MN FACE Investigation 99MN02701
DATE: October 18, 1999
Farmer Dies After Being Pinned Beneath The Front Of Skid-Steer Loader
A 51-year-old female farmer (victim) died after being pinned beneath the front of a skid-steer loader while using it to unload a piece of equipment from a hayrack. She routinely used the loader and was familiar with its operation. The loader showed significant signs of wear and duct tape was used on the control lever linkage for the hydraulic system and the forward/reverse control mechanism. The loader's operational controls consisted of two adjacent "T" levers located on a control panel in front of the operator's seat. Horizontal rods adjacent to the operator's feet connected the lower ends of the "T" levers to control valves located beneath the seat. The control linkage would sometimes jam which prevented normal operation of the loader.
The victim recently purchased a combine that included a front-end attachment that consisted of a cutting platform and a set of long cylindrical reels. The victim was unloading the reels from a hayrack that had been used to haul them to her farm. After positioning the hayrack near a row of bushes and a corn field, the victim drove the loader to the side of the hayrack. She used several chains to lift the reels from the hayrack. Limited space between the bushes and the corn field caused her to approach the bushes at an angle. When one end of the reels contacted the bushes, she apparently lowered the bucket enough to unhook one chain and may have been planning to lift the end of the reels that wasn't near the bushes and move it closer to the bushes.
After lowering the reels, the linkage controlling the loader operation apparently jammed. The victim climbed from the seat and knelt beneath the raised bucket in front of the loader. She reached along each side of the control panel to unjam the linkage rods and apparently caused the loader to move forward, pinning her legs beneath the machine. She was unable to free herself and was discovered the next day by a neighbor who notified emergency personnel. Rescue personnel arrived at the scene shortly after being notified, removed the victim and pronounced her dead at the scene. MN FACE investigators concluded that, in order to reduce the likelihood of similar occurrences, the following guidelines should be followed:
On July 1, 1999, MN FACE investigators were notified of a farm work-related fatality that occurred on June 27, 1999. The county sheriff's department was contacted and a releasable copy of their report of the incident was obtained. A site investigation was conducted on August 18, 1999 by a MN FACE investigator. During MN FACE investigations, incident information is obtained from a variety of sources such as law enforcement agencies, county coroners and medical examiners, employers, coworkers and family members.
On the day of the incident, the victim used a small skid-steer loader to unload a piece of farm equipment from a hayrack. The loader was a four-wheeled, gasoline powered skid-steer loader (commonly referred to as a "bobcat") and was equipped with a general purpose front-end bucket. The victim routinely used the loader and was familiar with its operation. Although the skid-steer loader make, model, and serial number were obtained during the site investigation, the year of manufacture and the horsepower of the unit could not be determined since the manufacturer apparently is no longer in business. The skid-steer loader was a small unit that was approximately 30-35 years old and was probably rated at 20-25 horsepower. Entry to the operator seat was made from the front of the vehicle by climbing over a control panel located in front of the seat.
During the investigation it was obvious that the loader had been extensively used and showed signs of significant wear. Although it was maintained in an overall useable operating condition, general maintenance and repair was less than optimal. An example of less than optimal maintenance and repair could be seen in the use of duct tape on the control linkage for both the hydraulic lift system and the forward/reverse control mechanism. Operational controls for the loader consisted of two adjacent "T" levers located on a control panel directly in front of the operator's seat. Each lever moved forward and backward to control various movements of the loader. The left lever controlled the forward and backward movement of the loader and the right lever controlled the raising and lowering of the bucket lift arms. Horizontal rods adjacent to the operators feet were used to connect the lower ends of the "T" levers to control valves located beneath the operator seat. Duct tape was used in several places to keep the connector pins in place at the ends of the horizontal rods.
During the investigation, it was learned that the control linkage would sometimes jam and prevent normal operation of the loader. It was also learned that on occasion the victim had been known to and observed to dismount the loader and unjam the linkage while the engine was still running. The victim accomplished this by kneeling on the ground in front of the loader, reaching along the sides of the control panel and grabbing the horizontal linkage rods. She would move the rods back and forth until they were free and then return to the seat to operate the loader. While in this position, she was directly in front of the loader and exposed to being runover by it if it moved forward.
