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Youth Worker Dies After Being Pinned Under Tractor at a Food Processing Plant

Wisconsin FACE 98WI074

SUMMARY:

A 14-year-old male groundskeeper assistant (the victim) died after being pinned under the wheel of a lawn tractor that rolled backward toward a pond on the grounds of a food processing plant. The company manager was the victim's father, and he hired the youth to provide lawn care services for the summer. The victim had been using the tractor, which was equipped with a mower deck, to mow grass in the vicinity of the pond. When the rear wheel of the tractor became stuck in mud on the edge of the pond, he apparently got off the tractor to push it from the rear, and it rolled backward, pinning him under the tire. A deliveryperson arrived at the company after the incident occurred, and saw the victim pinned under the tire. EMS responders arrived within minutes of the deliveryperson's call for help. Company workers had initiated CPR, which was continued while the victim was airlifted to a hospital. He died the next day.

To prevent future fatalities of this type, the FACE investigator recommends employers should:

  • train tractor operators to shift the tractor into park, set the brakes and turn off the engine before dismounting from the tractor. For tractors without a park position, operators should shift into neutral, set the brakes and turn off the engine before dismounting.
  • know and comply with child labor laws which exclude employment of youths less than 16 years of age in occupations which are deemed detrimental to their health or well-being by the Secretary of Labor.
  • provide workers with training in the recognition and avoidance of unsafe conditions and the required safe work practices that apply to their work environments.

 

INTRODUCTION:

On August 6, 1998, a 14-year-old male groundskeeper assistant died after being pinned under a yard tractor wheel. The Wisconsin FACE field investigator was notified by the Wisconsin Department of Workforce Development, Workers Compensation Division, on October 1, 1998. On December 15, 1998, the field investigator conducted a brief telephone interview with the plant manager. A site visit was made on a later date, but company staff were not available for interviews. The FACE investigator also obtained the death certificate and the coroner and sheriff"s reports and photos of the scene.

The company in this incident manufactured food additives. The incident occurred on the grounds of a food additive manufacturing plant. The plant was situated in a rural area, and was surrounded by landscaped acreage with woods and grass-covered rolling hills. A small pond was situated several hundred feet from the plant site. It is unknown how long the company had been in operation at this location, or the number and types of workers employed there.

The victim was living with family members and working part-time for his father's company during his summer vacation from school. He had used the lawn tractor equipped with a mower deck to mow grass during the prior summer, and for several weeks prior to the incident. He received on-the-job training, and was supervised by his father, the plant manager.

 

INVESTIGATION:

At about 3:45 PM on the day of the incident, the youth laborer was using a 30-year-old International Harvester Cub Lo-Boy tractor equipped with a mower deck to mow the grounds of the plant. He finished mowing the flat grassy areas around a small pond, then apparently backed the tractor closer to the pond's edge to mow taller plants close to the water. At the point where the incident occurred, there was approximately 20 degrees of slope toward the water's edge. There were no witnesses to the incident, but it appears the left rear tire of the tractor became stuck in the muddy edge of the pond and the victim dismounted the tractor to push it out of the mud. He turned the engine off, left the transmission in neutral, and did not engage the emergency brake. The tractor apparently rolled back over the victim as he was positioned behind the tractor. The left rear tire came to rest on his chest, while his feet extended into the water, and his head was on the inside area of the tire. A deliveryperson driving on the road leading to the plant saw the stalled tractor with the victim underneath it, and called for help. Plant employees tried to lift the tractor from the victim and started CPR, while others called for emergency medical services. When EMS responders arrived, they continued with CPR and transported the victim to a hospital. He died the next day.

 

CAUSE OF DEATH:

The medical examiner's report listed the cause of death as anoxic encephalopathy due to mechanical asphyxia.

 

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Tractor operators should shift the tractor into park, set the brakes and turn off the engine before dismounting from the tractor. For tractors without a park position, operators should shift into neutral, set the brakes and turn off the engine before dismounting.

Discussion: Tractors will roll downhill if parked on an incline without an effective braking device. Tractor operators can prevent tractors from rolling by shifting into park if possible, setting the brakes and turning off the engine before dismounting. In this incident, the lawn tractor was stuck on an incline leading to a small pond. The victim left the transmission in neutral and did not set the emergency brake before getting off the tractor and positioning himself behind the tractor. It is unknown if the victim was trained to safely park the tractor to prevent it from rolling on an incline.

 

Recommendation #2: Employers should know and comply with child labor laws which exclude employment of youths less than 16 years of age in occupations which are deemed detrimental to their health or well-being by the Secretary of Labor

Discussion: The Fair Labor Standards Act provides a minimum age of 16 for work which the Secretary of Labor determines to be detrimental to the health and well-being of youth. The Act prohibits 14 and 15-year-old minors from working with any power-driven machinery, other than office machines and specified machines in retail, food service and gasoline service establishments. The operation of a lawn tractor by a 14-year-old is prohibited under this Act.

 

Recommendation #3: Employers should provide workers with training in the recognition and avoidance of unsafe conditions and the required safe work practices that apply to their work environments.

Discussion: According to 29 CFR 1926.21 (b) (2), "the employer shall instruct each employee in the recognition and avoidance of unsafe conditions and the regulations applicable to his work environment to control or eliminate any hazards or other exposure to injury or illness." Youth less than 18 years of age should receive training on prohibited work tasks and settings (activities deemed to be especially dangerous for youth by the employer and/or child labor regulations), as well as hazards and safe work practices that apply to work they are permitted to perform. Training in recognizing and avoiding hazards should be given to all workers; coupled with employer assessments that workers are competent in the recognition of hazards and safe work practices. In this case, the victim performed work activities that are prohibited for minors under age 16. In addition, safe work practices of securing a tractor parked on an incline and seeking assistance to dislodge a vehicle stuck in mud were not followed.

 

REFERENCES

DOL. Child Labor Requirements in Nonagricultural Occupations Under the Fair Labor Standards Act. Washington D.C.: U.S. Department of Labor, Employment Standards Administration, Wage and Hour Division WH-1330

29 CFR 1926 (1998) Code of Federal Regulations, Washington D.C.: U.S. Government Printing Office, Office of the Federal Register.

 

photo of the tractor near the water

Figure 1. 98WI074

 


FATAL ASSESSMENT AND CONTROL EVALUATION (FACE) PROGRAM

FACE 98WI07401

Staff members of the FACE Project of the Wisconsin Division of Health, Bureau of Public Health, do FACE investigations when a work-related fatal machine-related, youth worker or road construction work-zone death is reported. The goal of these investigations is to prevent fatal work injuries in the future by studying: the working environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury and the role of management in controlling how these factors interact.

To contact Wisconsin 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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