During the summer of 2003, a 14- year-old boy died while helping his grandfather clear farmland of fence posts. The boy was operating a utility tractor equipped with a homemade rollbar and seatbelt. They had successfully removed several posts using the tractor’s three-point hitch lift arms, but encountered a post that wouldn’t budge. The grandfather switched to another method to pull posts using the rear wheel, something he had learned from his father many years ago. They backed up the tractor into position, adjacent to the 6-inch (15 cm) diameter wooden fence post. The tractor was facing up a slight slope. An old chain with 1/4 inch (6 mm) links was secured to the bottom of the post and the other end was looped around the rear tire. Normally, as the wheel would turn, it would pull the post upward and forward. The boy had the tractor in first gear, with throttle applied. As he released the clutch, the post, buried 4 feet (1.2 m) deep in dry ground, did not move, but the tractor’s front end jumped upward. The grandfather yelled, but the boy had no time to react, and the tractor rolled completely over backwards. The self-made rollbar was sturdy and did not break or bend, but large pieces of the axle housing snapped off from both sides as the rollbar collapsed. The boy was instantly crushed underneath. The tractor had been previously used for city maintenance, and originally had a two-post factory-installed Roll-Over Protective Structure (ROPS). The tractor was sold through an auction and was bought by the family without this ROPS. The original mounting brackets were still in place, but the long bolts connecting the top and bottom brackets were missing. The new rollbar was welded to the existing top bracket, which was bolted only to the topmounting base of the cast iron axle housing. Without the long bolts between the top and bottom brackets, this installation did not provide adequate strength for the rollbar attachment to the axle, and the axle housings broke, making the rollbar ineffective. Recommendations based on our investigation are as follows: 1. Factory installed Roll-Over Protective Structures (ROPS) should not be removed from tractors. 2. Non-ROPS tractors should be retrofitted with approved ROPS; otherwise, they should be recycled, or retired to stationary power source use. 3. Self-made rollbars are not recommended, as they may not provide adequate structural strength in an overturn. 4. The rear wheel of a tractor should not be used to pull posts from the ground. 5. Youth under 16 years of age should not operate tractors, unless they have received tractor operator training.
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