The victim had recently purchased a used combine that included a front-end attachment used for harvesting soybeans. The front-end attachment consisted of two main parts, a cutting platform and a set of 12-14 feet long cylindrical reels that rotate and tip soybeans into the combine after the stems are cut off near the ground. At the time of the incident, the victim was unloading the reels from a hayrack that was used to haul them to her farm. After positioning the hayrack near a row of bushes and a corn field near her farm place, the victim drove the loader up to the side of the hayrack. She used several chains fastened to the raised loader to lift the reels from the hayrack and attempted to set them on the ground near the bushes. Limited space between the bushes and the adjacent corn field may have caused her to approach the bushes at an angle. When one end of the reels contacted the bushes, she apparently lowered the bucket enough to unhook one chain while planning to lift the end of the reels that wasn't near the bushes and move it closer to the bushes.
After lowering the reels, it appears that the linkage controlling the loader operation jammed. Based on the position in which the victim was found, she apparently climbed from the seat while the loader was raised. She then knelt beneath the raised bucket and in front of the loader and reached along each side of the control panel to unjam the linkage rods. This position required her to be in direct contact with the front of the loader in order for her to reach the linkage rods. While in this position, she apparently caused the loader to move forward, pinning her legs beneath the front of the machine. When she was found, she had a large laceration under her chin that may have been caused by the steel framework across the front of the loader.
The victim was unable to free herself and was discovered by a neighbor who came to her farm to help bale hay. When the neighbor could not locate her at her house or farm buildings, he began to search and soon discovered her. The loader's ignition key was in the on position, however the engine had stopped when it ran out of gasoline. The victim was pinned between the loader bucket and the machine's frame when the bucket settled after the engine stopped. The neighbor notified emergency personnel who arrived at the scene shortly after being notified of the incident. After adding gasoline to the loader, the engine was started, the bucket was raised and the victim was removed. The local coroner examined the victim and estimated that she had been deceased for about a day.
CAUSE OF DEATH
The cause of death from the death certificate was not available when this report was completed.
Recommendation #1:Skid-steer loader controls should only be operated from the operator's compartment, never from outside the compartment.
Discussion: All machines that are designed with a dedicated operator's compartment or platform should only be operated from that position. Operator compartments and platforms are designed to provide a work space for the operator that reduces the risk of injury. The operator's seat and control levers on skid-steer loaders are located between the machine's lift arms and in front of the lift arm pivot points. The operator's seat is the only location from which the machine's controls can be safely operated. In this case, the victim apparently left the operator's seat, positioned herself on the ground in front of the machine and attempted to "unjam" the control lever linkage while the engine was running. In addition, she positioned herself beneath the raised loader bucket which exposed her to the risk of injury if the bucket suddenly lowered. Safe skid-steer operating procedures are provided in NIOSH Alert: Preventing Injuries and Deaths from Skid-Steer Loader, DHHS (NIOSH) Publication No. 98-117.
Recommendation #2:Skid-steer loader engines should be stopped before workers leaving the operator's seat.
Discussion: Whenever workers leave a machine's operator compartment or platform, they should stop the machine and secure or activate all safety devices such as brakes to reduce the risk of injury to themselves or other workers who approach the machine. Workers should never perform any skid-steer service or repair with the engine running unless directed to do so by the operator's manual. If any service or adjustments require that the engine be in operation, at least two persons should be present to ensure that the tasks can be safely completed and all manufacturer's safety recommendations must be followed to safely complete the task.
Recommendation #3: Loaders should be adequately maintained and serviced to keep them in safe and proper operating condition.
Discussion: The risk of serious injury or death to workers can be reduced if machines and equipment are maintained in proper operating condition. The skid-steer loader associated with this incident had been used extensively and although maintained in basic operating condition, some aspects of its maintenance, specifically the use of duct tape on the control linkage, were less than optimal. Various reasons for the loader being maintained in its condition at the time of the incident may have included uncertain and fluctuating financial conditions in the agriculture industry. The victim may have had to prioritize expenditures due to uncontrollable and often low commodity prices. These factors may have contributed to the use of duct tape to secure the control lever linkage or to a delay in having the linkage properly repaired to prevent it from jamming.
1. NIOSH (February 1998). NIOSH Alert: Preventing Injuries and Deaths from Skid-Steer Loader. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 98-117.
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