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Dairy Farmer Dies Following a Tractor Rollover While Trying to Roll-start Tractor in West Virginia

Case: 02WV002-01
Release Date: June 10, 2002

SUMMARY

On January 8, 2002, a 44-year-old male dairy farmer (victim) died of injuries sustained when the tractor he was trying to roll-start turned over and pinned him to the ground. The victim was trying to start a 23-year-old wide front-end configured tractor. The tractor's electrical system was in a state of disrepair and therefore this method of starting had been used for the past 2 years. The victim mounted the tractor and began rolling down a snow-covered farm road which traversed a hillside. As the tractor began to roll, a bump, rut, or snow-related irregularity caught one of the front wheels and canted the front end to the right in a downhill direction. The victim was unable to correct the unexpected change in direction because the tractor had not yet started and therefore the hydraulically-controlled steering system was not functioning. The tractor left the road and began rolling down the hillside. As the tractor approached another snow covered-road approximately 75 feet below the first, the victim was able to start the tractor. He pulled onto the second road while in a sliding left hand turn. The right front and right rear wheels dropped off the embankment below the second road causing the tractor to rollover sideways, landing on the victim and pinning him to the ground. The tractor did not have a rollover protective structure (ROPS) or a seat belt. The victim's employee, who was helping with the starting operation, witnessed the incident. He ran to the victim's aid and tried to free him. Unable to free him, he called 911. EMS arrived and found no signs of life. The tractor was removed from the victim and he was pronounced dead. The coroner estimated that the victim had died immediately after tractor impact. The WV FACE investigator concluded that to reduce the likelihood of similar occurrences, the following guidelines should be followed by tractor owners:

  • Equip all tractors with rollover protective structures and a seat belt.
  • Maintain tractors in serviceable condition.

 

INTRODUCTION

On February 12, 2002, the WV FACE Program was notified by the West Virginia University Extension Center for Agricultural and Natural Resources Development that a tractor-related death had occurred on January 8, 2002. The field investigator contacted the county extension agent. The field investigator traveled to the area on March 13, 2002 and met with the county agent to discuss the incident. Photographs and measurements were taken of the tractor and incident site. The death certificate, medical examiner's, and police reports were obtained. The victim's employee, who witnessed the incident, was interviewed.

The victim was a self-employed dairy farmer who had been farming the property his entire life. He was an experienced tractor operator. He had owned, operated, and maintained the tractor involved in the incident. The tractor, as purchased, did not have a ROPS or a seat belt.

At the time of the incident, the victim was attempting to roll-start a defective tractor. He had performed the task 2-3 times a week for the past several years. Although the victim had started the same tractor this way often, it was reported that at the time of the incident, there was approximately 8 inches snow which had recently fallen.

 

INVESTIGATION

On January 8, 2002, a 44-year-old male dairy farmer (victim) died of injuries sustained when the tractor he was trying to roll-start slid in the snow, turned over, and pinned him to the ground. The tractor was a 1979 Massey Ferguson Model 265 (see Figure 1). This particular tractor was one of three tractors used on the farm. The tractor's electrical system was in a state of disrepair and therefore this method of starting had been used for the past 2 years. The day before the incident, it had snowed and it was reported there was at least 8 inches of snow on the ground. The victim mounted the tractor and began rolling down a snow-covered farm road which traversed a hillside. As the tractor began to roll, a bump, rut, or snow-related irregularity caught one of the front wheels and canted the front end to the right in a downhill direction (see Figure 2). The victim was unable to correct the unexpected change in direction because the tractor had not yet started and therefore the hydraulically-controlled steering system was not functioning. The tractor left the road and began rolling down the hillside. As the victim approached another snow-covered road approximately 75 feet below the first he was able to start the tractor. He slid onto the second road while in a left hand turn. The right front and right rear wheels dropped off the 4 foot embankment below the second road (see Figure 3). The tractor then rolled over sideways, landing on the victim and pinning him to the ground (see Figure 4). The tractor did not have a ROPS or a seat belt. The victim's employee, who was helping with the starting operation, witnessed the incident. He ran to the victim's aid and tried to free him. Unable to free him, he called 911. EMS arrived and found no signs of life. The tractor was removed from the victim and he was pronounced dead. The coroner estimated that the victim had died immediately after tractor impact.

