-lingual signs should be posted on equipment to designate that a safety hazard exists.

Discussion: The primary language of the employee killed in this incident was Spanish. He had a very limited command of the English language. Although a warning label was in place on the equipment, it was printed in English.

 

Recommendation #3: Employers should develop, implement, and enforce a comprehensive written safety program.

Discussion: This employer did not have a written comprehensive safety program. All employers should evaluate the tasks done by workers to identify all potential hazards. The employer should then develop and implement a safety program addressing these hazards, provide worker training in safe work procedures and implement appropriate control measures.

 

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