Fatality Assessment and Control Evaluation (FACE) Program

 

City Equipment Operator Killed when Run Over by a Rotary Riding Mower

Massachusetts Case Report


On This Page...
 
  • Summary
 
  • Introduction
 
  • Investigation
 
  • Cause of Death
 
  • Recommendations and
    Discussion
 
  • References
 
  • Illustrations
 
  • Summary of OSHA'S Draft
    Proposed Safety and Health
    Program Rule for Employers

Massachusetts Case Report: 03-MA-041-01
Release Date: November 30, 2005

Summary

On August 20, 2003, a 54-year-old public sector equipment operator (the victim) was fatally injured when he was run over by a sit-down rough rotary mower. The victim, who was mowing a section of a city park, stopped the mower on an edge of a hill and turned off the engine. After exiting the mower, he noticed that it had started to roll down the hill. The victim attempted to stop the rolling mower by stepping in front of it, but became trapped underneath the mower and was dragged approximately 75 feet. The victim was ejected from underneath the mower and the mower continued to roll another 25 feet. Two co-workers who were working nearby witnessed the incident and went to assist the victim. A call was placed for Emergency Medical Services (EMS). EMS responded to the incident site within minutes and transported the victim to a local hospital where he was pronounced dead. The Massachusetts FACE Program concluded that to prevent similar occurrences in the future, employers should:

  • Develop, implement, and enforce standard operating procedures (SOPs) for operating and shutting down mowers, including requirements to park mowers on level ground.

  • Develop, implement, and enforce a comprehensive written safety program, which includes training on hazard recognition and the avoidance of unsafe work practices and conditions.

In addition, employers of state and municipal workers should:

  • Provide work environments that, at a minimum, meet all relevant Occupational Safety and Health Administration (OSHA) and American National Standards Institute (ANSI) requirements and standards.

Introduction

On August 26, 2003, the Massachusetts FACE Program was notified by the city clerk's office through the 24-hour Occupational Fatality Hotline, that on August 20, 2003, a 54-year-old male was fatally injured when he was run over by a lawn mower. An investigation was initiated. On October 2, 2003, the Massachusetts FACE Program Director traveled to the city parks department office and the incident location where the department’s deputy commissioner was interviewed. The death certificate, mower information, and police incident report were reviewed. Photographs of the machine involved in the incident and the incident location were taken during the course of the site visit.

The employer, a city parks department, employed approximately 60 people. The incident location was a 480 acre city-owned park that had been in existence for more than 100 years. At the time of the incident, the victim and 16 other employees held the job title of laborer/motor equipment operator. The victim had worked for the city parks department for approximately eight years.

The employer did not have a designated person in charge of safety and health and did not have a written safety and health program. Training provided by the city on the mower involved in the incident was on-the-job. The dealership from which the city purchased the mower had provided limited training to employees on the mower upon delivery. The victim did have a current Massachusetts Commercial Drivers' License (CDL) and a Hoisting Machinery Operator License, issued through the Massachusetts Department of Public Safety, although these licenses are not required to operate the equipment involved in the incident. The victim was a member of a public sector union.

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Investigation

The vehicle involved in the incident was a rough rotary mower that was approximately three years old (Figure 1). It was a sit down style mower with a four cylinder 87 horsepower diesel engine. The mower was equipped with four-wheel drive and 29 inch diameter front tires and 24 inch diameter rear tires. The maximum forward mowing speed was 8.5 miles per hour and the maximum forward transport speed was 20 miles per hour. The mower’s braking system consisted of drum brakes and a hand lever parking brake. The mower contained three cutting decks: a 92 inch front deck with five 21 inch blades and two 59 inch wing (side) decks each with three 21-inch blades. Each cutting deck could be placed in a folded up position so the mower would be able to fit into smaller spaces. The over all cutting width of the mower was 192 inches (16 feet). The mower weighed 6,350 pounds and was 16 ½ feet wide and 14 ½ feet long.

The victim's normal working hours were 7:00 a.m. - 3:30 p.m. On the day of the incident, the victim's task was to mow grass inside the city owned park. The deputy commissioner had reported that the ground conditions were wet/damp on this day. Mowing the grass at the park was an ongoing task, because once the entire park had been mowed, the sections that had been mowed first would have to be mowed again. The victim was specifically assigned to the mower involved in the incident and had been using the mower for the past few years. Two other employees had been working with the victim prior to the incident. One was using a different style mower and the other was weed trimming locations where the mowers could not fit.