 

CAUSE OF DEATH

The cause of death listed on the death certificate was chest trauma.

 

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Equip all tractors with rollover protective structures and a seat belt.

[ Owners of older model tractors should contact their county extension agent, equipment dealer or equipment manufacturer to determine if retrofit ROPS and operator restraint systems are available for their equipment. Such systems should be installed by the manufacturer or an authorized dealer. ]

Discussion: Preventing death and serious injury to tractor operators during rollovers requires the use of ROPS and a seat belt. These structures, either a roll-bar frame or an enclosed roll-protective cab, are designed to withstand the dynamic forces generated during a rollover. In addition, seat belt use is necessary to ensure that the operator remains within the "zone of protection" provided by the ROPS. OSHA regulations require that all tractors built after October 25, 1976, and used by employees of a farm which employs 11 or more must be equipped with ROPS and a seat belt.1 In West Virginia, many tractors are in use on family farms with fewer than 11 employees and therefore do not fall under OSHA regulations. Given the uneven terrain and environmental conditions in West Virginia, all farmers should voluntarily have their older tractors retrofit with a properly designed, manufactured, and installed ROPS as well as a seat belt. A ROPS retrofit kit is available for the Massey Ferguson Model 265 tractor. If the tractor involved in this incident had been fitted with a ROPS and a seat belt, and the seat belt had been in use, this fatality most likely would have been prevented.

 

Recommendation #2: Maintain tractors in serviceable condition.

Discussion: Tractor owners should realize the correlation between defective equipment and risk- taking. The tractor's electrical system was in a state of disrepair and the owner had inappropriately relied on roll-starting for the past 2 years. Roll-starting tractors is an unsafe practice, particularly on machines with hydraulically-controlled steering mechanisms which yield little if any directional control until the tractor starts. Tractors should be inspected regularly and defects or damage repaired or the unserviceable machines replaced. Had this tractor's starter been operating there would have been no need to head down a snow covered hillside and the fatality may have been prevented.

 

REFERENCES

  1. Office of the Federal Register: Code of Federal Regulations, Labor, 29 CFR Part 1928.51 (b), U.S. Department of Labor, Occupational Safety and Health Administration, Washington, D.C., April 25, 1975.

 

ILLUSTRATIONS

Figure 1. 1979 Massey Ferguson Model 265.

Figure 1. 1979 Massey Ferguson Model 265.

 

Figure 2. The dotted line represents the intended direction of the roll-start.  The solid white line represents the tractor's actual path.

Figure 2. The dotted line represents the intended direction of the roll-start. The solid white line represents the tractor's actual path.

 

Figure 3.  This photo shows the 4 foot bank which both the right front and right rear wheels dropped off, causing the tractor to roll and land upside-down on the victim.

Figure 3. This photo shows the 4 foot bank which both the right front and right rear wheels dropped off, causing the tractor to roll and land upside-down on the victim.

 

Figure 4. The tractor's final resting place as seen from the bank above.

Figure 4. The tractor's final resting place as seen from the bank above.


FATALITY ASSESSMENT AND CONTROL EVALUATION PROGRAM

The WVU Center for Rural Emergency Medicine, through a contract with the West Virginia Department of Health and Human Resources and Bureau for Public Health, conducts investigations on the causes of work-related fatalities within the state. The goal of this program is to prevent future fatal workplace injuries. West Virginia FACE intends to achieve this goal by identifying and studying the risk factors that contribute to workplace fatalities, by recommending intervention strategies, and by disseminating prevention information to employers, employees, trade associations, unions, equipment manufacturers, students, teachers, and others with an interest in workplace safety.


Please use information listed on the Contact Sheet on the NIOSH FACE website to 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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