A Rancher Was Killed When He Was Crushed by a Round Hay Bale
A 44-year old rancher died on October 29, 1999 from suffocation and internal injuries received when he was crushed by a round hay bale that rolled out of the front-end loader bucket that was mounted on the tractor he was driving. The hay bale was estimated to weigh in excess of 1000 pounds. At the time of the incident, the victim was operating a tractor on a rural farm owned by a neighbor who had hired him to move the hay from a storage pen into a pasture several hundred yards away. The tractor was not equipped with a general purpose enclosed cab, rollover protective structure, or seat belt. The victim was attempting to back the tractor with the front-end loader elevated when the hay bale became dislodged from the bucket and rolled onto him. A witness called for help and assembled several men and another tractor that removed the hay bale approximately 40 minutes after the incident occurred. An ambulance arrived approximately 15 minutes later and transported the victim to a hospital approximately 24 miles from the scene of the incident where he was pronounced dead.
OKFACE investigators concluded that to prevent similar occurrences employers should:
A 44-year old self-employed rancher died on October 29, 1999 from suffocation and internal injuries received when he was crushed by a round hay bale that had rolled off the tractor's front-end loader. OKFACE investigators reviewed the death certificate and the medical examiner's report and conducted a site investigation on April 14, 2000. While conducting the site survey, the investigators interviewed the victim's wife.
The rancher had worked in the agriculture industry for over 25 years and had extensive experience operating a variety of tractors and other farm equipment, including the tractor he was using at the time of the incident. The tractor belonged to a neighbor for whom the rancher moved hay two to three times a week to feed livestock. The hay was stored in an enclosed pen near the farmhouse and was being transported to an open pasture several hundred yards away. The rancher had moved hay bales for the neighbor for years, however, approximately one month prior to this incident, the owner of the farm had switched from square bales to round bales. During this time, the rancher had moved round hay bales approximately 6-8 times for the neighbor. The round hay bales were approximately five feet in diameter and weighed more than 1000 pounds. The extent of the rancher's safety training was not readily available; however, he reportedly had known at least one individual killed in an agricultural incident and had expressed some concern regarding farm safety issues.
On the afternoon of October 29, 1999, the rancher was using a tractor equipped with a front-end loader to move large round hay bales from a small fenced enclosure on a neighbor's ranch to a field several hundred yards away. The tractor, which belonged to the property owner, was not equipped with a general purpose enclosed cab, a rollover protective structure, or a seat belt. Since the tractor owner did not have a hay spear implement to use with the tractor's three-point hydraulic lift, the operator used the front-end loader to move the hay. Recent rainfall had caused the ground to be wet and muddy in the area of the gate through which the victim had to transport the hay out of the enclosed area. The victim, moving the second of two bales to be moved that day, had retrieved the bale with the front-end loader and was backing out of the enclosure up a slight incline through the mud. The weight of the hay had shifted the tractor's center of gravity such that the rear drive wheels were spinning in the mud, and the victim may have elevated the hay bale in an attempt to change the center of gravity and gain better traction in the mud.
The victim had twisted to look toward the rear of the vehicle while backing through the gate with the load in an elevated position high above the front end of the tractor when the front wheels of the tractor rolled into a depression causing the tractor to bounce. Consequently, the hay bale became dislodged from the bucket and rolled down the front-end loader, pinning the victim against the tractor seat with only his head remaining uncovered. The victim applied the clutch and held the tractor in a stationary position until he lost consciousness. The tractor then continued to roll backward until it struck a tree where it idled until rescuers turned it off. A witness saw the danger and attempted to notify the victim but was unable to intervene. After the incident occurred, the witness contacted her husband, the owner of the property, who assembled a team of rescuers. With the assistance of another tractor, the rescuers succeeded in removing the hay bale approximately 40 minutes later. The witness also contacted an ambulance service in a nearby community, and the ambulance arrived about 15 minutes after the hay bale was removed. Rescuers administered cardiopulmonary resuscitation (CPR) as soon as the victim was removed from the tractor. The ambulance crew loaded the victim and transported him to the nearest hospital while continuing CPR. The ambulance arrived at the hospital, located in a community approximately 24 miles from the scene of the incident, approximately 30 minutes later where the victim was pronounced dead.