At approximately 1:30 p.m. on the day the incident occurred, the victim had stopped the mower on the top edge of a hill (Figure 2) with the cutting decks in the folded up positions. The victim stopped the mower, turned off the engine and exited the operator's area. Within a few seconds of the victim exiting the operator's area, the mower started to roll in a forward direction down the hill. The victim noticed the unattended mower rolling down the hill and attempted to stop it by stepping in front of the mower and pushing against it in the direction opposite in which it was rolling. The mower rolled on top of the victim and he then became trapped underneath it. The mower continued to roll down the hill for approximately 75 feet with the victim trapped underneath it. The victim was then ejected from underneath the mower and the mower continued rolling down the hill for approximately another 25 feet and stopped on level ground.

Co-workers who witnessed the incident went to assist the victim and notified Emergency Medical Services (EMS). EMS responded to the incident site within minutes and started to administer first aid. The victim was then transported a local hospital where he was pronounced dead.

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Cause of Death

The medical examiner listed the cause of death as multiple traumatic injuries.


Recommendations/Discussion

Recommendation #1: Employers should develop, implement, and enforce standard operating procedures (SOPs) for operating and shutting down mowers, including requirements to park mowers on level ground with the cutting decks lowered to the ground.

Discussion: The safest location to stop and park a mower is on level ground. In this case, the victim stopped the mower at the edge of a hill, turned the mower to the off position and exited the mower with the cutting decks in the up position. While unattended, the mower started to roll in the forward direction down the hill. Following SOPs when shutting down mowers will ensure that mowers are stable and will help prevent mowers from moving unexpectedly.

When developing standard operating procedures (SOPs) for mowers, employers should refer to the manufacturer’s user/operator manual for mower specific operating features. Some general procedures for parking and shutting down mowers include, but are not limited to:

  • Stopping on level dry ground
  • Disengaging the power take-off (PTO) - if applicable
  • Lowering the cutting decks to the ground
  • Placing mower in park
  • Engaging the parking brake
  • Turning off the engine and removing the key

Once the SOPs have been developed, the employer should provide employees with training on the SOPs and adequate supervision, including unscheduled routine inspections of employee work practices.

Although the safest location to stop and park a mower is on level ground, in situations where mowers must be stopped on a slope, the mower should be position sideways across the slope. Then the operator should follow the above procedures with one additional requirement: blocking the mower's wheels.


Recommendation #2: Employers should develop, implement, and enforce a comprehensive written safety program, which includes training on hazard recognition and the avoidance of unsafe work practices and conditions.

Discussion: The employer did provide on-the-job training to employees, but this training did not address all hazards involved in mowing operations. A comprehensive written safety program that includes, training on hazard recognition and the avoidance of unsafe conditions should be developed, implemented, and enforced by employers.

Employers should evaluate tasks performed by employees for all potential hazards and incorporate these identified hazards and their controls into hazard recognition training. At a minimum, hazard recognition training should include, but not be limited to, hazard identification, the avoidance of unsafe conditions, and the abatement of identified hazards. Avoidance of unsafe conditions should also be included in this training and address employees not risking physical harm to accomplish tasks.

In this case, the incident occurred on a hill within large open grassy area. The bottom of the hill leveled off before the open grassy area ended. Co-workers and pedestrians could have been warned of the rolling mower and the mower could have been allowed to roll down the hill until it came to a stop on its own within the level grassy area.

The training programs content and the names and dates of employees completing the training should be documented and retained by the employer. Employers should ensure that the trainer who provides training is qualified through education and/or experience to conduct training. As a reference, a summary of the Occupational Safety and Health Administration's (OSHA) draft proposed safety and health program rule, which discusses employee training, has been included at the end of this report.


Recommendation #3: Employers of state and municipal workers should provide work environments that, at a minimum, meet all relevant Occupational Safety and Health Administration (OSHA) and American National Standards Institute (ANSI) requirements and standards.

