During the summer of 2003, a 69-year-old worker was run over while making repairs to a tractor. He worked part-time as a handyman for a land developer, and routinely used this utility tractor for various jobs on the property. A front axle attachment had become loose, and needed repair. This axle had a "wishbone" bracket underneath the engine, attached to the frame of the tractor with three bolts. The victim was replacing these bolts, and needed to re-align the bracket before he could insert the third bolt. He had worked as a mechanic most of his working career, and had considerable experience with machinery. He was familiar with the run-over risk, and had warned others about it. The exact circumstances in this incident are not clear, but it appears that he may have attempted to use the front-end loader to raise the front of the tractor off the ground. This would release weight from the front wheels and the wishbone bracket, and allow easy insertion of the bolts. No jacks or jack stands were present. While standing on the floor to the right side of the tractor, the man started the engine, assuming the transmission was in neutral. However, the transmission was in first gear, and as the tractor started, it lurched forward and continued moving into the adjoining room of the machine shed, where it crashed into the exterior wall. The victim was run over by the right rear wheel of the tractor and he received severe internal injuries, which caused his death later that day in the hospital. Recommendations based on our investigation are as follows: 1. Tractor operators should be seated at the controls when starting a tractor. 2. Tractors and self-propelled machinery should be equipped with interlock mechanisms that prevent starting the machine unless an operator is sitting at the controls and the drive train is disengaged. 3. Hydraulic jacks and jack stands should be used to raise and support the tractor during repair, rather than using the front-end loader.
Region-7; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Protective-measures; Personal-protective-equipment; Protective-equipment; Equipment-design; Equipment-operators; Equipment-reliability; Tractors; Mechanics