CAUSE OF DEATH
The Medical Examiner listed the cause of death as suffocation and internal injuries from crushing by a hay bale.
Recommendation #1: Employers should follow manufacturer's recommendations and safe work practices when operating farm equipment. For example, when using a front-end loader the operator should ensure that the bucket is positioned near the ground, particularly while the tractor is in motion.
Discussion: The operator's positioning of the front-end loader bucket higher than the front of the tractor was the underlying cause of the fatal incident. The round hay bale was too large to be securely transported in the front-end loader bucket, and elevation of the unstable load created the hazard that ultimately resulted in the fatality. Manufacturers' recommendations, when combined with safe work practices developed through adequate hazard analysis, provide procedures for safely accomplishing tasks for which the machinery or equipment was designed.
Recommendation #2: Employers should only use equipment that is designed for its intended use and properly maintained in a safe condition.
Discussion: Moving the bale with a tractor equipped with a front-end loader that had no grapple to secure it was a contributing cause of the fatal incident. The use of the front-end loader as a means for handling large round hay bales presented a hazard, particularly when the bucket was raised above the front end of a tractor, by significantly altering the tractor's center of gravity, thereby decreasing the machine's traction and maneuverability and increasing the risk of rollover of the tractor or displacement of the load. The use of a bale spear attachment (mounted front or back) or a front-end loader equipped with a grapple, both of which are designed for the task being performed by the operator, would have provided a safer means for handling the hay with much less risk to the operator.
Recommendation #3: Employers should ensure that tractors are equipped with roll-over protective structures (ROPS) and seat belts.
Discussion: The tractor being used by the operator was not equipped with a rollover protective structure (ROPS) or seat belt. Although this equipment may not have prevented the fatal injury, FACE investigators noted its absence. Occupational Safety and Health Administration regulations have required ROPS as standard equipment since October 28, 1976; however, many tractors commonly in use were manufactured before that time and may not be equipped with operator protection. Most manufacturers provide a ROPS and seat belt retrofit for such equipment, and in many instances tractor dealers and service centers will install the retrofits at cost.
Recommendation #4: Employers should inspect work areas and equipment before performing a task to identify actual and potential hazards and determine adequate controls.
Discussion: The operator backed the tractor through a wet, muddy area, thereby decreasing the vehicle's control and maneuverability. Additionally, the depression into which the tractor rolled jolted the vehicle and consequently dislodged the hay bale from the front-end loader bucket. Both conditions were contributing causes to the fatal incident. An inspection of the area and consequent identification and control of the hazards, such as selecting an alternate path or making repairs to the path to be used, may have prevented the incident.
Recommendation #5: Employers should familiarize themselves and their employees with farm safety documents and training materials and avail themselves to available training opportunities.
Discussion: Small family farms may not have a formal safety program or written safety procedures; however, the information to promote farm safety and health is available from many sources and in a variety of media. Safety training is a critical component of an effective farm safety program, whether or not the program has been formally developed, and the farm owner must ensure that all workers, including family members and part-time or occasional employees, participate in quality safety training that promotes safe job performance on the farm. Manufacturers and operating manuals for equipment such as the tractor involved in this incident are critical sources of safety information on the operation of such equipment. Employers should maintain equipment manuals and manufacturer safety information for future reference.
Additional resources for documents and training videos include:
Occupational Safety and Health Administration, 29 CFR 1928.51. Roll-over protective structures (ROPS) for tractors used in agricultural operations.
American Society of Agricultural Engineers, ASAE S383, Operator Protection for Wheel Type Agricultural Tractors.
National Ag Safety Database Website, http://www.cdc.gov/niosh/nasd.html.
The Oklahoma Fatality Assessment and Control Evaluation (OKFACE) is an occupational fatality surveillance project to determine the epidemiology of all fatal work-related injuries and identify and recommend prevention strategies. FACE is a research program of the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research. These fatality investigations serve to prevent fatal work-related injuries in the future by studying the work environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in injury, and the role of management in controlling how these factors interact.
To contact Oklahoma 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.