Discussion: The federal Occupational Safety and Health Act requires employers to provide workplaces that are free from recognized hazards likely to cause death or serious physical harm to employees. The American National Standards Institute (ANSI) (www.ansi.org) consensus standard covering commercial riding mowers recommends that mowers be stopped on level ground. Health and safety requirements and standards established by the Occupational Safety and Health Administration (OSHA) (www.osha.gov) and ANSI serve as accepted standards of practice for workplace health and safety in industry. While state and municipal workplaces in Massachusetts are not currently under OSHA’s jurisdiction, state and municipal employers should, at a minimum, provide work environments that meet all relevant OSHA and ANSI requirements and standards.

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References

  1. Equipment Manufacturers Institute, 1985, Industrial/Agricultural Mowers, Chicago, Illinois.

  2. Code of Federal Regulations, 29 CFR 1910.243 Hand and Portable Powered Tools and Other Hand-Held Equipment. Government Printing Office.

  3. NIOSH FACE Report Number 2004-01, Hispanic Laborer Dies After Being Crushed Between the Frame of a Skid Steer Loader and the Scraper Attachment on the Loader Lift Arms - Ohio.

  4. The Ohio State University Extension, Rotary Agricultural Mower Safe, accessed at http://www.nasdonline.org/document/1779/d001738/rotary-agricultural-mower-safety.html, on October 3, 2005. (Link updated 10/5/2009)
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Illustrations


Figure 1 – Mower involved in the incident.
Figure 1 – Mower involved in the incident

Figure 2 – Incident site showing grassy hillside.
Figure 2 – Incident site
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Summary of OSHA'S Draft Proposed Safety and Health Program Rule for Employers

(29 CFR 1900.1 Docket No. S&H-0027)

Core elements

  • Management leadership and employee participation
  • Hazard identification, assessment, prevention and control
  • Access to information and training
  • Evaluation of program effectiveness

Basic obligations

  • Set up a safety and health program, with employee input, to manage workplace safety and health to reduce injuries, illnesses and fatalities.
  • Ensure that the safety and health program is appropriate to workplace conditions taking into account factors such as hazards employees are exposed to and number of employees.
  • Establish and assign safety and health responsibilities to an employee. The assigned person must have access to relevant information and training to carryout their safety and health responsibilities and receive safety and health concerns, questions and ideas from other employees.

Employee participation

  • Regularly communicate with employees about workplace safety and health matters and involve employees in hazard identification, assessment, prioritization, training, and program evaluation.
  • Establish a way and encourage employees to report job-related fatalities, injuries, illnesses, incidents, and hazards promptly and to make recommendations about appropriate ways to control those hazards.

Identify and assess hazards to which employees are exposed

  • Conduct inspections of the workplace at least every two years and when safety and health information change or when a change in workplace conditions indicates that a new or increased hazard may be present.
  • Evaluate new equipment, materials, and processes for hazards before introducing them into the workplace and assess the severity of identified hazards and rank those hazards that cannot be corrected immediately according to their severity.

Investigate safety and health events in the workplace

  • Thoroughly investigate each work-related death, serious injury, illness, or incident (near miss).

Safety and health program record keeping

  • Keep records of identified hazards, their assessment and actions taken or the plan to control these hazards.

Hazard prevention and control

  • Comply with the hazard prevention and control requirements of the OSHA standards by developing a plan for coming into compliance as promptly as possible, which includes setting priorities and deadlines for controlling hazards and tracking the progress.

Information and training

  • Ensure each employee is provided with safety and health information and training.
  • If an employee is exposed to hazards, training must be provided on the nature of the hazards to which they are exposed to and how to recognize these hazards. Training must include what is being done to control these hazards and protective measures employees must follow to prevent or minimize their exposures.
  • Safety and health training must be provided to current and new employees and before assigning a job involving exposure to a hazard. The training should be provided routinely, when safety and health information is modified or a change in workplace conditions indicates a new or increased hazard exists.

Program evaluation and maintenance

  • Evaluate the safety and health program at least once every two years or as often as necessary to ensure program effectiveness.
  • Revise the safety and health program in a timely manner once deficiencies have been identified.

Multi-employer workplaces

  • The host employer's responsibility is to provide information about hazards and their controls, safety and health rules, and emergency procedures to all employers at the workplace. In addition, the host employer must ensure that assigned safety and health responsibilities are appropriate to other employers at the workplace.
  • The contract employer responsibility is to ensure that the host employer is aware of hazards associated with the contract employer's work and how the contract employer is addressing them. In addition, the contract employer must advise the host employer of any previously unidentified hazards at the workplace.

 

To contact Massachusetts State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

 

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