Farmer Killed After Fall From And Run Over By A Moving Windrower

FACE 92WI10201

SUMMARY:

A 63 year old white male farmer fell when he attempted to jump onto a moving International 5000 windrower driven by a neighbor but owned by the farmer. When he recognized that his neighbor was unable to control the machine, the farmer climbed the fixed ladder attached to the cab to reach the controls. The farmer then lost his balance and fell approximately 6 feet to loose soil where the left front tire of the windrower ran over his head and body. The deputy sheriff was first to arrive at the site and given the massive trauma caused by the run over that was clearly not consistent with life, canceled the EMS ambulance and summoned the coroner. The coroner pronounced the victim dead at the scene. Approximately 27 minutes had e lapsed when the coroner arrived. The Wisconsin FACE investigator concluded that, in order to prevent similar occurrences, employers should:

• Conduct a jobsite survey to identify potential hazards. All hazards should be removed or controls placed that will ensure a safe work environment.
• Train all workers in comprehensive safety hazard recognition. Specifically train workers to operate machinery prior to independent use of the machinery.
• Provide and enforce written safety policies. Included in these policies would be a policy prohibiting riding on non-passenger parts of machinery and prohibiting the use of alcohol prior to or during the operation of machinery.

INTRODUCTION:

On August 15, 1992 at approximately 2:PM the victim sustained fatal crushing injuries when he fell from a moving windrower and was run over. The FACE investigator was notified of the fatality by the Department of Industry Labor and Human Relations Workers Compensation Division on September 11, 1992. The investigation was initiated by the FACE investigator on March 17, 1993. Photographs were taken and the wife and son of the victim were interviewed. Reports were obtained from the coroner, sheriff’s office and a death certificate was obtained.

The farmer had been employed in farming for 53 years, 30 years on the farm where the incident occurred. He had no employees but a neighbor came over and helped out occasionally. This neighbor was attempting to operate the windrower which he had never operated before when the incident occurred. There were no written safety rules and no safety officer on the farm. Anyone who helped out was shown how to do things at the time it was to be done. The victim (farm owner/operator) was very familiar with high powered and sophisticated farm machinery.

INVESTIGATION:

On August 15, 1992, two men were working in a field cutting hay. It was a dry and sunny day. At about 2:00 PM the machine driven by one of the men (a neighbor cutting hay on the other farmer’s property) broke down. The farmer who owned the farm field and the machinery being used, directed the neighbor to operate the International 5000 windrower that he had operated himself earlier in the day. According to the farmer’s son, the farmer had operated the windrower that morning and it had functioned without incident. Apparently, when the farmer got off the machine that morning, he did not engage the handbrake. When the handbrake is engaged the machine cannot move or turn. The neighbor had never operated this windrower before. When he started the machine it lunged backward, the handbrake not being engaged. The foot brake on this machine when pressed half-way down slows the machine, when pressed all the way down the machine operated in reverse. Since the brake function of the tractor the neighbor had operated in the morning functioned differently than the windrower, the neighbor became confused and could not stop the machine. The farmer tried to help the neighbor gain control. He jumped on the first step/deck of the moving implement, then he lost his balance and fell to the ground. The neighbor was unable to stop the machine and the farmer was run over by the from left wheel of the vehicle which caused his death. The windrower continued to move backwards across the hayfield until it came to rest in a cornfield where it stopped. The farmer’s son indicated that the only way to turn this machine off, it being diesel powered, is to hit the kill switch. Simply turning off the key or cutting back the throttle will not stop the machine. The farmer’s family pointed out that the farmer was very knowledgeable regarding machinery but that alcohol consumed prior to the event may have affected his decision to allow the neighbor to drive the windrower and his decision regarding the appropriate way to assist his neighbor in gaining control of the machine.

CAUSE OF DEATH: Crushing head trauma, massive multiple fractures of ribs and fracture of pelvis.

RECOMMENDATIONS/DISCUSSION:

Recommendation #1: Conduct a jobsite survey to identify potential hazards. All hazards should be removed or controls placed that will ensure a safe work environment.

Discussion: A jobsite survey may have identified the way the windrower functioned as a potential hazard. Mechanical evaluation may have identified the need to remove the machine, repair it, or better understand it’s safe operation.

Recommendation #2: Train all workers in comprehensive safety hazard recognition. Specifically train workers to operate machinery prior to independent use of the machinery.

Discussion: The neighbor using the machine was not familiar with the machine and did not receive training and instruction in the operation of the windrower. His inability to control the machine prompted the farmer’s jumping onto the machine.

Recommendation #3: Provide and enforce comprehensive written safety policies. Included in these policies would be a policy prohibiting riding on non-passenger parts of machinery and prohibiting the use of alcohol prior or during the operation of machinery.

Discussion: A written policy may have reinforced the dangers of climbing onto moving machinery and or working around machinery after using alcohol.

General Discussion: Important features such as depressing the braking mechanism are not consistent between farm machines. Additionally, in diesel machines turning off the ignition does not stop the vehicle. Further consideration is needed regarding uniformity in the manufacture and operation of farm equipment.

FATALITY ASSESSMENT AND CONTROL EVALUATION (FACE) PROGRAM

FACE 92WI10201

Staff members of the FACE Project of the Wisconsin Division of Health, Bureau of Public Health, perform FACE investigations when there is a work-related fatal fall, electrocution, or enclosed/confined space death 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.