Farm Owner/Operator Died of Suffocation When his Clothing became Entangled in the Machinery
Colorado FACE Investigation 92CO02201
NOTICE TO READER: THIS IS A DUPLICATE REPORT. 92CO025 IS THE CORRECT REPORT AND CASE NUMBER.
A farm owner/operator in Colorado died of suffocation when his clothing became entangled in the machinery he was attempting to adjust.
The 42-year-old farmer was fatally injured when he attempted to adjust the spacing of the cultivator he was using. The deceased had stopped the forward motion of the tractor to which the cultivator was attached, but left the engine of the tractor running. The cultivator was equipped with a hydraulic-powered weeder bar that functioned off of the tractor’s power take-off (PTO). Because the engine was still running, the weeder bar was rotating. The farmer raised the cultivator and climbed under it to make adjustments. As the deceased was exiting from under the cultivator, his jacket caught on the connecting bolt of the rotating weeder bar and twisted to the point of strangulation. Coworkers discovered the body, and notified the county sheriff and coroner. The farmer was pronounced dead at the scene. The Colorado Department of Health (CDH) investigator concluded that to prevent future similar occurrences, employers should:
- Ensure that all power sources are shut off prior to making adjustments to machinery.
- Develop, implement, and enforce a comprehensive written safety program.
- Employers should conduct a job-site survey on a regular basis to identify potential hazards, implement appropriate control measures, and provide subsequent training to employees that specifically addresses all identified hazards.
Information obtained from the family members indicated that the cultivator the deceased was operating had a tendency to plug up with weeds because the hilling wings were not adjusted properly. The one-year-old cultivator was a “Dammer Diker: manufactured by AG Engineering of Tri Cities, Washington. This particular unit was equipped with a weeder bar that is manufactured by Coaldale Iron Products, LTD, Coaldale, Alberta, Canada. The weeder bar is a hexagonal rod that is rotated by a hydraulic drive unit powered by the PTO of the tractor (Photograph #1). The tractor being utilized with this piece of equipment was a John Deere Model 4640.
The safety warning label on the cultivator (Photograph #2) states “DO NOT RIDE OR WORK ON MACHINE WHILE IN MOTION”. This safety precaution was more clearly stated in the owner-operator manual, reading “DO NOT RIDE OR WORK IN MACHINE WHILE IT IS OPERATING OR IN MOTION”. (Attachment 1)
CAUSE OF DEATH:
The cause of death as listed on the death certificate was suffocation due to or as a consequence of clothes caught in the cultivator PTO.
Recommendation #1: Ensure that all power sources are shut off prior to making adjustments to machinery.
Discussion: Safety precautions recommended by the manufacturer should be strictly followed. In this incident, the manufacturer had a safety warning label on the equipment and safety precautions listed in the owner-operator manual warning that the equipment should not be worked in while it is in motion.
Recommendation #2: Employers should develop, implement, and enforce a comprehensive written safety program.
Discussion: This employer did not have a written comprehensive safety program. All employers should evaluate the tasks done by workers to identify all potential hazards. The employer should then develop and implement a safety program addressing thaes hazards, provide worker training in safe work procedures and implement appropriate control measures.
Recommendation #3: Employers should conduct a job site survey on a regular basis to identify potential hazards, implement appropriate control measures, and provide subsequent training to employees that specifically addresses all identified site hazards.
Discussion: A thorough inspection of the equipment would have revealed the potential hazard of the rotating shaft and connecting bolt. One appropriate control measure would be to replace the bolt with a steel roll pin that does not extend beyond the shaft edges.