February 18, 1998
Nebraska FACE Investigation 98NE001


Shop Worker Run Over by Tractor


SUMMARY:

A shop worker was killed when he was run over by a tractor he had been working on.  He had just finished installing a loader on an older tractor and had just leveled the bucket.  He apparently was going to start the tractor to check for proper operation of the loader attachment.  He was standing on the ground in front of the tractor's left rear wheel and apparently reached up to crank up the tractor.  The tractor was in second gear and moved forward, running over the victim and crushing his chest.  A local rescue squad member was working in the same building as the victim and immediately responded.  Efforts to revive the victim were unsuccessful due to massive internal injuries.

The Nebraska Department of Labor investigator concluded that to prevent future similar occurrences employers should:

 

PROGRAM OBJECTIVE:

The goal of the Fatality Assessment and Control Evaluation (FACE) workplace investigation is to prevent work-related deaths or injuries in the future by a 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 solely for the purpose of providing current, relevant education to employers, their employees and the community on methods to prevent occupational fatalities and injuries.

 

INTRODUCTION:

On January 13, 1998, at approximately 4:00 p.m., a 42-year-old worker was killed when he was run over by a tractor in the maintenance shop of an agricultural implement dealer.  The Nebraska Department of Labor was notified of the fatality by OSHA on January 14, 1998.  Information for this report was obtained from OSHA and a site visit conducted on January 27, 1998, which included interviews with the company owner and a coworker who is also a member of the local rescue squad.

The employer is an agricultural implement dealer who has been in business for over 22 years.  The company employs seven individuals.  The victim had been employed by the company for seven months.  The company did not have a written safety/injury prevention program.  This was the first fatality in the history of the company.

 

INVESTIGATION:

On the day of the incident the victim had been installing a bucket loader on a 1964 Allis Chalmers tractor.  The area he was working in was a large open bay with several tractors in the area.  The tractor he was working on was parked facing a large metal garage door.  The victim had installed the bucket and asked his boss to come take a look at it.  It was not leveled properly so the victim made some adjustments to it.  The boss had gone back to his office and shortly thereafter heard a crashing sound.  He ran from his office to the open bay maintenance area and saw that the tractor had crashed through the closed garage door.  He went over to the tractor and discovered the victim.  There were no witnesses to the incident.

It appears the victim was standing in front of the left rear wheel of the tractor and reached up to turn the key to start the tractor to check out the loader.  He had also pulled out the throttle in preparation for starting the tractor, and when he turned the key the tractor started.  It was in second gear and moved forward, crushing the victim beneath the left rear wheel.  Newer tractors have a safety interlock which will not allow the tractor to start while it is in gear, however, this being a 1964 model, it was not so equipped.  When the tractor crashed through the door apparently the hand clutch was pulled back into the neutral position and the tractor stopped moving and just continued idling.  Shop personnel immediately called 911 who responded and attempted to revive the victim.  Resuscitation attempts were unsuccessful and the victim was pronounced dead at 5:00 p.m.

 

CAUSE OF DEATH:

The cause of death was massive internal injuries.

 

RECOMMENDATIONS/DISCUSSION:

Recommendation #1: Employers should ensure personnel are sitting at the controls of any piece of machinery being started and that no one is standing in its path.

Discussion: No piece of machinery should ever be started without someone at the controls to ensure it is properly configured for activation.  In this case, had the victim been in the tractor seat, he could have ensured the tractor was in neutral before he started it and even if he had started it in second gear he would have been in a position to immediately stop the tractor.

 

Recommendation #2: Employers should develop, implement and enforce a comprehensive safety program that includes, but is not limited to, training in all hazard recognition and abatement.

Discussion: A comprehensive safety program should have addressed the hazards involved with starting a tractor from the ground.   When a new employee is hired he/she should be trained regarding basic safety requirements as well as specific requirements for the job they are performing.  In this case the danger of starting a tractor from the ground should have been covered.

 

Recommendation #3: Employers should consider implementing a spot inspection program to ensure all employees are complying with safety requirements and enforce consequences for noncompliance.

Discussion: To ensure safety program compliance, spot inspections by supervisors and management should be conducted regularly to verify proper procedures are being followed.  Deterrent consequences should be enforced when violations to procedures are noted. An effective safety program should instill an attitude in both employers and employees that safety will never be compromised.

 

To contact Nebraska 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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