Fatality Assessment and Control Evaluation (FACE) Program
A Farmer Was Killed While Bypass-Starting His Tractor
An 84-year-old farmer died on May 21, 2005 from injuries received after he was run over by the rear tire of a farm tractor he was attempting to bypass-start. The decedent was using one tractor to start a second tractor that was malfunctioning. The victim positioned himself between the two tractors and attached a set of jumper cables to the batteries. He then used a pair of metal pliers to create a short circuit at the starter of the tractor. When the tractor started, it struck him and caused him to fall. The farmer was then run over, pulled under the tire, and ejected behind the tractor. The victim was pronounced dead at the scene.
Agriculture requires a lot of work, and shortcuts may be tempting, but they are often dangerous. Bypass-starting is one of the more hazardous shortcuts.
Oklahoma Fatality Assessment and Control Evaluation (OKFACE) investigators concluded that to help prevent similar occurrences, farmers should:
On May 21, 2005, an 84-year-old farmer was killed when he was struck and run over by a tractor he was attempting to bypass-start. OKFACE investigators were notified of the incident and conducted an interview with the investigating officer on July 8, 2005. OKFACE investigators reviewed the death certificate, photos of the incident, and reports from the Medical Examiner, sheriff, and highway patrol.
Victim: The victim was a self-employed owner/operator of a farm. He had been involved in farming for over 60 years. The victim owned the field where the incident occurred and had worked at that site for many years. He was working with two tractors at the time of the incident that were each about 30 years old.
Training: At this privately owned, sole proprietor operation, there were no written safety procedures in use. It is unknown if the decedent received any formal safety training on the use of the machinery he operated.
Incident Scene: The scene of the incident was a large, very wet and muddy, freshly plowed agricultural field. The approximate time of day was 7:00-7:30 p.m.
Weather: The weather clear and dry. However, the ground conditions were wet and muddy due to rain from previous days. The ground was also very rutted from plowing, which had occurred prior to the rainstorms.
On the day of the incident, the victim needed to use a tractor that had a dead battery (tractor #2). Wanting to bypass-start it, the victim drove another tractor (tractor #1) to the field where it was located, while his wife followed him in a vehicle with emergency flashers. The decedent parked tractor #1 near tractor #2, each facing the same direction, and his wife parked on the other side of the access road (Figure 1). Tractor #2 had been left in gear when the battery died and the front axle was turned toward the left. The victim parked tractor #1 on the left side of tractor #2.
The victim positioned himself between the two tractors and attached a set of jumper cables to both tractors’ batteries. Instead of sitting in the operator’s seat and using the ignition to start the tractor, he remained on the ground between the two tractors and used a pair of pliers to bypass the ignition switch and create a short circuit to the starter of tractor #2. When tractor #2 started, it moved forward at an angle and struck the victim, causing him to fall to the muddy ground. Tractor #2 continued moving forward until it struck tractor #1 and pushed it west approximately 10 feet, with the front axle of tractor #2 under the front axle of tractor #1 (Figure 2). The left rear tire of tractor #2 was spinning in the mud and dug into the ground about five feet. The victim was run over, pulled under the tire, and ejected behind the tractor. The rear wheel of the tractor continued to spin, throwing mud onto the decedent (Figure 3).
During the incident, the victim’s wife remained in the parked vehicle until she noticed that her husband had a problem and may have been injured. Unable to walk across the muddy and rutted terrain of the field, she drove to a neighbor’s house to ask for help. The neighbor called for emergency response and returned to the incident site with her. By that time, the victim was completely buried under the mud except for one foot. The victim was pronounced dead at the scene by emergency responders.
Cause of Death
The Medical Examiner listed the cause of death as multiple injuries (full body).
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Recommendation # 1: Farmers should ensure that tractor engines are started from the operator’s seat with the transmission and power take-off in neutral and the parking brake engaged.
Discussion: Farmers should start the engine of a tractor with a key from the operator’s seat, which is the safest place to be during machine operation. Bypass-starting is often viewed as a timesaving shortcut to addressing a malfunction. The term “bypass-starting” points to its danger. It bypasses all the safety start and neutral start switches engineered in the tractor’s electrical and hydraulic systems. If the tractor is left in gear and a bypass-start is performed, the starter will engage and the engine will start as soon as the circuit is complete. The operator does not have enough time to jump away and may be pulled down by the drive wheel, run over, crushed, or otherwise injured. The running tractor also has the potential to injure others and destroy property. Tractors should be started with the transmission and power take-off (PTO) in neutral and the parking brake set. Operators should be seated with the seat belt securely fastened. If the tractor is not equipped with a rollover protective structure (ROPS), then a seat belt should not be worn. Operators should be careful not to position themselves or others in or near a tractor’s point of operation. Agriculture requires a lot of work, and shortcuts may be tempting, but they are often dangerous. Bypass-starting is one of the more hazardous shortcuts.
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